Effects of IL-1β inhibition on anemia and clonal hematopoiesis in the randomized CANTOS trial

Canakinumab, a monoclonal antibody targeting proinflammatory cytokine interleukin-1β (IL-1β), improved hemoglobin levels while preventing recurrent cardiovascular events in the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS). This cardiovascular (CV) preventive effect was greater in patients with TET2 mutations associated with clonal hematopoiesis (CH). The current proteogenomic analysis aimed to understand the clinical response to canakinumab and underlying proteomic profiles in the context of CH and anemia. The analysis included 4595 patients from the CANTOS study who received either canakinumab or placebo and evaluated multiplexed proteomics (4785 proteins) using SomaScan and targeted deep sequencing for CH mutations. Incident anemia was more common in the presence of CH mutations but reduced by canakinumab treatment. Canakinumab treatment was significantly associated with higher hemoglobin increment in patients with concurrent CH mutations and anemia than patients with CH mutations without anemia or without CH mutations. Compared with those without CH mutations, the presence of CH mutations was associated with proteomic signatures of inflammation and defense response to infection, as well as markers of high-risk CV disease which was further enhanced by the presence of anemia. Canakinumab suppressed hepcidin, proinflammatory cytokines, myeloid activation, and complement pathways, and reversed pathologically deregulated pathways to a greater extent in patients with CH mutations and anemia. These molecular findings provide evidence of the clinical use of IL-1β blockade and support further study of canakinumab for patients with concurrent anemia and CH mutations. This study was registered at www.clinicaltrials.gov as #NCT01327846.

A molecular staging model for accurately dating the endometrial biopsy

Natural variability in menstrual cycle length, coupled with rapid changes in endometrial gene expression, makes it difficult to accurately define and compare different stages of the endometrial cycle. Here we develop and validate a method for precisely determining endometrial cycle stage based on global gene expression. Our 'molecular staging model' reveals significant and remarkably synchronised daily changes in expression for over 3400 endometrial genes throughout the cycle, with the most dramatic changes occurring during the secretory phase. Our study significantly extends existing data on the endometrial transcriptome, and for the first time enables identification of differentially expressed endometrial genes with increasing age and different ethnicities. It also allows reinterpretation of all endometrial RNA-seq and array data that has been published to date. Our molecular staging model will significantly advance understanding of endometrial-related disorders that affect nearly all women at some stage of their lives, such as heavy menstrual bleeding, endometriosis, adenomyosis, and recurrent implantation failure.

Clinical characteristics of heart failure with reduced ejection fraction patients with rare pathogenic variants in dilated cardiomyopathy-associated genes: A subgroup analysis of the PARADIGM-HF trial

AIMS

To evaluate the prevalence of pathogenic variants in genes associated with dilated cardiomyopathy (DCM) in a clinical trial population with heart failure and reduced ejection fraction (HFrEF) and describe the baseline characteristics by variant carrier status.

METHODS AND RESULTS

This was a post hoc analysis of the Phase 3 PARADIGM-HF trial. Forty-four genes, divided into three tiers, based on definitive, moderate or limited evidence of association with DCM, were assessed for rare predicted loss-of-function (pLoF) variants, which were prioritized using ClinVar annotations, measures of gene transcriptional output and evolutionary constraint, and pLoF confidence predictions. Prevalence was reported for pLoF variant carriers based on DCM-associated gene tiers. Clinical features were compared between carriers and non-carriers. Of the 1412 HFrEF participants with whole-exome sequence data, 68 (4.8%) had at least one pLoF variant in the 8 tier-1 genes (definitive/strong association with DCM), with Titin being most commonly affected. The prevalence increased to 7.5% when considering all 44 genes. Among patients with idiopathic aetiology, 10.0% (23/229) had tier-1 variants only and 12.6% (29/229) had tier-1, -2 or -3 variants. Compared to non-carriers, tier-1 carriers were younger (4 years; adjusted p-value [padj ] = 4 × 10-3 ), leaner (27.8 kg/m2 vs. 29.4 kg/m2 ; padj  = 3.2 × 10-3 ), had lower ejection fraction (27.3% vs. 29.8%; padj  = 5.8 × 10-3 ), and less likely to have ischaemic aetiology (37.3% vs. 67.4%; padj  = 4 × 10-4 ).

CONCLUSION

Deleterious pLoF variants in genes with definitive/strong association with DCM were identified in ∼5% of HFrEF patients from a PARADIGM-HF trial subset, who were younger, had lower ejection fraction and were less likely to have had an ischaemic aetiology.

Superficial peritoneal endometriotic lesions are histologically diverse and rarely demonstrate menstrual cycle synchronicity with matched eutopic endometrium

STUDY QUESTION

Do menstrual cycle-dependent changes occur in the histological appearance of superficial peritoneal endometriotic lesions, and are they equivalent to those observed in the eutopic endometrium?

SUMMARY ANSWER

Only a small subset of superficial peritoneal endometriotic lesions exhibits some histological features in phase with menstrual cycle-related changes observed in eutopic endometrium.

WHAT IS KNOWN ALREADY

Endometriotic lesions are frequently described as implants that follow menstrual cycle-related changes in morphology, as per the eutopic endometrium. This concept has been widely accepted despite the lack of conclusive published evidence.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study of 42 patients, from across the menstrual cycle, with surgically and histologically confirmed endometriosis. Patients were a subset selected from a larger endometriosis study being conducted at the Royal Women's Hospital, Melbourne since 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Histological features of epithelium, stroma and gland morphology were examined in haematoxylin and eosin stained sections of superficial peritoneal endometriotic lesions and matched eutopic endometrium (menstrual: n = 4, proliferative: n = 11, secretory: n = 17, hormone-treated: n = 10). At least two biopsies (average = 4, range = 2-8 biopsies) and a matched endometrial sample were analysed for each patient and results were presented per endometriotic gland profile (n = 1051). Data were analysed using mixed effects logistic regression to account for multiple patients and multiple endometriotic biopsies, each with multiple endometriotic gland profiles. This model also enabled analysis of endometriotic lesions versus eutopic endometrium.

MAIN RESULTS AND THE ROLE OF CHANCE

There was considerable inter- and intra-patient variability in the morphology of superficial peritoneal endometriotic lesions. Menstrual cycle-associated changes were only observed for some features in a subset of endometriotic gland profiles. The proportion of endometriotic gland profiles with epithelial mitoses significantly increased in the proliferative phase (18% of gland profiles) relative to the menstrual phase (0% of endometriotic gland profiles) (odds ratios (OR) 9.30; 95% confidence intervals (CI) = 3.71-23.32; P < 0.001). Fewer blood-filled gland lumens were observed in the secretory phase (45% of endometriotic gland profiles) compared to the menstrual phase (67% of endometriotic gland profiles) (OR, 0.30; 95% CI = 0.11-0.79; P = 0.015). The features of the eutopic endometrium analysed in this study did not reflect the results in matched endometriotic lesions (P > 0.05).

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

This study focused on features observed in sections of superficial peritoneal lesions and these may differ from features of deep infiltrating endometriosis or ovarian endometriomas. Cycle phases were limited to menstrual, proliferative and secretory phases to allow appropriate statistical modelling.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights heterogeneity in the histological characteristics of superficial peritoneal lesions. It challenges the assumption that lesion morphology consistently reflects menstrual cycle-associated changes.

STUDY FUNDING/COMPETING INTEREST(S)

Research reported in this publication was supported in part by National Health and Medical Research Council (NHMRC) project grants GNT1012245, GNT1105321 and GNT1026033 (P.A.W.R., J.E.G. and S.J.H.-C.). There are no competing interests.

Generation of immortalized human endometrial stromal cell lines with different endometriosis risk genotypes

Endometriotic lesions are composed in part of endometrial-like stromal cells, however, there is a shortage of immortalized human endometrial stromal cultures available for research. As genetic factors play a role in endometriosis risk, it is important that genotype is also incorporated into analysis of pathological mechanisms. Human telomerase reverse transcriptase (hTERT) immortalization (using Lenti-hTERT-green fluorescent protein virus) took place following genotype selection; 13 patients homozygous for either the risk or non-risk 'other' allele for one or more important endometriosis risk single nucleotide polymorphism on chromosome 1p36.12 (rs3820282, rs56318008, rs55938609, rs12037376, rs7521902 or rs12061255). Short tandem repeat DNA profiling validated that donor tissue matched that of the immortalized cell lines and confirmed that cultures were genetically novel. Expression of morphological markers (vimentin and cytokeratin) and key genes of interest (telomerase, estrogen and progesterone receptors and LINC00339) were examined and functional assays for cell proliferation, steroid hormone and inflammatory responses were performed for 7/13 cultures. All endometrial stromal cell lines maintained their fibroblast-like morphology (vimentin-positive) and homozygous endometriosis-risk genotype following introduction of hTERT. Furthermore, the new stromal cultures demonstrated positive and diverse responses to hormones (proliferation and decidualisation changes) and inflammation (dose-dependent response), while maintaining hormone receptor expression. In conclusion, we successfully developed a range of human endometrial stromal cell lines that carry important endometriosis-risk alleles. The wider implications of this approach go beyond advancing endometriosis research; these cell lines will be valuable tools for multiple endometrial pathologies offering a level of genetic and phenotypic diversity not previously available.

Male ageing is negatively associated with the chance of live birth in IVF/ICSI cycles for idiopathic infertility

STUDY QUESTION

Is male age associated with the clinical outcomes of IVF/ICSI cycles for idiopathic infertility after adjustment for female age?

SUMMARY ANSWER

Male ageing is negatively associated with clinical IVF/ICSI outcomes in couples with idiopathic infertility independent of female age.

WHAT IS KNOWN ALREADY

The effect of male age on the outcomes of infertility treatments is controversial and poorly explored. In contrast, fertility is known to decline significantly with female age beyond the mid-30s, and reduced oocyte quality plays an important role. The negative effect of male age on sperm quality is largely associated with an increasing susceptibility to sperm DNA damage. Although increasing maternal age has been linked with poorer oocyte quality, studies on the effect of male age have disregarded the need to control for female age making it difficult to define clearly the role of male age in infertile couples.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study analysed 2425 cycles of couples with idiopathic infertility selected from a total of 24 411 IVF/ICSI cycles performed at Monash IVF in Australia between 1992 and 2017. The primary outcome was live birth and secondary outcomes were clinical pregnancy and miscarriage.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Couples with primary/secondary infertility who underwent IVF/ICSI cycles with male partners classified as normozoospermic were selected (inclusion criteria). Couples in which the female partner had endometriosis, tubal factors, polycystic ovarian syndrome, ovarian hyperstimulation syndrome, poor responders (≤3 mature oocytes retrieved) and couples with more than 15 cumulus oocyte complexes retrieved or who used cryopreserved gametes were excluded. Binary logistic multilevel modelling was used to identify the effect of male age and female age on clinical outcomes after controlling for confounding factors. Male age and female age were examined as continuous and categorical (male age: &lt;40, 40–44, 45–49, 50–54, ≥55; female age:&lt;30, 30–34, 35–39, ≥40) predictors.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a negative effect of male age and female age on live birth as odds ratios (OR) with 95% CI for each additional year of age (OR-male age: 0.96 [0.94–0.98]; OR-female age: 0.90 [0.88–0.93] P &lt; 0.001). Potential interactions with male age such as type of treatment (IVF/ICSI), embryo transfer day (Day 3/Day 5) and female age did not have significant associations with outcomes (P &gt; 0.05). Secondary outcomes showed a significant reduction in the odds of clinical pregnancy (OR-male age: 0.97 [0.96–0.99]; OR-female age: 0.92 [0.89–0.94] P &lt; 0.001) and an increase in the odds of miscarriage with older age: male age (OR: 1.05 [1.01–1.08]; P = 0.002); female age (OR: 1.11 [1.05–1.18]; P &lt; 0.001). Worse outcomes were associated with more cycles (clinical pregnancy-OR: 0.96 [0.93–0.99] P = 0.03; live birth-OR: 0.96 [0.92–0.99] P = 0.023) while more inseminated oocytes were associated with better outcomes (clinical pregnancy-OR: 1.06 [1.03–1.06] P &lt; 0.001; live birth-OR: 1.07 [1.04–1.11] P &lt; 0.001). Analyses for age categories showed a gradual worsening of clinical outcomes with increasing male age, with a significantly worse live birth and clinical pregnancy outcomes in males aged older than 50 years compared to males younger than 40 years (P &lt; 0.05).

LIMITATIONS, REASONS FOR CAUTION

This study is limited to the information on confounding factors included. The study may also be limited in its generalizability to a wider population due the strict selection criteria. Age as a category could potentially result in residual confounding due to categorizing a continuous variable.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides information for counselling of couples with idiopathic infertility.

STUDY FUNDING/COMPETING INTEREST(S)

Funded by the Education Program in Reproduction and Development, Department of Obstetrics and Gynaecology, Monash University. None of the authors has any conflict of interest to report.

TRIAL REGISTRATION NUMBER

N/A.

Physician Perceptions and Beliefs about Generating and Providing a Clinical Summary of the Office Visit

BACKGROUND

A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS.

OBJECTIVES

Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers.

METHODS

A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program.

RESULTS

Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001).

CONCLUSIONS

Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.

Physician beliefs about the impact of meaningful use of the EHR: a cross-sectional study

BACKGROUND

As adoption and use of electronic health records (EHRs) grows in the United States, there is a growing need in the field of applied clinical informatics to evaluate physician perceptions and beliefs about the impact of EHRs. The meaningful use of EHR incentive program provides a suitable context to examine physician beliefs about the impact of EHRs.

OBJECTIVE

Contribute to the sparse literature on physician beliefs about the impact of EHRs in areas such as quality of care, effectiveness of care, and delivery of care.

METHODS

A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who were preparing to qualify for the meaningful use of EHR incentive program.

RESULTS

Of the 1,797 physicians at both AMCs who were preparing to qualify for the incentive program, 967 completed the survey for an overall response rate of 54%. Only 23% and 27% of physicians agreed or strongly agreed that meaningful use of the EHR will help them improve the care they personally deliver and improve quality of care respectively. Physician specialty was significantly associated with beliefs; e.g., 35% of primary care physicians agreed or strongly agreed that meaningful use will improve quality of care compared to 26% of medical specialists and 21% of surgical specialists (p=0.009). Satisfaction with outpatient EHR was also significantly related to all belief items.

CONCLUSIONS

Only about a quarter of physicians in our study responded positively that meaningful use of the EHR will improve quality of care and the care they personally provide. These findings are similar to and extend findings from qualitative studies about negative perceptions that physicians hold about the impact of EHRs. Factors outside of the regulatory context, such as physician beliefs, need to be considered in the implementation of the meaningful use of the EHR incentive program.

Histology of lichen sclerosus varies according to site and proximity to carcinoma

To investigate why vulvar but not extragenital lichen sclerosus is associated with squamous cell carcinoma, we performed a histologic study of extragenital lichen sclerosus, vulvar lichen sclerosus without carcinoma, and vulvar lichen sclerosus with carcinoma adjacent to and distant from the carcinoma. We compared epidermal thickness, rete ridge length, mitotic activity, atypia, dermal collagen change, dermal inflammation, and presence of other dermatoses in 30 women in each group. Extragenital lichen sclerosus showed thinner epidermis (mean thickness of 0.13 mm versus 0.41 mm; P < 0.0005), shorter rete ridges (P = 0.0001), more dermal edema (P = 0.16), and absence of associated dermatoses of spongiotic dermatitis and lichen planus (P < 0.005) compared with vulvar lichen sclerosus. The epidermal thickening seen in vulvar lichen sclerosus was indistinguishable from lichen simplex chronicus. Vulvar lichen sclerosus without carcinoma was generally similar to that distant from carcinoma. Vulvar lichen sclerosus adjacent to carcinoma showed increased epidermal thickness (0.61 mm versus 0.26 mm; P < 0.005), more dermal fibrosis (P < 0.0005), more inflammation (P < 0.0005), and more simplex (differentiated) vulvar intraepithelial neoplasia (18 cases versus 1 case; P < 0.0005) compared with that distant from carcinoma. We concluded that (1) the classic histologic features of lichen sclerosus are seen in both vulvar and extragenital sites; (2) vulvar lichen sclerosus without associated carcinoma has a mean epidermal thickness more than three times that of extragenital lichen sclerosus; (3) the epidermal thickening is histologically indistinguishable from lichen simplex chronicus; (4) there is a tendency for vulvar lichen sclerosus to have a more sclerotic and inflamed dermis; (5) lichen sclerosus 10 mm from cancer is more similar to vulvar lichen sclerosus without carcinoma than lichen sclerosus 1 mm from carcinoma; and (6) lichen sclerosus adjacent to carcinoma tends to show exaggerated epidermis thickness, basal atypia, and loss of the edematous-hyaline layer.

Inhibition of human immunodeficiency virus type 1 transcription by chemical cyclin-dependent kinase inhibitors

Cyclin-dependent kinases (cdk's) have recently been suggested to regulate human immunodeficiency virus type 1 (HIV-1) transcription. Previously, we have shown that expression of one cdk inhibitor, p21/Waf1, is abrogated in HIV-1 latently infected cells. Based on this result, we investigated the transcription of HIV-1 in the presence of chemical drugs that specifically inhibited cdk activity and functionally mimicked p21/Waf1 activity. HIV-1 production in virally integrated lymphocytic and monocytic cell lines, such as ACH(2), 8E5, and U1, as well as activated peripheral blood mononuclear cells infected with syncytium-inducing (SI) or non-syncytium-inducing (NSI) HIV-1 strains, were all inhibited by Roscovitine, a purine derivative that reversibly competes for the ATP binding site present in cdk's. The decrease in viral progeny in the HIV-1-infected cells was correlated with a decrease in the transcription of HIV-1 RNAs in cells treated with Roscovitine and not with the non-cdk general cell cycle inhibitors, such as hydroxyurea (G(1)/S blocker) or nocodazole (M-phase blocker). Cyclin A- and E-associated histone H1 kinases, as well as cdk 7 and 9 activities, were all inhibited in the presence of Roscovitine. The 50% inhibitory concentration of Roscovitine on cdk's 9 and 7 was determined to be approximately 0.6 microM. Roscovitine could selectively sensitize HIV-1-infected cells to apoptosis at concentrations that did not impede the growth and proliferation of uninfected cells. Apoptosis induced by Roscovitine was found in both latent and activated infected cells, as evident by Annexin V staining and the cleavage of the PARP protein by caspase-3. More importantly, contrary to many apoptosis-inducing agents, where the apoptosis of HIV-1-infected cells accompanies production and release of infectious HIV-1 viral particles, Roscovitine treatment selectively killed HIV-1-infected cells without virion release. Collectively, our data suggest that cdk's are required for efficient HIV-1 transcription and, therefore, we propose specific cdk inhibitors as potential antiviral agents in the treatment of AIDS.

Ten-year review of hysterectomy morbidity and mortality: can we change direction?

The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Student's t-test, p = 0.02) and 40% (Student's t-test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.

Classification of ovarian endometriotic cysts

Current literature describes 3 different pathogenetic types of ovarian endometriotic cysts. Cortical invagination cysts arise when surface ovarian endometriotic deposits adhere to another structure (such as the broad ligament), blocking the egress of menstrual fluid produced by cycling endometriosis, which then collects and causes the ovarian cortex to invaginate. Surface inclusion cyst-related endometriotic cysts develop when endometriotic tissue colonizes preexisting inclusion cysts. Physiological cyst-related endometriotic cysts occur when endometriosis gains access to a follicle, such as at the time of ovulation. To determine whether routine histological examination is of use in the classification of endometriotic cysts, and if so, whether such classification is of clinical relevance, we reviewed the histology of endometriotic cysts of 29 women under 35 years of age. Young women were chosen so that ovarian cortex surrounding the endometriotic lining in invagination cysts could be identified by the finding of oocytes. Ten women (34%) had cortical invagination endometriotic cysts, but no inclusion or physiological cyst-related endometriomas were found. The remaining 19 women (66%) had unclassified endometriotic cysts, of which 14 (48% of total) had a fibrous wall between the endometriotic lining and medulla and 5 had extensive destruction of ovarian tissue. We concluded that cortical invagination cysts were the only common diagnosable sort of the 3 types currently being investigated and that unclassified cysts required further study to determine their pathogenesis. Our study highlights the need for a prospective study using standardized pathological and clinical methods.

Population-based study of hospital trauma care in a rural state without a formal trauma system

OBJECTIVE

Formalized systems of trauma care are believed to improve outcomes in an urban setting, but little is known of the applicability in a rural setting.

METHODS

We conducted a population-based analysis of hospital survival after trauma comparing an American College of Surgeons-verified Level I trauma center (TC) with the pooled results of 13 small community hospitals (CH) in a rural state with no formal trauma system. All patients admitted to any hospital within the state of Vermont over a 5-year period (1995-1999) with a trauma discharge diagnosis were included. Elderly patients with isolated femur fractures were excluded from the database. International Classification of Diseases Injury Severity Scores (ICISSs) were calculated for each patient and used to control for injury severity in an omnibus logistic regression model that included age, ICISS, and hospital type (TC vs. CH) as predictors of survival. Patients who died were characterized on the basis of ICISS into "expected" (ICISS < 0.25), "indeterminate" (ICISS = 0.26-0.50), and "unexpected" (ICISS > 0.5).

RESULTS

In 16,354 trauma admissions over the 5-year period in the rural state of Vermont, 370 (2.2%) died. There were 5,964 (36%) admitted to TC. Patients admitted to TC were more injured (ICISS 0.94 vs. 0.96) and had a higher mortality (3.1% vs. 1.8). Overall, care at the CH provided an improved survival (odds ratio = 1.75, 95% confidence internal = 1.31-2.18, p = 0.000). However, in the more severely injured cohort of trauma patients (expected and indeterminate; n = 133), overall survival was higher in the TC (16% CH vs. 38% TC, p = 0.02, chi2). Because the TC was known to provide care equivalent to Major Trauma Outcome Study norms during this time period (Z = -0.03, M = 0.894), we believe this study confirms that trauma care throughout the state is in accordance with national norms.

CONCLUSION

In a rural state, without a statewide formal trauma system, survival after trauma is no worse at CH than TC when corrected for injury severity and age. Future expenditures of resources might better be concentrated in other areas such as discovery or prehospital care to further improve outcomes.

Patient beliefs about the characteristics, causes, and care of the common cold: an update

BACKGROUND

Many people seek medical care for cold symptoms. The cold-related knowledge and beliefs of adults seeking medical care for themselves or their children may not correspond with current medical opinion.

METHODS

A total of 249 parents of symptomatic children and 257 symptomatic adults who sought medical advice in the spring of 1997 from 1 of 3 primary care clinics in the Minneapolis-St. Paul, Minnesota, area were surveyed by telephone 48 to 96 hours after contact with the medical system.

RESULTS

Of the adults seeking care for a child or themselves, 44% believed viruses alone cause the common cold: an additional 42% believed both viruses and bacteria play a role. Most thought rest (97%) and nonprescription medications (63%) were helpful for colds, which was consistent with published reports. Contrary to medical reports, however, most felt vitamin C (67%) and the inhalation of steam (70%) reduced cold symptoms, and 44% believed antibiotics help colds (chi2=19.57; P=.0002). But 85% believed colds could resolve on their own.

CONCLUSIONS

Those adults seeking medical care for uncomplicated colds are misinformed about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. Care providers should address these perceptions rather than enabling overuse of antibiotics.

Development of a digestive health status instrument: tests of scaling assumptions, structure and reliability in a primary care population

BACKGROUND

The absence of valid and reliable health status measures for functional gastrointestinal illness has limited research and patient care for this common group of disorders. A self-report survey has been developed.

METHODS

Initial development focused on extensive pre-testing of patients, primary care physicians and gastroenterologists. The disease-specific portion included the Rome criteria for dyspepsia subgroups and the Manning and Rome criteria for irritable bowel syndrome. The Short Form-36 was added. Psychometric analyses included techniques of multitrait scaling, scale internal consistency and criterion validation.

RESULTS

Six hundred and ninety patients presenting to their primary care physician for treatment of heartburn, abdominal pain or discomfort completed the 98 question survey. The disease-specific portion revealed five components including reflux, dysmotility, a two-domain bowel dysfunction complex, and a pain index. Internal consistency measures demonstrated good to excellent reliability. Scaling successes were observed on multitrait scaling. The disease-specific portion was reduced to 34 questions. Criterion validity was demonstrated with the correlation of the disease-specific questions to the SF-36.

CONCLUSIONS

The psychometric analyses lend credence to the concept of stomach and bowel symptom subgrouping as proposed by expert consensus. The psychometric properties of the five summated disease-specific scales compare favourably with standardized health status measures.

Factors associated with pain following operative laparoscopy: a prospective observational study

An open prospective observational study was performed, aiming to measure symptom severity following operative gynaecological laparoscopy and explore any associated factors. Women having concomitant procedures were excluded. Each woman had standardized analgesia, completed a symptom diary for 7 days postoperation, and had a standardized form completed by the surgeon detailing the operation. Back pain, nausea and vaginal pain were found to not be of clinical significance. Cutting major vessels, ligaments, vagina or ovary had major impacts on postoperative symptoms. In the presence of a standardized analgesic regimen, symptoms did not resolve for at least 5 days.

A 6-year review of the outcome of endometrial ablation

In June, 1995 a postal questionnaire was distributed to all 232 women who had an endometrial ablation at Monash Medical Centre between July, 1989 and December, 1994. Data was analyzed from the 149 who responded. Length of follow-up ranged from 6 months to 6 years 6 months. Of these 78% were satisfied with their ablation and 84% found their menses to be lighter or to have stopped. The repeat ablation rate was 13% and the hysterectomy rate was 17%.

Introducing external cephalic version at 36 weeks or more in a district general hospital: a review and an audit

OBJECTIVE

To audit the effect of introducing external cephalic version at > or = 36 weeks on breech delivery rates and modes, and to assess factors that affect external cephalic version success rates.

DESIGN

A prospective unblinded study over 12 months of factors affecting external cephalic version success. A retrospective review of breech deliveries for 12 months before introducing external cephalic version and the first 12 months of practising external cephalic versions.

SETTING

Royal United Hospital, Bath.

POPULATION

One hundred and three women (> or = 36 weeks) with breech presentation booked for external cephalic version, and 324 women with a singleton breech presentation at delivery between November 1992 and October 1994.

METHODS

External cephalic version attempted on 89 women. Tocolysis was used on 41 of these women.

MAIN OUTCOME MEASURES

External cephalic version success rate. Breech presentation rates (suitable for external cephalic version) at delivery. Delivery mode rates for breeches.

RESULTS

External cephalic version was successful in 39% of women. The breech presentation rate (external cephalic version suitable) at delivery fell from 2.7% to 2.4% of all deliveries. The vaginal breech delivery rate fell from 0.98% to 0.51%. The caesarean section rate was 63% for breeches (external cephalic version suitable) before external cephalic version introduction, and 47% among women who had an attempted external cephalic version.

CONCLUSIONS

Attempted external cephalic version reduces the woman's risk of vaginal breech delivery and caesarean section. It provides individual women with a third management option and the possibility of avoiding a vaginal breech delivery or a caesarean section. To avoid one caesarean section takes 5.9 attempted external cephalic versions. This approach is expensive in operator time. Operator, placental site, position of fetal back and amniotic fluid index had a significant effect on the success of external cephalic version.

Postoperative symptoms following LLETZ or radical cervical diathermy with fulgaration: a randomized double-blinded prospective study

Fifty-five patients were randomized in a double-blinded manner to large loop excision of the transformation zone (LLETZ) (29 patients) or radical cervical diathermy with fulgaration (RCDF) (26 patients) for treatment of cervical intraepithelial neoplasia (CIN). Patients completed a 2-month diary of symptoms and completed a 10-week postoperative questionnaire. White vaginal discharge lasted 7.3 (4.6) days (SD) for RCDF compared to 3.4 (1.6) days (SD) for LLETZ. There was no significant difference in any other symptoms on analysis This appears to be the first report clearly assessing the length and severity of postoperative symptoms following LLETZ or RCDF. There is no reason on length and severity of postoperative symptoms to choose 1 of these 2 treatment methods over the other.

Healing of the bronchus in pulmonary transplantation

OBJECTIVE

To review the results of bronchial healing in a consecutive series of 100 isolated pulmonary transplants, performed at one centre between 1987 and 1994.

METHODS

A retrospective review of 123 assessable bronchi (61 in single lung and 62 in bilateral lung) transplants was carried out. All anastomoses were assessed by bronchoscopy at 7-10 days, and follow up was from one to seven years. The effect on bronchial dehiscence or stenosis requiring endobronchial stent, of suture technique, pre and post operative steroid administration, bronchial wrap, donor ischaemic time and time to first rejection episode was assessed.

RESULTS

Complications of airways healing occurred in four patients: stenosis in two and dehiscence in two (1.6% of bronchi at risk in both groups). Airway complication was not affected by steroids, pre-operative diagnosis, presence of a wrap (34 with pericardium or omentum, 89 with peribronchial tissue alone) or any other variable. There was a higher incidence of dehiscence (2/36) with continuous rather then interrupted (0/87) suture, but this was not statistically significant. There was one airway-related death. Two patients who required anastomotic stenting remain alive and well.

CONCLUSIONS

A very low complication rate can be achieved without recourse to bronchial wrapping, telescoping anastomoses or steroid avoidance. Combined heart-lung transplantation or bronchial revascularisation are not required to achieve reliable bronchial healing.

Genetic and phenotypic trends in Polish large white nucleus swine herds

Performance test records collected from 1978 to 1987 from on-farm tests of young Polish Large White boars from 94 herds and reproductive records of Polish Large White sows from 81 nucleus farms were used to estimate the phenotypic, environmental, and genetic trends. There were, after editing, 114,347 boar performance records and 41,080 litter records on sows. Both data sets were analyzed by use of an animal model. Estimated annual phenotypic and environmental trends were relatively large and desirable and were, respectively, .17 +/- .05, .11 +/- .05 (number born alive); .16 +/- .04, .10 +/- .04 (21-d litter size); 1.86 +/- .63, 1.43 +/- .62 (21-d litter weight, kg); 6.80 +/- .60, 6.76 +/- .72 (average daily gain, g/d); -.065 +/- .007, -.058 +/- .023 (backfat thickness, mm); -2.76 +/- .28, -2.75 +/- .29 (days to 110 kg). In contrast, all estimated genetic trends were relatively small and not always favorable. The genetic trends estimated from animal, sire and dam genetic values were, respectively, .01 +/- .01, .02 +/- .01, .01 +/- .01 (number born alive and 21-d litter size); .04 +/- .06, .10 +/- .05, .05 +/- .04 (21-d litter weight, kg); .04 +/- .04, .50 +/- .10, -.43 +/- .05 (average daily gain, g/d), -.009 +/- .001, -.015 +/- .002, -.004 +/- .0004 (backfat thickness, mm); and -.01 +/- .01, -.17 +/- .04, .19 +/- .02 (days to 110 kg). Neither examination of selection practices nor boar utilization provided an explanation for the lack of genetic progress.

Population parameter estimates for performance and reproductive traits in Polish Large White nucleus herds

Performance test records from on-farm tests of young Polish Large White boars and reproductive records of Polish Large White sows from 94 nucleus farms during 1978 to 1987 were used to estimate population parameters for the measured traits. The number of boar performance records after editing was 114,347 from 3,932 sires, 21,543 dams, 44,493 litters and 1,075 herd-year-seasons. Reproductive performance records of sows involved 41,080 litters from 2,348 sires, 18,683 dams and 1,520 herd-year-seasons. Both data sets were analyzed by using restricted maximum-likelihood programs. The model used for the performance records included fixed herd-year-seasons, random sires, dams and error effects, and covariances for the year of birth of sire and year of birth of dam. The model used for the reproduction data set was the same as the performance data with parity as an additional fixed effect. Estimated heritabilities were .27, .29, .26, .07, .06, .06 for average daily gain standardized to 180 d (ADG), backfat thickness standardized to 110 kg BW (BF), days to 110 kg (DAYS), litter size at birth born alive (NBA), litter size at 21 d (N21) and litter weight at 21 d (W21), respectively. Estimated common environmental effects for the same traits were .09, .10, .09, .06, .07 and .08, respectively. Genetic correlations were .25 (ADG and BF), -.99 (ADG and DAYS), -.21 (BF and DAYS), .91 (NBA and N21), .68 (NBA and W21) and .80 (N21 and W21). The respective phenotypic correlations were .23, -.99, -.20, .88, .75, .86. These population parameters for Polish Large White pigs are similar to those for breeds in other countries.

Effects of clorazepate, diazepam, lorazepam, and placebo on human memory

Healthy adults (N = 10) were given oral doses of lorazepam (1 and 2 mg), diazepam (5 and 10 mg), clorazepate (7.5 and 15 mg), or placebo and tested 30, 60, 90, and 120 minutes later on a word-recall memory task. All subjects received each drug dose once and placebo twice in randomized order at weekly intervals. Testing was double-blind. Lorazepam was found to have a significantly greater effect on memory than placebo. Diazepam and clorazepate did not differ significantly from placebo in their effect on word recall. High doses of lorazepam produced more pronounced memory effects than did low doses; neither diazepam nor clorazepate was found to exert a dose-related effect on memory.