Reduced postprandial serum paraoxonase activity after a meal rich in used cooking fat

Paraoxonase is an enzyme associated with HDL in human serum that hydrolyzes oxidized phospholipids and inhibits LDL oxidation, which is an important step in atherogenesis. In animals, addition of oxidized lipids to the circulation reduces paraoxonase activity, and diets rich in oxidized fat accelerate the development of atherosclerosis. The current randomized, crossover study was designed to compare the effect of a meal rich in oxidized lipids in the form of fat that had been used for deep-frying in a fast food restaurant and a control meal rich in the corresponding unused fat on postprandial serum paraoxonase (arylesterase) activity and peroxide content of LDL and its susceptibility to copper ion catalyzed oxidation in 12 healthy men. Four hours into the postprandial period, serum paraoxonase activity had decreased significantly after the used fat meal (-17%, P=0.005) and had increased significantly after the meal rich in unused fat (14%, P=0. 005). These changes were significantly (P=0.003) different. A time-course study indicated that serum paraoxonase activity remained lower than baseline for up to 8 hours after the used fat meal. Serum apoA1 concentration tended to decrease after the unused fat meal and tended to increase after the used fat meal. These changes were different at a marginal level of significance (P=0.07). Also, a significantly (P=0.03) greater decrease in apoA1 content of postprandial HDL was recorded after the unused fat meal. The peroxide content of LDL tended to decrease after the used fat meal and tended to increase after the control meal. These changes were significantly (P=0.04) different. Susceptibility of isolated LDL to copper ion oxidation and plasma levels of malondialdehyde were unchanged during the study. These data suggest that in the postprandial period after a meal rich in used cooking fat, the enzymatic protection of LDL against accumulation of peroxides and atherogenic oxidative modification may be reduced, possibly due to factors associated with apoA1, without acutely affecting the intrinsic resistance of LDL to in vitro oxidation.

The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology

AIMS

The Mirena coil is a levonorgestrel releasing intrauterine device that is in widespread use. This study aims to document the endometrial morphology associated with this device.

METHODS

Endometrial specimens from 75 women with the Mirena coil were reviewed and the histological features detailed.

RESULTS

Morphological features found in most of the endometria were decidualisation of stroma (72 of 75 cases), atrophy of endometrial glands (65 of 75 cases), a surface papillary pattern (38 of 75 cases), and a stromal inflammatory cell infiltrate (59 of 75 cases). Additional common histological features were the presence of foci of stromal myxoid change (29 of 75 cases) and stromal haemosiderin pigment (24 of 75 cases). Reactive atypia of surface glands, glandular metaplastic changes, stromal necrosis, and stromal calcifications were found in small numbers of cases.

CONCLUSION

The endometrial features are characteristic and relatively constant and are in keeping with the effects of both a progestogenic compound and a mechanical device. Pathologists should be aware of these histological features because the Mirena coil is in widespread use.

The analysis of censored treatment cost data in economic evaluation

This article investigates the way in which the presence of censored cost data in clinical trials should dictate the inferential tests adopted when comparing treatment and nontreatment groups for the purpose of economic evaluation. The authors argue that the techniques of survival analysis are appropriate where censoring is present, and that bias will be imparted if cruder methods are used to analyze cost data, even if that data is drawn from a relevant population. The first section of the article discusses the problem of censoring and survival analysis, while the second examines three methods of dealing with censored cost data and possible biases resulting from them. The third section presents results from actual trial data using the three methods described in the preceding section. Conclusions are presented in section four, where it is argued that these methodological issues are likely to become more important as economists are called upon to evaluate the treatment of chronic conditions using data from clinical trials with finite end points.

Hypoxia-selective 3-alkyl 1,2,4-benzotriazine 1,4-dioxides: the influence of hydrogen bond donors on extravascular transport and antitumor activity

Tirapazamine (TPZ) and related 1,2,4-benzotriazine 1,4 dioxides (BTOs) are selectively toxic under hypoxia, but their ability to kill hypoxic cells in tumors is generally limited by their poor extravascular transport. Here we show that removing hydrogen bond donors by replacing the 3-NH2 group of TPZ with simple alkyl groups increased their tissue diffusion coefficients as measured in multicellular layer cultures. This advantage was largely retained using solubilizing 3-alkylaminoalkyl substituents provided these were sufficiently lipophilic at pH 7.4. The high reduction potentials of such compounds resulted in rates of metabolism too high for optimal penetration into hypoxic tissue, but electron-donating 6- and 7-substituents moderated metabolism. Pharmacokinetic/pharmacodynamic model-guided screening was used to select BTOs with optimal extravascular transport and hypoxic cytotoxicity properties for evaluation against HT29 human tumor xenografts in combination with radiation. This identified four novel 3-alkyl BTOs providing greater clonogenic killing of hypoxic cells than TPZ at equivalent host toxicity, with the 6-morpholinopropyloxy-BTO 22 being 3-fold more active.

Frailty status predicts futility of cardiopulmonary resuscitation in older adults

AIM

To determine if frailty is associated with poor outcome following in-hospital cardiac arrest; to find if there is a "frailty threshold" beyond which cardiopulmonary resuscitation (CPR) becomes futile.

METHODS

Retrospective review of patients aged over 60 years who received CPR between May 2017 and December 2018, in a tertiary referral hospital, which does not provide primary coronary revascularisation. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index were retrospectively assigned.

RESULTS

Data for 90 patients were analysed, the median age was 77 (IQR 70-83); 71% were male; 44% were frail (CFS > 4). Frailty was predictive of in-hospital mortality independent of age, comorbidity and cardiac arrest rhythm (OR 2.789 95% CI 1.145-6.795). No frail patients (CFS > 4) survived to hospital discharge, regardless of cardiac arrest rhythm, whilst 13 (26%) of the non-frail (CFS ≤ 4) patients survived to hospital discharge. Of the 13 survivors (Age 72; range 61-86), 12 were alive at 1 year and had a good neurological outcome, the outcome for the remaining patient was unknown.

CONCLUSION

Frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest, these results may facilitate clinical decision making regarding whether CPR may be considered futile. The Clinical Frailty Scale is a simple bedside assessment that can provide invaluable information when considering treatment escalation plans, as it becomes more widespread, larger scale observations using prospective assessments of frailty may become feasible.

Oxyphilic Adenomatoid Tumor of the Ovary

We describe an unusual example of ovarian adenomatoid tumor that was an incidental finding in the ovary of a 52-year-old woman and was characterized by cells with abundant eosinophilic cytoplasm, an occasional feature of the adenomatoid tumor but one that, in an ovarian example, may cause added diagnostic confusion to that already engendered by the rarity of this neoplasm in the ovary. The typical numerous small vacuoles of the neoplasm sometimes had the appearance of signet ring cells. These 2 features (oxyphil and signet ring cells) caused a broad differential. Tumor cells were positive with broad-spectrum cytokeratins as well as mesothelial markers CK5/6, WT1, and calretinin. In reporting this case, we focus on the differential diagnosis of ovarian neoplasms and tumorlike conditions with vacuoles and related spaces, a topic that embraces many diverse entities.

Erratic hatching in Aedes eggs: a new interpretation

Erratic hatching of eggs in Aedes aegypti (and other aedine mosquitoes) has long been something of an enigma, although the temporal scatter it provides, when coupled with drought resistance, is advantageous to species utilizing small, temporary breeding places. It is well known that eggs of Aedes hatch when the amount of dissolved oxygen ( p o 2 ) in the surrounding water is lowered, as when the medium becomes contamina­ted with bacteria. But erratic hatching in small instalments may occur in the absence of any obvious stimulus. We have re-examined this problem, postulating that the eggs themselves harbour microbial colonies and that these, by lowering the ( p o 2 ) in the microenvironment of each egg, quantitatively influence hatching. When laid the eggs are sterile, but each acquires surface colonies of bacteria, which they pick up from the environment. By rearing each egg in isolation we have shown that the number of bacteria acquired in a given time differs markedly from egg to egg and, as predicted, those with the highest counts hatch first. Under natural conditions, with eggs of different ages massed together, the first larvae to hatch browse over the surfaces of the remaining eggs, presumably consuming the bacteria and thus lowering the likelihood of further hatching. Thus, in this simple fashion, and not, it seems, by means of some hypothetical pheromone (as previously suggested), the first eggs to hatch influence the prospects of the other eggs, ensuring that a proportion of them remain unhatched, thus serving as a reserve for the future.

Results of a questionnaire regarding criteria for adequacy of endometrial biopsies

AIMS

Pathologists are faced with increasing numbers of endometrial biopsies containing scant tissue. Anecdotal evidence points to significant variation among pathologists regarding criteria used to assess adequacy, and no standard recommendations exist. An initial audit showing variation in endometrial biopsy adequacy reporting prompted this assessment of the criteria used by specialist gynaecological pathologists for the classification of adequacy.

METHODS

A questionnaire regarding criteria used for endometrial biopsy assessment adequacy was sent to members of the British Association of Gynaecological Pathologists and the National Gynaecological Pathology External Quality Assessment Scheme (UK). One hundred and thirty questionnaires were distributed and 61 pathologists responded.

RESULTS

The responses showed great variation in criteria used to classify endometrial biopsies as adequate. Most respondents felt it would be useful if criteria were proposed to aid this assessment.

CONCLUSIONS

Wide variation exists among specialist gynaecological pathologists regarding what constitutes an adequate endometrial biopsy. The gynaecologist should interpret the biopsy report in the light of clinical, radiological, and hysteroscopic features. The presence of scanty tissue in postmenopausal women with a thin endometrium and no focal lesion is expected, and is not a reason for repeat biopsy. Pathologists should exercise caution before classifying endometrial biopsies as inadequate, because this may have medicolegal and management implications.

Impact of insurance type on eligibility for advanced heart failure therapies and survival

BACKGROUND

Medicaid insurance in Georgia provides limited reimbursement for heart transplant (HT) and left ventricular assist devices (LVAD). We examined whether insurance type affects eligibility for and survival after receipt of HT or LVAD.

METHODS AND RESULTS

We retrospectively identified patients evaluated for HT/LVAD from 2012 to 2016. We used multivariable logistic and Cox proportional hazards regression to examine the association of insurance type on treatment eligibility and 1-year survival. Of 569 patients evaluated, 282 (49.6%) had private, 222 (39.0%) had Medicare, and 65 (11.4%) had Medicaid insurance. Patients with Medicaid were younger, more likely to be Black, with fewer medical comorbidities. In adjusted models, Medicare and Medicaid insurance predicted lower odds of eligibility for HT, but did not affect survival after HT. Among those ineligible for HT, Medicaid patients were less likely to receive destination therapy (DT) LVAD (adj OR 0.08, 95% CI 0.01-0.66; P = .02) and had increased risk of death (adj HR = 2.03, 95% CI 1.13-3.63; P = .01).

CONCLUSIONS

Despite younger age and fewer comorbidities, patients with Medicaid insurance are less likely to receive DT LVAD and have an increased risk of death once deemed ineligible for HT. Medicaid patients in Georgia need improved access to DT LVAD.

Relactation in mothers of children over 12 months

Six Australian children aged 12-48 months whose mothers relactated through suckling alone are described. During the period between the initial weaning and relactation the mothers had not attempted to maintain lactation; nor had the children been breastfed by any other person, yet they were able to 'milk' the breast. All mothers produced fluid from their breasts in response to suckling. In all but one case (Case 2) the initiative came from the child and there was no performance anxiety as the mothers' aims were other than milk production, for instance, to soothe the child after separation. All except one child continued to breastfeed for many months after relactation.

Environmental Drivers of Gulf Coast Tick (Acari: Ixodidae) Range Expansion in the United States

In the United States, the Gulf Coast tick (Amblyomma maculatum Koch) is a species of growing medical and veterinary significance, serving as the primary vector of the pathogenic bacterium, Rickettsia parkeri (Rickettsiales: Rickettsiaceae), in humans and the apicomplexan parasite, Hepatozoon americanum, in canines. Ongoing reports of A. maculatum from locations outside its historically reported distribution in the southeastern United States suggest the possibility of current and continuing range expansion. Using an ecological niche modeling approach, we combined new occurrence records with high-resolution climate and land cover data to investigate environmental drivers of the current distribution of A. maculatum in the United States. We found that environmental suitability for A. maculatum varied regionally and was primarily driven by climatic factors such as annual temperature variation and seasonality of precipitation. We also found that presence of A. maculatum was associated with open habitat with minimal canopy cover. Our model predicts large areas beyond the current distribution of A. maculatum to be environmentally suitable, suggesting the possibility of future northward and westward range expansion. These predictions of environmental suitability may be used to identify areas at potential risk for establishment and to guide future surveillance of A. maculatum in the United States.

Radioimmunoassay for melatonin

A radioimmunoassay for melatonin has been developed and used to measure the level of melatonin of male and post-menopausal female patinets coming to operation for benign and malignant conditions. The amount of melatonin in the serum of the females was considerably lower than that in males. No difference could be found between patients suffering from benign and malignant conditions. A patient with a non-parenchymatous pineal tumour had considerably lower levels in the serum at three months after surgery and radiotherapy. A further month later melatonin could not be found in samples of serum taken over a 24-hour period.

Medial opening wedge high tibial osteotomy: more than ten years of experience with Puddu plate technique supports its indication

PURPOSE

To describe the short-term and long-term results of patients who underwent a medial opening wedge high tibial osteotomy (MOW-HTO) for unicompartmental medial knee joint osteoarthritis.

METHODS

A retrospective review was conducted of patients with MOW-HTO using a Puddu plate®, with more than ten year follow-up. The degree of correction, initial chondral damage, number of meniscal lesions, preoperative and 1-year postoperative functional scale scores (IKDC and Lysholm), and arthroplasty conversion rates at the ten year follow-up were registered. We assumed early indication when patients underwent the operation before they were 40 years old and delayed ≥ 40. Functional outcomes were analyzed by adjusting for pre-operative values. Fisher's exact test was used to study the association between the arthroplasty conversion rates and the timing of indication.

RESULTS

Fifty-five patients were included, 37 of whom were male (67%). Twenty-nine patients had early indications for surgery (53%). All patients completed ten year follow-up. All patients improved IKDC (p < 0.01) and Lysholm (p < 0.01) scores compared to their presurgical scores at the one year post-operative evaluation. We had six minor complications, none requiring revision surgery. We had three conversions to arthroplasty, all in the late indication group, not statistically significant different. Linear regression showed that early indication was associated with a higher IKDC score when adjusting for the Outerbridge chondral damage score, the number of meniscal lesions, and sex (p < 0.01).

CONCLUSION

All patients improved functional scores one year after surgery. Early indication (i.e., younger than 40 years of age) was independently associated with better functional outcomes than late indication at one year follow-up.

Prescription Drug Spending and Medication Adherence Among Medicare Beneficiaries with Heart Failure

BACKGROUND

Evidence suggests that cost sharing adversely affects appropriate prescription drug use for chronic disorders. However, few studies have evaluated this effect in heart failure (HF), the most common cause of hospitalization in Medicare.

OBJECTIVE

To determine whether spending on HF pharmacotherapy by Medicare Part D enrollees was associated with prescription refill adherence.

METHODS

This correlational study used pooled data from the 2010-2012 Medicare Current Beneficiary Survey (MCBS). The analysis sample consisted of community-dwelling MCBS participants with self-reported HF and continuous Part D coverage during the year of participation. 3 drug classes were analyzed independently: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). 1,448 weighted participant-year records (derived from 964 individuals) met the inclusion criteria, of which 846 (58%) were included for beta-blockers, 633 (44%) for ACE inhibitors, and 229 (16%) for ARBs. Spending was measured by average out-of-pocket payment for the relevant prescription, standardized to a 30-day supply, as a percentage of average monthly income. Adherence was measured by the medication possession ratio (MPR): total days supplied for all but the last refill divided by number of days between the first and last fills of the year.

RESULTS

Accounting for sampling weights, the median (interquartile range) monthly income was $1,472 ($949-$2,466), and average percentage of monthly income spent on a 30-day medication supply was 0.22% for beta-blockers, 0.19% for ACE inhibitors, and 0.90% for ARBs. Mean MPR was 88.9% for beta-blockers, 88.5% for ACE inhibitors, and 90.4% for ARBs. Risk-adjusted models showed that percentage of income spent on a beta-blocker prescription was directly associated with odds of nonadherence (MPR < 80%), odds ratio = 1.38, 95% CI = 1.01-1.89, P = 0.045, and inversely associated with beta-blocker MPR, B = -4.17, SE = 1.23, P = 0.001. No such association was observed for ACE inhibitors or ARBs.

CONCLUSIONS

Price sensitivity was evident for beta-blockers but not for antiangiotensin drugs, despite very low out-of-pocket costs and high adherence. This study is relevant to value-based pricing of HF management drugs in Part D plans.

DISCLOSURES

No outside funding supported this study. Butler has served as a paid consultant or advisor on unrelated projects for Amgen, Array, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, G3, Innolife, Janssen, Medtronic, Merck, Novartis, Relypsa, Stealth Peptide, SC Pharma, Vifor, and ZS Pharma. The other authors have no potential conflicts of interest to declare. An early version of this paper was presented as a poster at Sigma Theta Tau International's 28th Nursing Research Congress; July 27-31, 2017; Dublin, Ireland.

Simulations Show Diagnostic Testing For Malaria In Young African Children Can Be Cost-Saving Or Cost-Effective

Malaria imposes a substantial global disease burden. It disproportionately affects sub-Saharan Africans, particularly young children. In an effort to improve disease management, the World Health Organization (WHO) recommended in 2010 that countries test children younger than age five who present with suspected malaria fever to confirm the diagnosis instead of treating them presumptively with antimalarial drugs. Costs and concerns about the overall health impact of such diagnostic testing for malaria in children remain barriers to full implementation. Using data from national Malaria Indicator Surveys, we estimated two-stage microsimulation models for Angola, Tanzania, and Uganda to assess the policy's cost-effectiveness. We found that diagnostic testing for malaria in children younger than five is cost-saving in Angola. In Tanzania and Uganda the cost per life-year gained is $5.54 and $94.28, respectively. The costs projected for Tanzania and Uganda are less than the WHO standard of $150 per life-year gained. Our results were robust under varying assumptions about cost, prevalence of malaria, and behavior, and they strongly suggest the pursuit of policies that facilitate full implementation of testing for malaria in children younger than five.

Prescription drug spending and hospital use among Medicare beneficiaries with heart failure

BACKGROUND

Heart failure (HF) is a common cause of hospitalization in Medicare. Optimal medication adherence lowers hospitalization risk in HF patients. Although out-of-pocket spending can adversely affect adherence to HF medications, it is unknown whether medication spending ultimately increases hospital use for Medicare beneficiaries with HF.

OBJECTIVE

To examine the association between out-of-pocket medication payments and HF-related hospital use among Medicare Part D subscribers.

METHODS

Retrospective analysis of the 2010-12 Medicare Current Beneficiary Survey. The sample comprised community-dwelling respondents with fee-for-service Medicare, continuous Part D coverage, and self-reported HF (n = 819 participant-year records). The effects of average out-of-pocket payment for a 30-day HF-related prescription on odds and frequency of hospitalization and total inpatient days attributable to HF were estimated. Design-adjusted models adjusted for sociodemographic and health status variables, survey year and censoring, and included a pre-specified interaction of out-of-pocket payment with Medicaid co-eligibility.

RESULTS

The interaction term was statistically significant in all the models. For beneficiaries without Medicaid, average out-of-pocket payment per prescription was not significantly associated with odds of HF-related hospitalization (odds ratio = 1.01, 95% CI = 0.98-1.05, P = .399). The association between out-of-pocket payment and hospitalization frequency was statistically significant (incidence rate ratio [IRR] = 1.02, 95% CI = 1.00-1.05, P = .048), as was the association between out-of-pocket payment and total inpatient days (IRR = 1.04, 95% CI = 1.00-1.08, P = .041). For Medicaid co-eligible beneficiaries, the validity of model estimates is limited, because the range of actual out-of-pocket payments was negligible.

CONCLUSIONS

Fee-for-service Medicare beneficiaries with Part D, self-reported HF, and no supplemental Medicaid tolerated out-of-pocket medication payments without elevated risk of HF-related hospital use, but medication spending modestly increased hospital use intensity. Therefore, Part D plans with higher out-of-pocket requirements for essential HF medications may warrant additional scrutiny.

Anaesthetic management and complications of transvascular patent ductus arteriosus occlusion in dogs

OBJECTIVE

To retrospectively analyse the anaesthetic management, complications and haemodynamic changes in a cohort of dogs undergoing transvascular patent ductus arteriosus (PDA) occlusion in a tertiary referral centre (from January 2017 to August 2018).

STUDY DESIGN

Retrospective study.

ANIMALS

A total of 49 client-owned dogs.

METHODS

Anaesthetic records of dogs with PDA that underwent transvascular occlusion of the ductus were reviewed. Anaesthetic complications evaluated included tachycardia [heart rate (HR) > 160 beats minute^-1], bradycardia (HR < 50 beats minute^-1), hypertension [systolic arterial pressure (SAP) > 150 mmHg], hypotension [mean arterial pressure (MAP) < 60 mmHg], hypothermia (<37 °C) and the presence of arrhythmias. Cardiovascular variables [HR and invasive SAP, MAP and diastolic arterial pressure (DAP)] at the time of occlusion device deployment (time 0) were compared with variables at 5 and 10 minutes after deployment. Descriptive statistics, Shapiro-Wilk test and repeated measures analysis of variance followed by a Dunnett's post hoc test were used to analyse the data (p < 0.05).

RESULTS

Crossbreed dogs were the most commonly represented followed by the Cavalier King Charles Spaniel. The median age was 8 (2-108) months, and female dogs were over-represented (65.3%). The most common American Society of Anesthesiologists score was III. Mean duration of anaesthesia was 96 ± 26 minutes and mean surgery time was 58 ± 21 minutes. Acepromazine with methadone was the most commonly used premedication combination (77.6%). Propofol was the most common induction agent (73.5%). General anaesthesia was maintained with isoflurane in oxygen in all dogs. Complications included hypotension (63%), hypothermia (34%), bradycardia (28%), arrhythmias (16%), hypertension (16%) and haemorrhage (2%). MAP and DAP increased significantly 10 minutes after device deployment compared with time 0.

CONCLUSIONS

and clinical relevance: Hypotension was the most common complication reported in dogs undergoing transvascular PDA occlusion. No major adverse events were documented.