Prophylactic use of a lidocaine constant rate infusion versus saline in dogs undergoing balloon valvuloplasty for management of pulmonic stenosis: A randomized control trial

OBJECTIVE

To evaluate the effect of a prophylactic lidocaine constant rate infusion (CRI) on the incidence and malignancy of catheter-induced ventricular ectopic complexes (VECs) during balloon valvuloplasty for management of pulmonic stenosis in dogs.

STUDY DESIGN

Single-centre, prospective, randomized study.

ANIMALS

Client-owned dogs (n = 70) with pulmonic stenosis.

METHODS

Dogs were randomly assigned to one of two anaesthetic protocols: administration of lidocaine 2 mg kg-1 bolus followed by a CRI (50 μg kg-1 minute-1; group LD) or a saline placebo (group SL) during balloon valvuloplasty. All dogs were premedicated with methadone (0.3 mg kg-1) intramuscularly and a digital three-lead Holter monitor was applied. Anaesthetic co-induction was performed with administration of alfaxalone (2 mg kg-1) and diazepam (0.4 mg kg-1), and anaesthesia was maintained with isoflurane vaporised in 100% oxygen. CRIs were started on positioning of the dog in theatre and discontinued as the last vascular catheter was removed from the heart. All dogs recovered well and were discharged 24 hours postoperatively. Blinded Holter analysis was performed by an external veterinary cardiologist using commercially available dedicated analysis software; p < 0.05.

RESULTS

Of the 70 dogs enrolled in the study, 61 were included in the final analysis: 31 in group LD and 30 in group SL. There was no significant difference between sinus beats (p = 0.227) or VECs (p = 0.519) between groups. In group LD, 19/31 (61.3%) dogs had a maximum ventricular rate ≥250 units and 20/30 (66.7%) dogs in group SL (p = 0.791).

CONCLUSION AND CLINICAL RELEVANCE

In this study, the use of a prophylactic lidocaine bolus followed by CRI in dogs undergoing balloon valvuloplasty for management of pulmonic stenosis did not significantly decrease the incidence nor the malignancy of VECs during right heart catheterization compared with a saline CRI.

A Cost-Effective Analysis of Motivational Interviewing with Palliative Care Versus Usual Care: Results from the Living Well Project

Little is known about the impact of early palliative care (EPC) combined with motivational interviewing (MI) for persons living with AIDS (PWA). We compared the cost and quality-adjusted life-years (QALYs) of EPC + MI (n = 61) versus usual care (UC) (n = 60) for patients with AIDS, not on antiretroviral medications, enrolled into the Living Well Project trial. Data on clinic, emergency department, and hospital visits were collected through self-report and billing records. Risk-adjusted average annual health care costs were estimated using a generalized linear model with a gamma log-link function. QALYs were calculated using the SF-12v2. Cost-effectiveness was defined as cost per QALY gained. Estimated intervention costs were $165 per participant. EPC + MI reduced costs by 33% (AOR = 0.67; CI 95%: 0.15, 0.93). QALYs did not differ between groups. Results suggest EPC + MI for PWA is cost-saving and maintains quality of life compared to UC due to reduced hospital and ED costs.

Identification of Actionable Targets for Breast Cancer Intervention Using a Diversity Outbred Mouse Model

HER2-targeted therapy has improved breast cancer survival, but treatment resistance and disease prevention remain major challenges. Genes that enable HER2/Neu oncogenesis are the next intervention targets. A bioinformatics discovery platform of HER2/Neu-expressing Diversity Outbred (DO) F1 Mice was established to identify cancer-enabling genes. Quantitative Trait Loci (QTL) associated with onset ages and growth rates of spontaneous mammary tumors were sought. Twenty-six genes in 3 QTL contain sequence variations unique to the genetic backgrounds that are linked to aggressive tumors and 21 genes are associated with human breast cancer survival. Concurrent identification of TSC22D3, a transcription factor, and its target gene LILRB4, a myeloid cell checkpoint receptor, suggests an immune axis for regulation, or intervention, of disease. We also investigated TIEG1 gene that impedes tumor immunity but suppresses tumor growth. Although not an actionable target, TIEG1 study revealed genetic regulation of tumor progression, forming the basis of the genetics-based discovery platform.

Carboxyl-terminal modulator protein (CTMP) deficiency mitigates denervation-induced skeletal muscle atrophy

Denervated skeletal muscles show decreased Akt activity and phosphorylation, resulting in atrophy. Akt inhibits downstream transcription of atrophy-associated ubiquitin ligases like muscle ring-finger protein 1 (MuRF-1). In addition, reduced Akt signaling contributes to aberrant protein synthesis in muscles. In ALS mice, we recently found that carboxyl-terminator modulator protein (CTMP) expression is increased and correlated with reduced Akt signaling in atrophic skeletal muscle. CTMP has also been implicated in promoting muscle degeneration and catabolism in an in vitro muscle atrophy model. The present study examined whether sciatic nerve injury (SNI) stimulated CTMP expression in denervated skeletal muscle during muscle atrophy. We hypothesized that CTMP deficiency would reduce neurogenic atrophy and reverse Akt signaling downregulation. Compared to the unaffected contralateral muscle, wild-type (WT) gastrocnemius muscle had a significant increase in CTMP (p < 0.05). Furthermore, denervated CTMP knockout (CTMP-KO) gastrocnemius weighed more than WT muscle (p < 0.05). Denervated CTMP-KO gastrocnemius also showed higher Akt and downstream glycogen synthase kinase 3β (GSK3β) phosphorylation compared to WT muscle (p < 0.05) as well as ribosomal proteins S6 and 4E-BP1 phosphorylation (p < 0.001 and p < 0.05, respectively). Moreover, CTMP-KO mice showed significantly lower levels of E3 ubiquitin ligase MuRF-1 and myostatin than WT muscle (p < 0.05). Our findings suggest that CTMP is essential to muscle atrophy after denervation and it may act by reducing Akt signaling, protein synthesis, and increasing myocellular catabolism.

Interest in and Uptake of Postabortion Long-Acting Reversible Contraception After Counseling at a Free-Standing Abortion Care Ambulatory Surgery Center, Atlanta, Georgia, 2017‒2018

We sought to determine the impact of brief previsit counseling on long-acting reversible contraception (LARC) interest and uptake immediately after abortion. We conducted a randomized controlled trial at a free-standing abortion care ambulatory surgery center in metro-Atlanta, Georgia (2017-2018). Among 1270 women, a brief previsit counseling intervention increased interest in LARC by 4.5 percentage points, and interest in LARC after the intervention increased uptake by 9.6 percentage points. Providing brief previsit counseling significantly increased postabortion LARC uptake. (Am J Public Health. 2022;112(9):1257-1260. https://doi.org/10.2105/AJPH.2022.306940).

Computed tomography diagnosis of a caval-azygos communication in a dog with cor triatriatum dexter

An 18-month-old Springer Spaniel was presented for investigation of ascites, exercise intolerance and suspected cor triatriatum dexter. Division of the right atrium into two separate chambers by an anomalous perforated membrane consistent with cor triatriatum dexter was confirmed during echocardiography. However, a routine agitated saline contrast (bubble) study yielded results that could not be explained by the congenital heart defect alone. Computed tomography angiography was performed and revealed a dilated ventral internal vertebral venous plexus and a short, dilated vessel in the midlumbar region redirecting blood flow away from the caudal vena cava and into the azygos vein. Balloon dilatation of the orifice within the cor triatriatum dexter membrane successfully reduced pressure within the caudal chamber of the right atrium and enhanced return via the caudal vena cava with subsequent resolution of clinical signs. This case report highlights the use of cross-sectional imaging in dogs with cor triatriatum dexter and unexpected contrast study results, as a means by which concurrent vascular anomalies may be identified.

Cost implications of patient spending on heart failure medications in the US Medicare program

Objectives

The aim of this study was to model the associations between patient spending on heart failure (HF) medications and Medicare and all-payer expenditures on health care services for participants in the Medicare prescription drug (Part D) program.

Methods

Correlational analysis of pooled 2011–12 data from the Medicare Current Beneficiary Survey. Analysis was restricted to community-dwelling beneficiaries with self-reported HF at baseline, continuous Part D coverage, and no Low-Income Subsidy (LIS). The main predictor was mean patient expenditure on a HF-related prescription per 30-day supply. The outcomes were all-payer and Medicare-specific payments for inpatient and total health care services during the observation year.

Key findings

Mean patient drug expenditure was not statistically associated with Medicare or all-payer inpatient payments or (after covariate adjustment) with total health care payments. However, patient expenditure was statistically associated with total Medicare payments, eγ = 1.022, 95% CI [1.004 to 1.041]. Marginal effects analysis predicted an average rise in total Medicare payments of $190.32, 95% CI [$40.54 to $341.10], for each additional $1 of patient spending per prescription, P = 0.013. Given an average 2.4 HF-indicated drug classes per participant and assuming 12.2 copays per year, a hypothetical $1 increase in prescription copay predicted a net loss to Medicare of $160.90 per participant.

Conclusion

Prescription drug spending by Medicare beneficiaries with HF was not associated with higher inpatient or all-payer costs. A modest association between patient drug spending and total Medicare costs was observed, but longitudinal and cost-effectiveness analyses are needed to support causal inference.

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.

The Cost and Public Health System Effects of Active Monitoring and Illness Response for Ebola Virus Disease: A Case Evaluation of Georgia

In August 2014, the World Health Organization declared the Ebola virus disease epidemic in West Africa a public health emergency of international concern. After 2 imported cases of the disease were identified in the United States in autumn 2014, the Centers for Disease Control and Prevention recommended that all jurisdictions begin active monitoring of travelers at risk of developing Ebola virus disease for 21 days from the last day of a potential exposure to minimize the risk of disease transmission. Here we describe the infrastructure development, monitoring processes, total planned expenditures, and effects on the public health system in Georgia associated with active monitoring and illness response of all travelers from Ebola-affected West African countries from October 2014 to March 2016. We conducted qualitative interviews with Georgia Department of Public Health (GDPH) staff. We identified state active monitoring and illness response infrastructure investments and monitoring activities and state and federal funds spent in both areas. And, we evaluated whether active monitoring and illness response enhanced Georgia's ability to respond to future infectious disease outbreaks. Developing the infrastructure to support the monitoring and response required investment in information technology, training of public health and medical personnel, increasing laboratory capacity, and securing personal protective equipment. Estimated total expenditures were $8.25 million, with 76% spent on infrastructure and 17% on daily monitoring. The GDPH leveraged internal resources and partnerships to implement active monitoring and illness response. Infrastructure investment increased surveillance capacity, strengthened relationships between the GDPH and medical providers, and led to the creation of infectious disease transport and hospital networks. Active monitoring and illness response increased outbreak preparedness, but it warrants comparison with other possible responses to determine its overall value.

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.

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.

95 Goals-Of-Care and Advance Care Planning Discussions with Hospitalised Frail Older People: What is the Evidence?

Introduction

National guidelines suggest that patients in the last year of life should be identified, their prognosis and future care options discussed, with advance care planning (ACP) recorded. Goals-of-care should be discussed with hospitalised patients at risk of deteriorating or with life-limiting conditions. The stated purpose of ACP and goals-of-care discussions is to increase goal-concordant care (i.e. patients receiving treatments they would wish to receive, and not receiving those they would not want). This literature review investigates the evidence-base for these policies and outcomes.

Review question

What is the evidence for goals-of-care and ACP discussions with hospitalised frail older people?

Methods

Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO, and Embase databases from January 1990 to September 2017. An updated search until May 2019 is currently underway.

Results

Of 8077 unique articles identified, 17 met inclusion criteria. There is no evidence that goals-of-care discussions lead to increased goal-concordant care; there is observational evidence that they increase the accuracy of documented preferences. Currently, rates of goals-of-care discussions are variable (38-72%), and there is poor concordance between patients’ actual and documented preferences, with agreement in only 31-33% of cases.

Present rates of ACP are very low (0-3%), with mixed evidence for benefits of ACP. One single-centre randomised controlled trial suggests ACP improves outcomes for patients who die within 6 months of discharge, including increased goal-concordant care and reduced family distress.

There is very limited evidence concerning patients’ and family members’ experiences of these discussions, their reasons for wishing (or not) to participate in discussions, or their perceptions of the important outcomes. Most (80%) patients would like to be involved in decisions about their care; 48% consider these conversations very important. The views and experiences of healthcare professionals have been little studied.

Conclusions

The asserted aim of goals-of-care and ACP discussions is to increase goal-concordant care; the extent to which this reflects patients’ priorities is unknown. In younger patient populations, while 40% of patients consider goal-concordant care the most important outcome, one third of patients consider family-related outcomes to be more important. Further research is needed to understand the perspectives of frail older patients, their families and clinicians, in order to make these discussions and subsequent care truly patient-centred.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Methylguazone, vindesine and cisplatin for the treatment of patients with relapsed or refractory malignant lymphoma: an Eastern Cooperative Oncology Group Study (PA482)

A new regimen not cross-resistant with standard regimens was developed for patients with relapsed or refractory Hodgkin's disease and non-Hodgkin's lymphoma. The regimen consisted of cisplatin, 70 mg/M2 given intravenously on day 1, vindesine, 3 mg/M2 given intravenously on days 1 and 8 (and also on day 15 of the first cycle only), and methylguazone, 600 mg/M2 given intravenously on days 8 and 15. Courses were repeated every 21 days. Thirty-nine patients (35 with non-Hodgkin's and 4 with Hodgkin's lymphoma) were treated and all were evaluable for response and toxicity. There were 5 complete and 14 partial responses for a total response rate of 49% (C.I. = 35%-63%). The median durations of partial and complete response were only 2.8 and 4.2 months, respectively. Only one patient remained in complete response for more than a year. There was one treatment-related death from renal failure on the study. Although this regimen was, in general. well tolerated the results are disappointing and seem no better than those obtained with many other salvage regimens for lymphoma.

Post-amplification primer extension of heat-denatured AmpliType PCR products: effects on typing results

Alleles of the HLA, DQA1, LDLR, GYPA, HGBB, D7S8 and GC loci, which are amplified using the AmpliType(R) PM PCR Reaction Mix and Primer Set, can be detected using sequence-specific oligonucleotide probes immobilized on a nylon membrane strip. Using reagents supplied in AmpliType PCR Amplification and Typing Kits, patterns of blue dots corresponding to particular alleles are visualized on the DNA probe strips. Frequently, the correct interpretation of typing results is dependent not only on the presence of probe signals but also on their relative intensities. The relative probe signal intensities obtained from an undegraded DNA sample extracted from a single individual will be different from those obtained from degraded DNA and from samples containing DNA from more than one source. Because probe signal intensity is an essential consideration for interpretation, factors that can influence it need to be identified. Clearly, the time and temperature of the assay steps and the salt concentration in the typing solutions can affect probe signal intensity. Also, if heat-denatured PCR products are allowed to cool for several minutes, the strands will reanneal and become unavailable for binding to the probes immobilized on the strips. However, the selective loss of GC B and HLA DQA1 4.1 probe signals observed after shorter cooling times cannot be explained by these factors. We demonstrate that following heat denaturation of PM PCR products there is sufficient residual Taq DNA polymerase activity to extend primers as the solution cools and that this primer extension occurs at a more rapid rate than PCR product reannealing. Primer extension across probe binding sites will prevent hybridization of the PCR product to complementary probes on the strip. The extent of signal reduction is dependent on the position of the probe binding site relative to the 3' ends of the primers and on the strand to which the probe is complementary. We recommend a simple modification to the AmpliType typing protocol to ensure all probe binding sites will be available for hybridization to PM and HLA DQA1 DNA probe strips.

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.

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.

Evaluation of a voluntary in-service on breastfeeding

Overall, the recent "Breastfeeding Update Course for Health Professionals" was well received and successful, with the strengths outweighing the mainly minor weaknesses. This is further supported by the fact that most participants put their names and addresses on the list for the next course. This proposed course already is in the planning stages.