Health-related quality of life and productivity impact in haemophilia patients with inhibitors

To measure health-related quality of life (HRQL), its determinants, and its association with patient and caregiver productivity among a sample of haemophilia patients with inhibitors in the United States (US). Data on demographical and clinical characteristics, treatment patterns, HRQL (SF-12v2), and productivity outcomes were reported for 53 patients. Mean SF-12v2 domain and mental (MCS) and physical (PCS) component summary scores were assessed and compared with US norms. Regression analyses explored the association of patient and treatment factors with HRQL and productivity. Patients' mean age was 20.7 years (SD = 18.8), 88.5% were type A, and 39.6% received on-demand therapy as their only mode of treatment. Mean PCS was significantly lower than the US norm (PCS, 39.9, P < 0.01) and mean MCS showed no significant difference (MCS, 49.9, P = ns). On-demand treatment (B = -0.336, P < 0.05) and number of haemorrhages (B = -0.366, P < 0.05) were negatively associated with PCS; and PCS was associated with patients' missed work or school days [incidence rate ratio (IRR) = 0.93, P < 0.001] and perceived impact on daily activities (OR = 0.72, P < 0.05). Younger age (IRR = 0.91, P < 0.01), lower PCS (IRR = 0.94, P < 0.01), more haemorrhages (IRR = 1.05, P < 0.05), and surgery (IRR = 2.74, P < 0.05) were associated with fewer patients' productive days. Physical functioning among inhibitor patients in the US is compromised and is negatively associated with their daily activities and productivity. These data suggest a positive association of prophylactic and immunotolerance therapy with HRQL, specifically physical impairment.

Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina

BACKGROUND AND PURPOSE

Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina.

METHODS

Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis.

RESULTS

The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 +/- 20.3 and 3.6 +/- 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD +/-14,336) for ICH and $3888 (SD +/-4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1-388.4) and $239.9m for IS (range 119.9-479.7).

CONCLUSION

The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.

Timely confirmation of gastro-esophageal reflux disease via pH monitoring: estimating budget impact on managed care organizations

BACKGROUND

Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States.

METHODS

A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypothetical MCO with 10 000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitoring were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules.

RESULTS

An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236,363 from $238,086, while increases were observed in pH monitoring (from $16 739 to $21 973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs.

CONCLUSIONS

Timely and increased use of pH monitoring as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.

Physicians' preferences towards coagulation factor concentrates in the treatment of Haemophilia with inhibitors: a discrete choice experiment

This study sought to identify attributes of treatment important to haematologists in making their decisions regarding optimal care for inhibitor patients in the United States. A conjoint analysis using a discrete choice experiment was conducted to elicit factors that are most important to haematologists. Twelve product attributes were chosen based on published literature and expert opinion: risk of human viral infections, possibility that the titre of the inhibitor may rise, reduction in the likelihood of dose-related thromboembolic events, the number of infusions required to stop haemorrhage, infusion preparation time, infusion time, infusion volume, time required to stop bleeding, time required to alleviate pain, prophylaxis use, ability to undergo major surgery and cost of medications. Thirty haematologists completed the questionnaires via face-to-face interviews at a scientific meeting in April 2006. Data were analysed using a multinomial logit model to obtain the relative importance of each attribute. Responding haematologists had considerable experience in treating haemophilia patients with inhibitors (average : 13 +/- 9 years). 'Time required to stop bleeding' was the most important factor affecting treatment decisions [relative importance (RI) = 16.3%]. Physicians also preferred treatments that resulted in quick pain relief [RI = 12.9%], reduced the possibility that the titre of inhibitor may rise [RI = 12.8%], required fewer number of infusions to stop a haemorrhage [RI = 12.7%] and reduced the risk of human viral infection [RI = 10.8%]. This study revealed that certain clinical outcomes attributes are the most preferred and important. These findings can assist decision makers in their assessments of optimal first-line care.

Expressed transcripts associated with high rates of egg production in chicken ovarian follicles

The purpose of this study was to characterize differentially expressed transcripts associated with varying rates of egg production in Taiwan country chickens. Ovarian follicles were isolated from two strains of chicken which showed low (B) or high (L2) rates of egg production, then processed for RNA extraction and cDNA library construction. Three thousand and eight forty clones were randomly selected from the cDNA library and amplified by PCR, then used in microarray analysis. Differentially expressed transcripts (P<0.05, log(2)> or = 1.75) were sequenced, and aligned using GenBank. This analysis revealed 20 non-redundant sequences which corresponded to known transcripts. Eight transcripts were expressed at a higher level in ovarian tissue prepared from chicken strain B, and 12 transcripts were expressed at a higher level in L2 birds. These differential patterns of expression were confirmed by semi-quantitative RT-PCR. We show that transcripts of cyclin B2 (cycB2), ferritin heavy polypeptide 1 (FTH1), Gag-Pol polyprotein, thymosin beta4 (TB4) and elongation factor 1 alpha1 (EEF1A1) were enriched in B strain ovarian follicles. In contrast, thioredoxin (TXN), acetyl-CoA dehydrogenase long chain (ACADL), inhibitor of growth family member 4 (ING4) and annexin II (ANXA2) were expressed in at higher levels in the L2 strain. We suggest that our approach may lead to the isolation of effective molecular markers that can be used in selection programs in Taiwan country chickens.

Validity of the 3 min step test in moderate altitude: environmental temperature as a confounder

The 3 min step test is a widely used method to evaluate physical fitness, but whether this method is valid when performed at altitude is unknown. The purpose of this study was to examine the effect of altitude on the fitness score of the 3 min step test, and the role of ambient temperature in this effect. In study I, 11 healthy volunteers (aged 18.1 ± 1.1 years) performed a 3 min step test at sea level and at altitude (1950 m). Plasma lactate and stress hormones, as indicators of metabolic stress, were measured before and after the test. To determine the role of ambient temperature, we performed study II at sea level with the same step test simulating the altitude temperature condition (24 °C at high altitude versus 32 °C at sea level) with 23 subjects (aged 20.4 ± 0.4 y). In study I, plasma lactate of the subjects was elevated during the step test at sea level and to a greater extent at high altitude. Plasma cortisol and testosterone levels were elevated only at high altitude. However, the heart rate (HR) recovery after the step test was faster at high altitude than at sea level, producing a better physical fitness index. Furthermore, in study II, we demonstrated that the subjects who performed the 3 min step test at 24 °C exhibited faster HR recovery than at 32 °C. The current study therefore suggests that environmental conditions leading to temperature variation have strong confounding effects on the fitness score of the 3 min step test.

A possible link between exercise-training adaptation and dehydroepiandrosterone sulfate- an oldest-old female study

The purpose of this study was to determine the association between the level of salivary dehydroepiandrosterone sulfate (DHEA-S) and the magnitude of adaptation to exercise training in insulin sensitivity for aged females. A group of 16 females, aged 80-93 years old, was divided into 2 groups according to their baseline DHEA-S levels: Lower Halves (N = 8) and Upper Halves (N = 8), and participated in a 4-month exercise intervention trial. Insulin response with an oral glucose tolerance test (OGTT), cholesterol, blood pressure (BP), motor performance, and DHEA-S were determined at baseline and 4 months after the training program. Glucose tolerance and body mass index (BMI) remained unchanged with training for both groups. Insulin, fasted cholesterol, diastolic blood pressure, reaction time, and locomotive function were significantly lowered by training only in the Upper Halves group. Changes in the area under curve of insulin (IAUC) were negatively correlated with the baseline DHEA-S level (R= - 0.60, P < 0.05). The current study provides the first evidence that oldest-old subjects with low DHEA-S level appear to be poor responders to exercise-training adaptations.

The Role of Dehydroepiandrosterone Levels on Physiologic Acclimatization to Chronic Mountaineering Activity

Previous studies have reported that glucose tolerance can be improved by short-term altitude living and activity. However, not all literature agrees that insulin sensitivity is increased at altitude. The present study investigated the effect of a 25-day mountaineering activity on glucose tolerance and its relation to serum levels of dehydroepiandrosterone-sulfate (DHEA-S) and tumor necrosis factor-alpha (TNF-alpha) in 12 male subjects. On day 3 at altitude, we found that serum DHEAS was reduced in the subjects with initially greater DHEA-S value, whereas the subjects with initially lower DHEA-S remained unchanged. To further elucidate the role of DHEA-S in acclimatization to mountaineering activity, all subjects were then divided into lower and upper halves according to their sea-level DHEA-S concentrations: low DHEA-S (n = 6) and high DHEA-S groups (n = 6). Glucose tolerance, insulin level, and the normal physiologic responses to altitude exposure, including hematocrit, hemoglobin, erythropoietin (EPO), and cortisol were measured. We found that glucose and insulin concentrations on an oral glucose tolerance test were significantly lowered by the mountaineering activity only in the high DHEA-S group. Similarly, hematocrit and hemoglobin concentration in altitude were increased only in the high DHEA-S group. In contrast, the low DHEA-S subjects exhibited an EPO value at sea level and altitude greater than the high DHEA-S group, suggesting an EPO resistance. The findings of the study imply that DHEA-S is essential for physiologic acclimatization to mountaineering challenge.

Association of serum protein levels with egg productivity in Taiwan red-feathered country chickens

This study investigated the relationship between serum protein levels and egg productivity in Taiwan red-feathered country chickens (TRFCC). The total egg numbers of TRFCC (n=157) were recorded from 25 to 48 weeks of age. Serum samples were collected at 24 and 35 weeks of age, then classified by total egg number into four groups according to mean+/-1S.D. Serum X protein levels were evaluated by protein chip technology and with an insulin-like growth factor-I (IGF-I) immunoassay. Other serum proteins (apolipoprotein A-I, ovotransferrin and vitellogenin) were found at different levels between the most productive and the least productive groups of TRFCC, were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and were quantified by age. The results showed that levels of vitellogenin were positively correlated with total egg number at 24 and at 35 weeks old (p<0.01). Levels of apolipoprotein A-I and an IGF-1-related marker (termed X protein) in serum at 35 weeks old were correlated with total egg number (p<0.01). Serum ovotransferrin levels remained constant regardless of total egg number. To investigate the concentration differences among the four groups of TRFCC, serum protein levels of each group were analyzed by one-way ANOVA. The results showed that those protein levels, except for ovotransferrin, in the least productive group significantly differed from the other three groups (p<0.05). Although the correlation between those protein levels and the total egg number was not significant at the time of initial egg production, the selection strategy of those protein levels at later stages of egg production should provide a screening model to improve selection.

Heat shock protein 72 overexpression protects against hyperthermia, circulatory shock, and cerebral ischemia during heatstroke

This study extends our earlier studies in rats by applying our heatstroke model to a new species. Additionally, transgenic mice are used to examine the role of heat shock protein (HSP) 72 in experimental heatstroke. Transgenic mice that were heterozygous for a porcine HSP70i gene ([+]HSP72), transgene-negative littermate controls ([−]HSP72), and normal Institute of Cancer Research strain mice (ICR) under pentobarbital sodium anesthesia were subjected to heat stress (40°C) to induce heatstroke. In [−]HSP72 or ICR, the values for mean arterial pressure, the striatal blood flow, and the striatal Po2after the onset of heatstroke were significantly lower than those in preheat controls. The core and brain temperatures, the extracellular concentrations of ischemic and injury markers in the striatum, and the striatal neuronal damage scores were significantly greater than those in the preheat controls. In [−]HSP72 or ICR, the body temperatures, cell ischemia content, and injury marker in the striatum were significantly higher, and the mean arterial pressure, striatal blood flow, and striatal Po2concentration were significantly lower during heatstroke than in [+]HSP72. Accordingly, the latency and the survival times for [+]HSP72 significantly exceeded those of [−]HSP72 or ICR. These results demonstrate that the overexpression of HSP72 in multiple organs improves survival during heatstroke by reducing hyperthermia, circulatory shock, and cerebral ischemia and damage in mice.

Exercise training exacerbates tourniquet ischemia-induced decreases in GLUT4 expression and muscle atrophy in rats

The current study determined the interactive effects of ischemia and exercise training on glycogen storage and GLUT4 expression in skeletal muscle. For the first experiment, an acute 1-h tourniquet ischemia was applied to one hindlimb of both the 1-week exercise-trained and untrained rats. The contralateral hindlimb served as control. For the second experiment, 1-h ischemia was applied daily for 1 week to both trained (5 h post-exercise) and untrained rats. GLUT4 mRNA was not affected by acute ischemia, but exercise training lowered GLUT4 mRNA in the acute ischemic muscle. GLUT4 protein levels were elevated by exercise training, but not in the acute ischemic muscle. Exercise training elevated muscle glycogen above untrained levels, but this increase was reversed by chronic ischemia. GLUT4 mRNA and protein levels were dramatically reduced by chronic ischemia, regardless of whether the animals were exercise-trained or not. Chronic ischemia significantly reduced plantaris muscle mass, with a greater decrease found in the exercise-trained rats. In conclusion, the exercise training effect on muscle GLUT4 protein expression was prevented by acute ischemia. Furthermore, chronic ischemia-induced muscle atrophy was exacerbated by exercise training. This result implicates that exercise training could be detrimental to skeletal muscle with severely impaired microcirculation.

Volatilisation of diacetylmorphine: in vitro simulation of 'chasing the dragon'

In preparation for a trial on co-prescription of heroin to chronic treatment-resistant addicts, a pharmaceutical dosage form for smokable heroin was developed. During development of this product (a mixture of diacetylmorphine and caffeine), in vitro experiments were performed simulating 'chasing the dragon': the technique used by addicts for inhalation of heroin after volatilisation. Samples were heated on aluminium foil using a heating device and the vapours were collected and analysed using a HPLC-UV method. The recovery of diacetylmorphine and caffeine in vapours was studied after volatilisation of different powder mixtures at temperatures between 200 and 350 degrees C. Furthermore, the volatilisation set-up was combined with an Andersen sampler to determine the sizes of aerosol particles. Only small differences in recovery of diacetylmorphine and caffeine were found between temperatures and between powder mixtures: 46-62% of diacetylmorphine from the sample was recovered in vapour and 65-83% of caffeine. The only degradation product detected in vapour was 6-acetylmorphine (4.1-7.1%). In the temperature range studied, temperature mainly influenced the volatilisation rate. Mass median aerodynamic diameters of aerosols from diacetylmorphine-containing samples ranged from 1.8-4.1 microm; 45-60% of each sample was recovered as aerosol particles <5 microm. Volatilising pharmaceutical smokable heroin resulted in sufficient amounts of diacetylmorphine in vapour and in particles suitable for effective deposition in the lungs.

Acute pancreatitis following antilymphocyte globulin therapy in a renal transplant recipient

Acute pancreatitis is a rare complication following OKT3 therapy, which to our knowledge has never been reported in patients treated with antilymphocyte globulin (ALG). We herein report a case of a kidney transplantation patient who developed acute pancreatitis 2 days after treatment with ALG for grade IIb acute rejection. The symptoms subsided after discontinuing this drug. Resumption of ALG therapy triggered another episode of acute pancreatitis. Therefore, the clinical course strongly suggests that ALG was the etiological factor of acute pancreatitis in this particular patient.

Stellate transformation of invasive trophoblast: a distinct phenotype of trophoblast that is involved in decidual vascular remodelling and controlled invasion during pregnancy

BACKGROUND

Successful implantation relies on the tightly regulated invasion of extravillous trophoblasts (EVTs). However, little is known about their phenotypic differentiation and relevant motile behaviour. Furthermore, the cell-cell interactions between EVTs and decidual arterioles during physiological transformation are also poorly understood.

METHODS

A total of 128 decidual specimens from early and late gestations containing components of EVTs and spiral arterioles were investigated using immunohistochemistry and periodic acid-Schiff reaction.

RESULTS

Unipolar, tadpole-like EVTs are observed throughout the interstitial area, with a tendency to decrease along the invasive pathway. The stellate differentiation of the EVTs is identified around and inside decidual arterioles or in the third-trimester myometrium. Furthermore, stellate transformation of EVTs precedes its interactions with the decidual arteriole. These specialized stellate trophoblasts invade and infiltrate the tunica media, accompanying lacuna formation inside the vessel wall and perturbation of actin fibre alignment of the tunica media.

CONCLUSION

Stellate transformation of trophoblasts may explain controlled invasion of EVTs and probably plays a key role in initiating cell-cell interaction in decidual vascular remodelling.

Germ-plasm specification and germline development in the parthenogenetic pea aphid Acyrthosiphon pisum: Vasa and Nanos as markers

The germarium, oocytes and embryos of the parthenogenetic viviparous pea aphid Acyrthosiphon pisum are contained within a single ovariole. This species provides an excellent model for studying how maternally-inherited germ plasm is specified and how it is transferred to primordial germ cells. Previous studies have shown that germ cells are first segregated at the embryonic posterior after formation of the blastoderm. We used two cross-reacting antibodies against the conserved germline markers Vasa and Nanos, which specifically identified these presumptive germ cells, to investigate whether germ cells were determined during early development. We observed randomly-distributed weak expression of Vasa signals in the developing oocyte but no localization in the oocyte segregated from the germarium. Localized Vasa was not apparent until it was detected at the posterior in the embryo undergoing the second nuclear division. Nanos, on the other hand, was localized to a nuage-like structure surrounding the nucleus in the developing and segregated oocytes. At the beginning of the oocyte maturation division, Nanos localization shifted to the posterior and could be identified in successive stages until it was incorporated into the germ cells. Taken together, our results suggest that germ plasm is specified in the developing oocyte and that Nanos is an earlier germline marker than Vasa. Germ cells stained for Vasa remained at a dorsal location in the egg during mid-development and then were guided into abdominal segments A1 to A6 during germ-band retraction. We infer that germ cells coalesce with segmented gonadal mesoderm during this period.

Gene duplication, gene loss and evolution of expression domains in the vertebrate nuclear receptor NR5A (Ftz-F1) family

Fushi tarazu factor 1 (Ftz-F1, NR5A) is a zinc-finger transcription factor that belongs to the nuclear receptor superfamily and regulates genes that are involved in sterol and steroid metabolism in gonads, adrenals, liver and other tissues. To understand the evolutionary origins and developmental genetic relationships of the Ftz-F1 genes, we have cloned four homologous Ftz-f1 genes in zebrafish, called ff1a, ff1b, ff1c and ff1d. These four genes have different temporal and spatial expression patterns during development, indicating that they have distinct mechanisms of genetic regulation. Among them, the ff1a expression pattern is similar to mammalian Nr5a2, while the ff1b pattern is similar to that of mammalian Nr5a1. Genetic mapping experiments show that these four ff1 genes are located on chromosome segments conserved between the zebrafish and human genomes, indicating a common ancestral origin. Phylogenetic and conserved synteny analysis show that ff1a is the orthologue of NR5A2, and that ff1b and ff1d genes are co-orthologues of NR5A1 that arose by a gene-duplication event, probably a whole-genome duplication, in the ray-fin lineage, and each gene is located next to an NR6A1 co-orthologue as in humans, showing that the tandem duplication occurred before the divergence of human and zebrafish lineages. ff1c does not have a mammalian counterpart. Thus we have characterized the phylogenetic relationships, expression patterns and chromosomal locations of these Ftz-F1 genes, and have demonstrated their identities as NR5A genes in relation to the orthologous genes in other species.