Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study

BACKGROUND

In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.

METHODS

We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.

RESULTS

Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.

CONCLUSION

Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Nucleation and growth inhibition of biological minerals by cementum attachment protein-derived peptide (CAP-pi)

Biomineralization is a highly regulated process where proteins/peptides-crystal interactions contribute to the shaping, phasing and aggregation of minerals. We have identified and synthesized a cementum attachment protein-derived peptide (CAP-pi), which corresponds to amino acids 40-53 of the N-terminal CAP domain (MASSDEDGTNGGAS) and its phosphorylated variant (MASpSpDEDGTNGGASp) (CAP-pip). The peptide is composed of polar and negatively charged amino acids, which are disordered, according to in silico analysis. Our results show that CAP-pi inhibits hydroxyapatite (HA) formation and growth. However, it possesses low capacity to inhibit calcium oxalate crystal growth. CAP-pip showed a stronger inhibitory effect on the formation and growth of HA. As well as a high capacity to inhibit calcium oxalate monohydrate growth, mainly due to adsorption on specific growth faces. Small peptides have many advantages over the full-size protein, including low-cost production and modulation characteristics that allow for structural changes. Our findings suggest that CAP-pip-derived peptide could possess therapeutic potential to prevent or treat pathological calcifications such as renal stones and vascular calcification.

Carboxy-Terminal Cementum Protein 1-Derived Peptide 4 (cemp1-p4) Promotes Mineralization through wnt/β-catenin Signaling in Human Oral Mucosa Stem Cells

Human cementum protein 1 (CEMP1) is known to induce cementoblast and osteoblast differentiation and alkaline phosphatase (ALP) activity in human periodontal ligament-derived cells in vitro and promotes bone regeneration in vivo. CEMP1's secondary structure analysis shows that it has a random-coiled structure and is considered an Intrinsic Disordered Protein (IDP). CEMP1's short peptide sequences mimic the biological capabilities of CEMP1. However, the role and mechanisms of CEMP1's C-terminal-derived synthetic peptide (CEMP1-p4) in the canonical Wnt/β-catenin signaling pathway are yet to be described. Here we report that CEMP1-p4 promotes proliferation and differentiation of Human Oral Mucosa Stem Cells (HOMSCs) by activating the Wnt/β-catenin pathway. CEMP1-p4 stimulation upregulated the expression of β-catenin and glycogen synthase kinase 3 beta (GSK-3B) and activated the transcription factors TCF1/7 and Lymphoid Enhancer binding Factor 1 (LEF1) at the mRNA and protein levels. We found translocation of β-catenin to the nucleus in CEMP1-p4-treated cultures. The peptide also penetrates the cell membrane and aggregates around the cell nucleus. Analysis of CEMP1-p4 secondary structure revealed that it has a random-coiled structure. Its biological activities included the induction to nucleate hydroxyapatite crystals. In CEMP1-p4-treated HOMSCs, ALP activity and calcium deposits increased. Expression of Osterix (OSX), Runt-related transcription factor 2 (RUNX2), Integrin binding sialoproptein (IBSP) and osteocalcin (OCN) were upregulated. Altogether, these data show that CEMP1-p4 plays a direct role in the differentiation of HOMSCs to a "mineralizing-like" phenotype by activating the β-catenin signaling cascade.

Cementum protein 1-derived peptide (CEMP 1-p1) modulates hydroxyapatite crystal formation in vitro

A cementum protein 1-derived peptide (CEMP1-p1) consisting of 20 amino acids from the CEMP1's N-terminus region: MGTSSTDSQQAGHRRCSTSN, and its role on the mineralization process in a cell-free system, was characterized. CEMP1-p1's physicochemical properties, crystal formation, and hydroxyapatite (HA) nucleation assays were performed. Crystals induced by CEMP1-p1 were analyzed by scanning electron microscopy, Fourier-transform infrared spectroscopy-attenuated total reflectance (FTIR-ATR), X-ray diffraction (XRD), high resolution transmission electron microscopy (HRTEM), and atomic force microscopy. The results indicate that CEMP1-p1 lacks secondary structure, forms nanospheres that organize into three-dimensional structures, possesses affinity to HA, and induces its nucleation. CEMP1-p1 promotes the formation of spherical structures composed by densely packed prism-like crystals, which revealed a Ca/P ratio of 1.56, corresponding to HA. FTIR-ATR showed predominant spectrum peaks that correspond and are characteristic of HA and octacalcium phosphate (OCP). Analysis by XRD indicates that the crystals show planes with a preferential crystalline orientation for HA and for OCP. HRTEM showed interplanar distances that correspond to crystalline planes of HA and OCP. Crystals are composed by superimposed lamellae, which exhibit epitaxial growth, and each layer of the crystals is structured by nanocrystals. This study reveals that CEMP1-p1 regulates HA crystal formation, somehow mimicking the in vivo process of mineralized tissues bioformation.

Synthetic cementum protein 1-derived peptide regulates mineralization in vitro and promotes bone regeneration in vivo

The use of recombinant proteins has revolutionized the development of biologic pharmaceuticals; however, they are not free of complications. Some have very high molecular weight, some demonstrate in vivo instability, and the high cost of producing them remains a major problem. On the other hand, it has been shown that peptides derived from active domains keep their biologic activity and can trigger events, such as osteogenesis and bone regeneration. Small peptides are advantageous because of their ease of synthesis and handling and their low immunogenic activity. The purpose of this study was to investigate the functions of a synthetic peptide, cementum protein 1-peptide1 (CEMP-1-p1), both in vitro and in vivo. Our results show that CEMP-1-p1 significantly enhanced the proliferation and differentiation of human periodontal ligament cells toward a mineralizing-like phenotype, as evidenced by increasing alkaline phosphatase (ALP)-specific activity and osterix, runt-related transcription factor (RUNX)-2, integrin binding sialoprotein, bone morphogenetic protein-2, osteocalcin, and cementum protein (CEMP)-1 expression at mRNA and protein levels. In vivo assays performed through standardized critical-size calvarial defects in rats treated with CEMP-1-p1 resulted in newly formed bone after 30 and 60 d. These data demonstrate that CEMP-1-p1 is an effective bioactive peptide for bone tissue regeneration. The application of this bioactive peptide may lead to implementing new strategies for the regeneration of bone and other mineralized tissues.-Correa, R., Arenas, J., Montoya, G., Hoz, L., López, S., Salgado, F., Arroyo, R., Salmeron, N., Romo, E., Zeichner-David, M., Arzate, H. Synthetic cementum protein 1-derived peptide regulates mineralization in vitro and promotes bone regeneration in vivo.

Human recombinant cementum attachment protein (hrPTPLa/CAP) promotes hydroxyapatite crystal formation in vitro and bone healing in vivo

Cementum extracellular matrix is similar to other mineralized tissues; however, this unique tissue contains molecules only present in cementum. A cDNA of these molecules, cementum attachment protein (hrPTPLa/CAP) was cloned and expressed in a prokaryotic system. This molecule is an alternative splicing of protein tyrosine phosphatase-like A (PTPLa). In this study, we wanted to determine the structural and functional characteristics of this protein. Our results indicate that hrPTPLa/CAP contains a 43.2% α-helix, 8.9% β-sheet, 2% β-turn and 45.9% random coil secondary structure. Dynamic light scattering shows that this molecule has a size distribution of 4.8 nm and aggregates as an estimated mass of 137 kDa species. AFM characterization and FE-SEM studies indicate that this protein self-assembles into nanospheres with sizes ranging from 7.0 to 27 nm in diameter. Functional studies demonstrate that hrPTPLa/CAP promotes hydroxyapatite crystal nucleation: EDS analysis revealed that hrPTPLa/CAP-induced crystals had a 1.59 ± 0.06 Ca/P ratio. Further confirmation with MicroRaman spectrometry and TEM confirm the presence of hydroxyapatite. In vivo studies using critical-size defects in rat cranium showed that hrPTPLa/CAP promoted 73% ± 2.19% and 87% ± 1.97% new bone formation at 4 and 8 weeks respectively. Although originally identified in cementum, PTPLa/CAP is very effective at inducing bone repair and healing and therefore this novel molecule has a great potential to be used for mineralized tissue bioengineering and tissue regeneration.

Bacterial consortium for copper extraction from sulphide ore consisting mainly of chalcopyrite

The mining industry is looking forward for bacterial consortia for economic extraction of copper from low-grade ores. The main objective was to determine an optimal bacterial consortium from several bacterial strains to obtain copper from the leach of chalcopyrite. The major native bacterial species involved in the bioleaching of sulphide ore (Acidithiobacillus ferrooxidans, Acidithiobacillus thiooxidans, Leptospirillum ferrooxidans and Leptospirillum ferriphilum) were isolated and the assays were performed with individual bacteria and in combination with At. thiooxidans. In conclusion, it was found that the consortium integrated by At. ferrooxidans and At. thiooxidans removed 70% of copper in 35 days from the selected ore, showing significant differences with the other consortia, which removed only 35% of copper in 35 days. To validate the assays was done an escalation in columns, where the bacterial consortium achieved a higher percentage of copper extraction regarding to control.

Cementum protein 1 (CEMP1) induces differentiation by human periodontal ligament cells under three-dimensional culture conditions

PDL (periodontal ligament) is a source of multi-potent stem cells in humans and their differentiation potential to a cementoblast and osteoblast phenotypes has been shown. Tissue construction from PDL-derived cells could be considered as a valuable technique for periodontal regenerative medicine. On these basis, we determined the role of CEMP1 (cementum protein 1) as a factor to induce differentiation of human PDL cells in a 3D (three-dimensional) fashion. Human PDL cells were grown in an RCCS (rotary cell culture system) D-410 RWV (rotating wall vessel) bioreactor, and maintained in either experimental (CEMP1 2.5 μg/ml) or control media during 4 weeks. Cell proliferation in the presence of CEMP1 was determined. The tissue-like structure formed was analysed histologically, stained with Alizarin Red and Alcian Blue. ALP (alkaline phosphatase)-specific activity, immunostaining, RT-PCR (reverse transcription-PCR) and Western blotting were performed to determine the expression of BSP (bone sialoprotein), enamel [AMBN (ameloblastin) and AMEL (amelogenin)], cementum [CAP (cementum attachment protein) and CEMP1] and cartilage-related proteins (Sox9, aggrecan, types II and X collagens). Our results show that hrCEMP1 (human recombinant CEMP1) promoted cell proliferation by human PDL cells in 3D cultures and induced the formation of a tissue-like structure resembling bone and/or cementum and material similar to cartilage. The addition of hrCEMP1 to the 3D human PDL cell cultures increased ALP-specific activity by 2.0-fold and induced the expression of markers for the osteogenic, cementogenic and chondrogenic phenotypes at the mRNA and protein levels. Our data show that human PDL cells in 3D cultures with the addition of CEMP1 has the potential to be used for the bioengineering reconstruction of periodontal tissues and cartilage since our results suggest that CEMP1 stimulates human PDL cells to differentiate towards different phenotypes.

Longitudinal analysis of immune function in the first 3 years of life in thymectomized neonates during cardiac surgery

The purpose of this study is to evaluate the effects of neonatal thymectomy in the functional capacity of the immune system. We selected a group of 23 subjects, who had undergone thymectomy in their first 30 days of life, during an intervention for congenital heart disease. Several parameters of the immune system were evaluated during their first 3 years of life. Lymphocyte populations and subpopulations (including naive, memory and effector subpopulations), T cell receptor (TCR) Vbeta repertoire, response of T cells following in vitro stimulation by mitogen, quantification of immunoglobulins, TCR excision circles (TRECS) and interleukin (IL)-7 were measured. We found that neonatal thymectomy produces long-term diminution in total lymphocyte counts, especially in naive CD4+ and CD8+ T cells. Additionally, TRECS were decreased, and plasma IL-7 levels increased. A statistically significant negative correlation was found between absolute CD4+ T cells and IL-7 (r = -0.470, P = 0.02). The patients did not suffer more infectious events than healthy control children, but thymectomy in neonates resulted in a significant decrease in T lymphocyte levels and TRECS, consistent with cessation of thymopoiesis. This could produce a compromise in immune function later in life, especially if the patients suffer T cell depletion and need a reconstitution of immune function.

E-, N- and P-cadherin, and alpha-, beta- and gamma-catenin protein expression in normal, hyperplastic and carcinomatous human prostate

The expression of E-, N- and P-cadherin, alpha-, beta- and gamma-catenin, and actin was studied by immunohistochemistry, ELISA, and Western blot analysis in normal prostates, and in the prostates of men with benign prostatic hyperplasia and men with prostatic carcinoma, in order to evaluate their possible role in the pathogenesis of these diseases. Present results reveal that the immunophenotype of hyperplastic prostates differs from those of both normal and carcinomatous prostates in the intracellular distribution (observed by immunohistochemistry) and the intensity (measured by ELISA) of immunoreactions to cadherins, catenins, and actin. Hyperplastic prostates differ form normal prostates in the weaker immunoreaction to the three cadherin types, the two catenins, and actin, as well as in the intracellular distribution of P-cadherin, beta- and gamma-catenin, and actin. Differences between benign prostatic hyperplasia and prostatic carcinoma are less marked because hyperplastic prostates differ from carcinomatous prostates only in the weaker immunoreactions to P-cadherin, and alpha-catenin. The most remarkable findings in this study were: (1) alpha-catenin production was elevated in prostatic carcinoma in comparison with benign prostatic hyperplasia and normal prostate; and (2) P-cadherin expression in benign prostatic hyperplasia is reduced with regard to those of normal and carcinomatous prostates. It may be concluded that a decreased immunoreaction to cadherins, catenins, and actin, as well as changes in the intracellular distribution of actin in prostatic cells are not necessarily suggestive of malignancy, because these alterations are also present in BPH, and thus, the loss of cadherin-catenin-mediated adhesion alone is not sufficient to establish an invasive phenotype.

Morphometric evaluation of the human prostate

In order to clarify the ageing-related histological changes in the human prostate, a quantitative morphometric analysis was performed. Complete prostates were obtained at autopsy from 281 men (aged 20-84 years) who died in traffic accidents and presented no clinical symptoms of prostatic disease. The prostates were classified as: histologically normal (n=182), with nodular hyperplasia (n=42), with intraepithelial neoplasia (n=40) and carcinomatous with low Gleason grade (n=20). Each prostate was divided into three regions (periurethral, central and peripheral) and the volume of each region, as well as the average volume occupied by stroma and epithelium in each region were quantified. For each parameter, the average values for each age group were compared. In the histologically normal prostates, an increase with ageing in the total volume and the volume occupied by the central region were observed; these increases were mainly caused by an increase in the stromal volume of the central region in men after 30 years of age. No histologically normal prostates were found in men older than 70 years of age. Nodular prostatic hyperplasia was found in men over 30 years of age and a fluctuation in the total volume throughout ageing was observed. Prostates with intraepithelial neoplasia (PIN) and carcinoma were observed in men aged >20 years and the total volume and those of each prostatic region showed multiple variations, except for the eighth decade where a marked increase with regard to that of the previous decades was observed.

Interferon-gamma and its functional receptors overexpression in benign prostatic hyperplasia and prostatic carcinoma: parallelism with c-myc and p53 expression

The therapeutic potential of IFN-gamma in prostatic cancer has been documented in several reports, although no immunohistochemical studies of this factor and its receptors in the prostate have been reported. The aim of the present study was to investigate the expression of IFN-gamma and its receptor components (IFN-gamma-Ralpha and IFN-gamma-Rbeta) in normal prostate, benign prostatic hyperplasia (BPH) and prostatic cancer (PC), as well as the possible relationship between this factor and the products of the p53 gene (the wild and mutant forms) and the oncogene c-myc, by means of immunochemical techniques (Western blot, ELISA, and quantification of immunostaining in histological sections). In normal prostate, IFN-gamma and its two receptors were expressed in the basal cells of the epithelium and some stromal cells. In BPH specimens, immunostaining of basal epithelial cells was significantly increased for IFN-gamma and its a receptor, whereas stromal cell immunostaining was significantly increased for IFN-gamma and its b receptor. In addition, columnar epithelial cells immunostained for IFNbeta-Rbeta. PC specimens differed from BPH specimens in the significantly increased immunostaining of epithelial cells for IFN-gamma and its two receptors, and the immunostaining of columnar epithelial cells for IFN-gamma-Ralpha. Immunodetection of wild-p53 was weak and limited to some stromal cells in the three types of specimens. Immunostainings for both mutant-p53 and c-myc were negative in normal prostate, and positive in the epithelium and stromal cells of both BPH and PC specimens. Immunostaining intensity in PC was significantly higher than in BPH. These observations suggest that the expression of both mutant-p53 and c-myc, together with other factors, might be involved in the development of prostatic hyperplasia and neoplasia, while the increased expression of IFN-gamma and its receptors could be regarded as an attempt, although insufficient, to inhibit the uncontrolled cell proliferation.

A lectin histochemistry comparative study in human normal prostate, benign prostatic hyperplasia, and prostatic carcinoma

The partial oligosaccharide sequences of glycoconjugates and the nature of their glycosidic linkages were investigated in normal human prostate, benign prostatic hyperplasia (BPH) and prostatic carcinoma by means of lectin histochemistry, using light microscopy and Western blot analysis. The labeling pattern of BPH differed from that of normal prostate in having more intense staining with DSA, HPA, UEA-I and AAA, and in showing lesser staining with WGA and SBA. Prostatic carcinoma differed from normal prostates in displaying the more intense labeling with PNA, DSA, SBA, DBA, UEA-I and AAA, and in having lesser labeling with WGA. The main differences in labeling pattern between prostatic carcinoma and BPH were that the latter specimens showed more marked staining with PNA, DSA, DBA, SBA, UEA-I and AAA, and lesser staining with WGA and HPA. The staining patterns of SNA, MAA, ConA, LCA and GNA were similar in all three groups of specimens. For most of the lectins studied, including those showing a similar immunohistochemical staining in the three groups of specimens studied, the Western blot analysis showed differences in the banding pattern among normal, hyperplastic, and carcinomatous prostates. Present results suggest that the glycosylation of proteins was modified in both BPH and prostatic carcinoma. In BPH a strong expression of N-acetylgalactosamine residues occurred, while in prostatic carcinoma an increase of sialic acid, galactose and fucose residues was observed. No changes in mannose residues were detected.

Ultrastructure and lectin cytochemistry of the cloacal ventral glands in the male newt Triturus marmoratus marmoratus

Ventral glands are found in the cloacal walls of male urodele amphibians except for sirenids. These glands are mucous, and secrete substances that will form part of the spermatophore used in transfer of sperm during fertilization. Ventral glands are formed by secretory and ductal portions; both possess epithelial and myoepithelial cells with different characteristics. Urodeles have cyclic reproduction, and cloacal ventral glands show seasonal differences with electron microscopy. The glycoproteins secreted by these glands have been studied by means of lectin histochemistry. The labeling was detected mainly in the nuclei, rough endoplasmic reticulum, Golgi complex, and cytosol. Secretory granules in these glands are composed by mucous glycoproteins that bind PNA lectin (which binds galactose) and SBA and HPA lectins (N-acetylgalactosamine), UEA-I (fucose), and LcA (glucose and/or mannose). These findings suggest that the mucins secreted by ventral glands contain both N- and O-linked oligosaccharides. Ventral glands secrete higher quantity and more diverse mucous substances in the reproductive period, as confirmed by lectin-histochemical reactions. Based on these results, the major similarity between ventral cloacal glands and accessory mammalian glands, can be established with bulbourethral glands.

Ultrastructure and lectin cytochemistry of the cloacal pelvic glands in the male newt Triturus marmoratus marmoratus

The cloacal organ of Salamandridae species contains four glands: pelvic, dorsal, ventral, and Kingsbury's glands. Pelvic glands have been studied only by light microscopy with conventional methods, and consist of multiple tubular serous glands with a prismatic epithelium which contains numerous PAS positive secretory granules. The present report is an ultrastructural and lectin cytochemistry characterization of the pelvic glands of Triturus marmoratus marmoratus throughout the reproductive cycle. Our methods consisted of conventional electron microscopy, and colloidal-gold lectin cytochemistry of the following lectins: WGA, ConA, LcA, UEA-I, PNA, SBA, and HPA. In the prereproductive period, the glands showed a tall epithelium which consisted of two cell types, dark and clear cells, surrounded by elongated, myoepithelial cells. Both dark and clear cells showed the ultrastructural characteristics of secretory cells, and exhibited many secretory granules in the apical cytoplasm. Areas showing densely packed, degenerating cell organelles--which were not surrounded by membrane--were observed in the dark cells whereas the clear cells showed large heterolysosomes. In the postreproductive period the number of secretory granules decreased, the rough endoplasmic reticulum was less developed, and areas of degenerating organelles were absent. In addition, small basal cells appeared. The results of the lectin histochemistry study were similar in both reproductive periods. In the epithelial cells, the rough endoplasmic reticulum, the Golgi complex, and secretory granules exclusively labeled to ConA. In all cell types, the nuclei reacted to all lectins while the cytosol only reacted to LcA lectin. The ultrastructural and histochemical characteristics of the pelvic glands of T. marmoratus suggest that these glands could be homologous to the mammalian seminal vesicles and prostate.

Immunocytochemical and quantitative study of actin, desmin and vimentin in the peritubular cells of the testes from elderly men

A quantitative immunohistochemical study using light and electron microscopy was carried out to evaluate the morphological and quantitative distribution of the peritubular cells that immunoreact with actin, vimentin and desmin, alone or in combinations, in normal adult testes and the changes in these cells in elderly men. Seminiferous tubules in ageing testes were classified in three groups according to the degree of lamina propria thickening due to tubular sclerosis: group I, < 8 microns; group II, 8.1-12 microns; and group III, > 12.1 microns. The number of peritubular cells per cross-sectioned tubule increased from group I to group III tubules. However, no significant differences between ageing men and controls were found in the total number of peritubular cells per testis. Most peritubular cells of control testes and of group I and group II tubules displayed immunoreactivity to actin. The peritubular cells in the outermost layers of group III tubules showed no or scanty reaction. The number of actin-immunostained cells per cross-sectioned tubule decreased (P < 0.05) with tubular sclerosis. The total number of these cells per testis was significantly lower (P < 0.05) in elderly men. A narrow band around the seminiferous epithelium immunostained for desmin in control testes and group I tubules. These cells also immunoreacted to actin and vimentin. In group II and, principally, in group III tubules, only isolated peritubular cells were immunostained for desmin. The number of desmin-immunostained cells per cross-sectioned tubule decreased with tubular sclerosis and the total number per testis was also lower in elderly men. Vimentin immunostaining was observed in most peritubular cells in all tubule groups; these cells also immunoreacted to actin. Vimentin and desmin co-localized only in the inner peritubular cell layers. The number of vimentin-immunostained cells per cross-sectioned tubule increased with the degree of tubular sclerosis but the total number of these cells per testis did not differ significantly between control and ageing testes.

[An analysis of the factors and phenomena associated with the formation of a spontaneous echo contrast in the left atrium]

INTRODUCTION AND AIMS

To determine the factors related to the formation of spontaneous echo contrast in left atrium.

PATIENTS AND METHODS

We have analyzed our series of 1,066 patients undergoing transesophageal echocardiography until December 1991. It was found in left atrium in 387 patients (36%) and was associated with another pathology in 99%. We defined spontaneous echo contrast as mild in 64% and severe in 36%.

RESULTS

The prevalence of spontaneous echo contrast was greater in patients with atrial fibrillation (p < 0.001), mitral stenosis (p < 0.001), double mitral lesion (p < 0.001), prosthesis (p < 0.001), embolism (p < 0.05) and a dilated left atrium (left atrial dimension greater than 60 ml) (p < 0.01). The presence of mitral regurgitation made it less frequent (p < 0.05). Thrombi were visualized in 104 patients and they were more frequent in the presence of spontaneous echo contrast. Severe spontaneous echo contrast was significantly more frequent in patients with atrial fibrillation (p < 0.001), mitral stenosis (p < 0.05) and thrombi (p < 0.001).

CONCLUSIONS

Spontaneous echo contrast in left atrium is a common finding in transesophageal studies and it is associated with another pathology in 99%. It is more frequent in patients with atrial fibrillation, mitral stenosis, embolism or prosthesis. Left atrial enlargement is one of the more important factors. It is less frequent in patients with mitral regurgitation. Thrombi are less frequent in patients without spontaneous echo contrast. Severe spontaneous echo contrast is significantly associated with mitral stenosis, atrial fibrillation and left atrial thrombi.

Factors determining late success after mitral balloon valvulotomy

Mitral balloon valvulotomy (MBV) has proved to be an effective method in the treatment of patients with mitral stenosis. Although several factors determining an optimal immediate result have been described, there is little information regarding long-term follow-up, as well as factors influencing late success after MBV. This study analyzes 350 patients (mean age 46 +/- 12 years) treated by MBV who were clinically followed up between 6 months and 6 years. At least 1 echo-Doppler follow-up study was obtained in 298 patients 28 +/- 14 months after MBV; hemodynamic reevaluations were performed in 66 patients after 23 +/- months. Late success was considered if the patient was in functional class I to II and free of major events (death, restenosis and valve surgery). Restenosis was defined as a 50% loss of initial gain with regard to valve area by echocardiography, which was confirmed hemodynamically. After a mean follow-up of 38 +/- 15 months, 296 patients (84%) remained in functional class I to II, without surgery or the need for an increase in medical treatment. The 5-year Kaplan-Meier survival rate was 94 +/- 1%, whereas restenosis, valve surgery and major event-free probability were 90 +/- 3%, 91 +/- 2% and 85 +/- 2%, respectively. Multivariate study (Cox regression model) identified the presence of sinus rhythm (p < 0.001) and the absence of calcium at fluoroscopy (p < 0.003) as the only independent factors of late success.(ABSTRACT TRUNCATED AT 250 WORDS)

Adapting to the ANSI 835 transaction set

Adapting to the American National Standards Institute (ANSI) 835 Health Care Claims Payment/Advice format--the first nationwide, all-payer electronic standard for healthcare claims--requires an approach tailored to the individual provider's system. Providers have four options for receiving ANSI 835 claims payments. They include: direct transmission from payers, value added network services (VANs), banks with electronic data interchange capabilities, and paper reports. Providers' claims processing systems vary enormously in the formats they use and in their capacities to transmit and receive claims payments electronically. Author Romo reviews factors that providers need to consider when refining internal capabilities and selecting external processors to accept the 835 format.

[Listeria monocytogenes endocarditis in a patient with mitral prosthesis, left auricular thrombus and adenocarcinoma of the colon]

A case of Listeria monocytogenes endocarditis in a patient with mitral prosthetic valve, left atrial thrombus and colonic adenocarcinoma is reported. Vegetations were not demonstrated by transesophageal echocardiography and the clinical course was benign and without complications. Cure was achieved with antibiotic therapy, and surgery was not required. These features suggest that atrial thrombus could be the source of infection.

[Acute pericarditis as initial clinical manifestation of hypereosinophilia syndrome]

The case of a patient in whom acute pericarditis was the initial manifestation of an idiopathic hypereosinophilia is reported. Endomyocardial abnormalities were not found by echocardiography. Response to prednisone therapy was good; symptoms, pericardial effusion and eosinophilia early disappeared after therapy. Some clinical aspects of this uncommon disease are discussed.

[The management by medical treatment of an intracranial mycotic aneurysm in a patient with infectious endocarditis with negative blood cultures and hypertrophic myocardiopathy]

A case of intracranial mycotic aneurysm due to culture-negative infective endocarditis involving a patient with hypertrophic cardiomyopathy is reported. The patient, a 22-year-old woman with no history of known prior disease, had fever, headache and focal neurologic symptoms 3 days before admission. An echocardiogram performed after admission disclosed an obstructive hypertrophic cardiomyopathy and a gross vegetation on septal leaflet of mitral valve. Cerebral angiography revealed a mycotic aneurysm involving a peripheral branch of the left middle cerebral artery. Causal agent was not identified, and empiric treatment with penicillin G and streptomycin achieved medical cure and disappearance of the aneurysm 2 weeks later. Four months after endocarditis had been cured, the patient was electively operated because of progression of mitral regurgitation. Six months later, she is asymptomatic.