Obesity-related health status is a better predictor of pregnancy with fertility treatment than body mass index: a prospective study

This study assessed whether an obesity-related health status instrument (Edmonton obesity scoring system - EOSS) or body mass index (BMI) better predicted pregnancy rates in overweight women undergoing fertility treatments. A prospective cohort study was conducted on patients with a BMI ≥ 25 kg m(-2) undergoing a fertility treatment cycle (ovulation induction, superovulation, or in vitro fertilization). Obesity-related health status including blood pressure, blood work, health history, and functional assessment were assessed. A total of 101 patients were included in the study with an average age of 36.3 ± 4.2 years and a mean BMI of 31.8 ± 5.2 kg m(-2) . EOSS was found to be statistically predictive of pregnancy rate/cycle (OR 0.51, 95% CI 0.27-0.94; P = 0.03), whereas BMI was not (OR 0.95, 95% CI 0.86-1.05). A similar trend was seen for clinical pregnancy rate/cycle started. However, the association between clinical pregnancy rates and EOSS or BMI did not reach statistical significance (OR 0.53, P = 0.06 and OR 0.98, P = 0.62 respectively). Our results demonstrated that EOSS better predicted pregnancy rates after fertility treatments than BMI. In fact, for every EOSS stage increased by one unit, the odds of pregnancy were approximately halved. A multi-centre study powered for live birth is warranted to establish effective pre-fertility management of overweight women.

Removal of toxic and alkali/alkaline earth metals during co-thermal treatment of two types of MSWI fly ashes in China

This study aims to vaporize heavy metals and alkali/alkaline earth metals from two different types of fly ashes by thermal treatment method. Fly ash from a fluidized bed incinerator (HK fly ash) was mixed with one from a grate incinerator (HS fly ash) in various proportions and thermally treated under different temperatures. The melting of HS fly ash was avoided when treated with HK fly ash. Alkali/alkaline earth metals in HS fly ash served as Cl-donors to promote the vaporization of heavy metals during thermal treatment. With temperature increasing from 800 to 900°C, significant amounts of Cl, Na and K were vaporized. Up to 1000°C in air, less than 3% of Cl and Na and less than 5% of K were retained in ash. Under all conditions, Cd can be vaporized effectively. The vaporization of Pb was mildly improved when treated with HS fly ash, while the effect became less pronounced above 900°C. Alkali/alkaline earth metals can promote Cu vaporization by forming copper chlorides. Comparatively, Zn vaporization was low and only slightly improved by HS fly ash. The low vaporization of Zn could be caused by the formation of Zn2SiO4, ZnFe2O4 and ZnAl2O4. Under all conditions, less than 20% of Cr was vaporized. In a reductive atmosphere, the vaporization of Cd and Pb were as high as that in oxidative atmosphere. However, the vaporization of Zn was accelerated and that of Cu was hindered because the formation of Zn2SiO4, ZnFe2O4 and ZnAl2O4 and copper chloride was depressed in reductive atmosphere.

Treatment of Aspergillus fumigatus in patients with cystic fibrosis: a randomized, placebo-controlled pilot study

Background

Many patients with cystic fibrosis develop persistent airway infection/colonization with Aspergillus fumigatus, however the impact of A. fumigatus on clinical outcomes remains unclear. The objective of this study was to determine whether treatment directed against Aspergillus fumigatus improves pulmonary function and clinical outcomes in patients with cystic fibrosis (CF).

Methods

We performed a double-blind randomized placebo-controlled pilot clinical trial involving 35 patients with CF whose sputum cultures were chronically positive for A. fumigatus. Participants were centrally randomized to receive either oral itraconazole 5 mg/kg/d (N = 18) or placebo (N = 17) for 24 weeks. The primary outcome was the proportion of patients who experienced a respiratory exacerbation requiring intravenous antibiotics over the 24 week treatment period. Secondary outcomes included changes in FEV₁ and quality of life.

Results

Over the 24 week treatment period, 4 of 18 (22%) patients randomized to itraconazole experienced a respiratory exacerbation requiring intravenous antibiotics, compared to 5 of 16 (31%) placebo treated patients, P = 0.70. FEV₁ declined by 4.62% over 24 weeks in the patients randomized to itraconazole, compared to a 0.32% improvement in the placebo group (between group difference = −4.94%, 95% CI: −15.33 to 5.45, P = 0.34). Quality of life did not differ between the 2 treatment groups throughout the study. Therapeutic itraconazole blood levels were not achieved in 43% of patients randomized to itraconazole.

Conclusion

We did not identify clinical benefit from itraconazole treatment for CF patients whose sputum was chronically colonized with A. fumigatus. Limitations of this pilot study were its small sample size, and failure to achieve therapeutic levels of itraconazole in many patients.

Trial Registration

ClinicalTrials.govNCT00528190

Infection with transmissible strains of Pseudomonas aeruginosa and clinical outcomes in adults with cystic fibrosis

CONTEXT

Studies from Australia and the United Kingdom have shown that some patients with cystic fibrosis are infected with common transmissible strains of Pseudomonas aeruginosa.

OBJECTIVES

To determine the prevalence and incidence of infection with transmissible strains of P. aeruginosa and whether presence of the organism was associated with adverse clinical outcomes in Canada.

DESIGN, SETTING, AND PARTICIPANTS

Prospective observational cohort study of adult patients cared for at cystic fibrosis clinics in Ontario, Canada, with enrollment from September 2005 to September 2008. Sputum was collected at baseline, 3 months, and yearly thereafter for 3 years; and retrieved P. aeruginosa isolates were genotyped. Vital status (death or lung transplant) was assessed for all enrolled patients until December 31, 2009.

MAIN OUTCOME MEASURES

Incidence and prevalence of P. aeruginosa isolation, rates of decline in lung function, and time to death or lung transplantation.

RESULTS

Of the 446 patients with cystic fibrosis studied, 102 were discovered to be infected with 1 of 2 common transmissible strains of P. aeruginosa at study entry. Sixty-seven patients were infected with strain A (15%), 32 were infected with strain B (7%), and 3 were simultaneously infected with both strains (0.6%). Strain A was found to be genetically identical to the Liverpool epidemic strain but strain B has not been previously described as an epidemic strain. The incidence rate of new infections with these 2 transmissible strains was relatively low (7.0 per 1000 person-years; 95% confidence interval [CI], 1.8-12.2 per 1000 person-years). Compared with patients infected with unique strains of P. aeruginosa, patients infected with the Liverpool epidemic strain (strain A) and strain B had similar declines in lung function (difference in decline in percent predicted forced expiratory volume in the first second of expiration of 0.64% per year [95% CI, -1.52% to 2.80% per year] and 1.66% per year [95% CI, -1.00% to 4.30%], respectively). However, the 3-year rate of death or lung transplantation was greater in those infected with the Liverpool epidemic strain (18.6%) compared with those infected with unique strains (8.7%) (adjusted hazard ratio, 3.26 [95% CI, 1.41 to 7.54]; P = .01).

CONCLUSIONS

A common strain of P. aeruginosa (Liverpool epidemic strain/strain A) infects patients with cystic fibrosis in Canada and the United Kingdom. Infection with this strain in adult Canadian patients with cystic fibrosis was associated with a greater risk of death or lung transplantation.

Alendronate once weekly for the prevention and treatment of bone loss in Canadian adult cystic fibrosis patients (CFOS trial)

BACKGROUND

Patients with cystic fibrosis (CF) are at risk for early bone loss, and demonstrate increased risks for vertebral fractures and kyphosis. A multicenter, randomized, controlled trial was conducted to assess the efficacy, tolerability, and safety of therapy with oral alendronate (FOSAMAX; Merck; Whitehouse Station, NJ) in adults with CF and low bone mass.

METHODS

Participants received placebo or alendronate, 70 mg once weekly, for 12 months. All participants received 800 IU of vitamin D and 1,000 mg of calcium daily. Adults with confirmed CF with a bone mineral density (BMD) T score of < - 1.0 were eligible for inclusion. Participants who had undergone organ transplantation or had other reported contraindications were excluded from the study. The primary outcome measure was the mean (+/- SD) percentage change in lumbar spine BMD after 12 months. Secondary measures included the percentage change in total hip BMD, the number of new vertebral fractures (grade 1 or 2), and changes in quality of life.

RESULTS

A total of 56 participants were enrolled in the study (mean age, 29.1 +/- 8.78 years; 61% male). The absolute percentage changes in lumbar spine and total hip BMDs at follow-up were significantly higher in the alendronate therapy group (5.20 +/- 3.67% and 2.14 +/- 3.32%, respectively) than those in the control group (- 0.08 +/- 3.93% and - 1.3 +/- 2.70%, respectively; p < 0.001). At follow-up, two participants (both in the control group) had a new vertebral fracture (not significant), and there were no differences in quality of life or the number of adverse events (including serious and GI-related events).

CONCLUSION

Alendronate therapy was well tolerated and produced a significantly greater increase in BMD over 12 months compared with placebo.

Predictors of pulmonary exacerbations in patients with cystic fibrosis infected with multi-resistant bacteria

BACKGROUND

This study examined characteristics of adult and adolescent patients with cystic fibrosis (CF) to determine factors associated with an increased risk of pulmonary exacerbations.

METHODS

249 patients with CF infected with multidrug resistant bacteria were recruited and prospectively followed for up to 4.5 years until they experienced a pulmonary exacerbation severe enough to require intravenous antibiotics. Multivariable regression analyses were used to compare the characteristics of patients who experienced an exacerbation with those who did not.

RESULTS

124 of the 249 patients (50%) developed a pulmonary exacerbation during the first year and 154 (62%) experienced an exacerbation during the 4.5 year study period. Factors predictive of exacerbations in a multivariable survival model were younger age (OR 0.98, 95% CI 0.96 to 0.99), female sex (OR 1.45, 95% CI 1.07 to 1.95), lower forced expiratory volume in 1 second (FEV(1)) (OR 0.98, 95% CI 0.97 to 0.99), and a previous history of multiple pulmonary exacerbations (OR 3.16, 95% CI 1.93 to 5.17). Chronic use of inhaled corticosteroids was associated with an increased risk of exacerbation (OR 1.92, 95% CI 1.00 to 3.71) during the first study year.

CONCLUSIONS

Patients who experience pulmonary exacerbations are more likely to be younger, female, using inhaled steroids, have a lower FEV(1), and a history of multiple previous exacerbations. It is hoped that knowledge of these risk factors will allow better identification and closer monitoring of patients who are at high risk of exacerbations.

Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial

BACKGROUND

We did a randomised, double-blind, controlled clinical trial to prospectively assess whether use of combination antibiotic susceptibility testing improved clinical outcomes in patients with acute pulmonary exacerbations of cystic fibrosis who were infected with multiresistant bacteria.

METHODS

251 patients with cystic fibrosis who were chronically infected with multiresistant gram negative bacteria gave sputum at 3-month intervals for conventional culture and sensitivity tests and for combination antibiotic susceptibility tests using multiple combination bactericidal antibiotic testing (MCBT). Patients who developed an exacerbation of pulmonary disease were randomised to receive a 14-day course of any two blinded intravenous antibiotics chosen on the basis of either results from conventional sputum culture and sensitivity testing or the result of MCBT. The primary outcome was time from randomisation until the patient's next pulmonary exacerbation. Analysis was by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN60187870.

FINDINGS

132 patients had a pulmonary exacerbation and were randomised during the 4.5-year study period. The time to next pulmonary exacerbation was not prolonged in the MCBT-treated group (hazard ratio 0.86 in favour of the conventionally-treated group, 95% CI 0.60-1.23, p=0.40). There was no difference between the groups in treatment failure rate. After 14 days of intravenous antibiotic therapy, changes in lung function, dyspnoea, and sputum bacterial density were similar in both groups.

INTERPRETATION

Antibiotic therapy directed by combination antibiotic susceptibility testing did not result in better clinical and bacteriological outcomes compared with therapy directed by standard culture and sensitivity techniques. The non-bactericidal effects of antibiotic therapy might play an important part in determining improvement in patients with cystic fibrosis pulmonary exacerbations.

Lithium monitoring before and after the distribution of clinical practice guidelines

OBJECTIVE

To determine whether distribution of clinical practice guidelines improves lithium monitoring and whether standards of monitoring differed between patients in psychiatric contact and those seen only in primary care.

METHOD

Standards of monitoring were assessed for patients on lithium in northeast Scotland throughout 1995 and/or throughout 1996. Guidelines were circulated in January 1996 to all local general practitioners and psychiatrists. Monitoring was compared between 1995 and 1996 and for patients with and without psychiatric contact.

RESULTS

Both primary care and psychiatric records were scrutinized for 422 and 403 patients prescribed lithium throughout 1995 and 1996, respectively. While monitoring was poor on several parameters during both years, frequency of measurement of both thyroid and renal function improved in 1996. Standards of monitoring were better for patients in psychiatric care.

CONCLUSION

Standards of lithium monitoring require further improvement. Locally agreed practice guidelines are helpful but patients on lithium should be in continuing contact with an experienced psychiatrist.

The effect of allowing clinical discretion in ordering biochemical tests. Evaluation by complementary methods

We describe the effects on costs, working patterns, and clinical behavior of installing a DAX "discretionary" biochemistry analyzer. Use of the new analyzer encouraged doctors to be more specific in requesting biochemical tests, which substantially reduced the number of tests requested and slightly reduced overall costs. Doctors preferred being able to order tests in this more specific way.

Effect of sepsis and surgery on trace minerals

The purpose of this study was to evaluate effect of infection and surgery on serum iron, zinc, and the copper simultaneously. Twenty patients who had emergency abdominal surgery for acute inflammatory conditions, and 15 controls who had elective abdominal surgery were studied. Preoperatively, serum iron levels were significantly decreased in the septic group compared to controls (p less than 0.001). Following surgery and removal of the septic focus, serum iron, ferritin, and zinc levels increased, while serum transferrin levels decreased significantly. Serum copper levels did not show any significant difference. It is concluded that serum iron, transferrin, ferritin, and zinc levels are affected profoundly by septic and the surgical stress.

Pulmonary permeability edema in a large animal model of nonpulmonary sepsis. A morphologic study

Morphologic studies were undertaken in a sheep model of pulmonary permeability edema (PPE) induced by cecal ligation and perforation. Biopsies taken every 24 hours through 96 hours following induction of sepsis showed, at 24 hours, interstitial edema accompanied by widespread aggregation of polymorphonuclear leukocytes. This was confirmed by electron microscopy, which also demonstrated endothelial cell swelling, platelet aggregation, and fibrin deposition. By 48 hours, a "thromboangiitis" had developed that persisted through 96 hours. In vitro pulmonary angiograms done at 60 and 96 hours showed multiple filling defects; it was possible to demonstrate that these defects corresponded to the "thromboangiitis." These thrombotic lesions, which were not the result of embolization from indwelling lines, closely resembled vascular changes described in the adult respiratory distress syndrome. It is believed that this is the first time that such lesions have been described in a model of PPE resulting from nonpulmonary sepsis.

Evaluation of a time-resolved immunofluorometric assay for serum thyroid stimulating hormone

The LKB 'Delfia, immunofluorometric assay for serum TSH has been evaluated. The assay is simple and rapid to perform and is capable of processing in excess of 100 specimens within a working day. The sensitivity of the assay is 0.05 microU/L, with a working range extending beyond 324 microU/L. The change in signal at each point over the standard curve approaches 1000-fold, significantly greater than that of a typical immunoradiometric assay. Mean figures for intra-assay and inter-assay precision were 4.7% and 8.6% CV, respectively. Mean recovery of added TSH was 98.3%, and samples containing high levels of endogenous TSH diluted parallel to the standard curve. The method showed good correlation with an immunoradiometric assay for TSH. The reference ranges for clinically defined groups of subjects were euthyroid 0.47-3.84 microU/L (n = 83); primary hypothyroidism 15--greater than 324 microU/L (n = 28); thyrotoxicosis less than 0.05 microU/L (n = 46). It is concluded that the 'Delfia' assay offers the clinical biochemistry laboratory an attractive and reliable alternative to a sensitive immunoradiometric assay for serum TSH.

The analysis of tricyclic antidepressant drugs at therapeutic blood levels by reversed-phase high-performance liquid chromatography using pairing and organic counter-ions

A serum assay method incorporating two internal standards suitable for routine clinical analysis of tricyclic antidepressant drugs at the therapeutic level is described. The method involves extraction and chromatography using a reversed-phase high-performance liquid chromatography system incorporating pairing and organic counter-ions. The quantitative characteristics of the method are reported and results are compared with consensus values for four commonly encountered drugs, amitriptyline, nortriptyline, imipramine and desipramine. The method is shown to be applicable to more recently developed antidepressants such as nomifensine and maprotiline and the flexibility of the chromatography is discussed. Sample chromatograms obtained from patient samples in the presence and absence of potentially interfering drugs and metabolites are discussed.

Incorporation of a SMAC analyzer into the data-processing procedures of a computer-assisted laboratory

This paper describes the incorporation of a SMAC (Technicon) analyzer into data-processing techniques that have been developed on existing computer hardware during several years. The SMAC system is interfaced directly to a small computer, and suitable peripherals produce a manageable form of result tabulation for subsequent reporting, as well as provide quality-control information to the SMAC operators in real time. The design is such as to facilitate the performance analysis of the SMAC system during its initiation period and during normal service operation.

Incorporation of a SMAC analyzer into the data-processing procedures of a computer-assisted laboratory

This paper describes the incorporation of a SMAC (Technicon) analyzer into data-processing techniques that have been developed on existing computer hardware during several years. The SMAC system is interfaced directly to a small computer, and suitable peripherals produce a manageable form of result tabulation for subsequent reporting, as well as provide quality-control information to the SMAC operators in real time. The design is such as to facilitate the performance analysis of the SMAC system during its initiation period and during normal service operation.