Prevalence, Distribution, and Characteristics Associated with Possession of Buprenorphine Waivers Among Infectious Diseases Physicians in the United States

BACKGROUND

Persons with opioid use disorder (OUD) may present with infectious complications from injection drug use, thus ID physicians are uniquely positioned to treat OUD. Buprenorphine is safe and effective for OUD but remains underutilized. The prevalence and geographic distribution of ID physicians who are waivered to prescribe buprenorphine are unknown.

METHODS

This cross-sectional study merged data from several publicly available datasets from November 1, 2021 to January 15, 2022. Our primary outcome was proportion of ID physicians possessing buprenorphine waivers in the United States. We identified individual and county-level characteristics associated with buprenorphine waiver possession. We then used geospatial analysis to determine geographic distribution of waivered ID physicians.

RESULTS

We identified 6372 ID physicians in the US, among whom 170 (2.7%) possessed waivers. Most ID physicians (97.3%) practiced in metropolitan counties. In our multivariable analysis, ID physicians had lower odds of having a waiver for every 10-year increase since graduating medical school (OR 0.79, 95% CI 0.68-0.91). ID physicians practicing in counties with higher proportion of uninsured residents had lower odds of having a waiver (OR 0.75, 95% CI 0.62-0.90). Among counties with at least one ID physician (n = 729), only 11.2% had at least one waivered ID physician.

CONCLUSIONS

We found an extremely low prevalence and skewed geographic distribution of ID physicians with buprenorphine waivers. Our findings suggest an urgent need to increase the workforce of ID physicians waivered to prescribe buprenorphine and a call for increased integration of OUD education into ID training and continuing medical education.

A web-based application for initial screening of living kidney donors: development, implementation and evaluation

Most centers utilize phone or written surveys to screen candidates who self-refer to be living kidney donors. To increase efficiency and reduce resource utilization, we developed a web-based application to screen kidney donor candidates. The aim of this study was to evaluate the use of this web-based application. Method and time of referral were tabulated and descriptive statistics summarized demographic characteristics. Time series analyses evaluated use over time. Between January 1, 2011 and March 31, 2012, 1200 candidates self-referred to be living kidney donors at our center. Eight hundred one candidates (67%) completed the web-based survey and 399 (33%) completed a phone survey. Thirty-nine percent of donors accessed the application on nights and weekends. Postimplementation of the web-based application, there was a statistically significant increase (p < 0.001) in the number of self-referrals via the web-based application as opposed to telephone contact. Also, there was a significant increase (p = 0.025) in the total number of self-referrals post-implementation from 61 to 116 per month. An interactive web-based application is an effective strategy for the initial screening of donor candidates. The web-based application increased the ability to interface with donors, process them efficiently and ultimately increased donor self-referral at our center.

Photochemical reactions involved in the phototoxicity of the anticonvulsant and antidepressant drug lamotrigine (Lamictal)

Lamotrigine (LTG) [3,5-diamino-6-(2,3-dichlorophenyl)-1,2,4-triazine], an anticonvulsant and antidepressant drug Lamictal, produces a (photo)toxic response in some patients. LTG absorbs UV light, generating singlet oxygen (1O2) with a quantum yield of 0.22 in CH2Cl2, 0.11 in MeCN and 0.01 in D2O. A small production of superoxide radical anion was also detected in acetonitrile. Thus, LTG is a moderate photosensitizer producing phototoxicity and oxidizing linoleic acid. LTG is a weak 1O2 quencher (k(q) = 3.2 x 10(5) M(-1) s(-1) in MeCN), but its photodecomposition products in dimethyl sulfoxide (DMSO) quenched 1O2 very efficiently. Upon intense UV irradiation from a xenon lamp, LTG was photobleached rapidly in DMSO and slowly in acetonitrile, alcohol and water. The rate increased significantly when laser pulses at 266 nm were employed. The photobleaching products generated 1O2 twice as strongly as LTG. Photobleaching was usually accompanied by the release of chloride anions, which increased in the presence of ascorbic acid. This suggests the formation of aryl radicals via dechlorination, a process which may be responsible for the photoallergic response observed in some patients. Our results demonstrate that LTG is a moderate generator of 1O2 prone to photodechlorination, especially in a reducing environment, which can contribute to the reported phototoxicity of LTG.

Principles and practice of drug photodegradation studies

A review is presented of the underlying principles and experimental techniques used for the study of the photochemical degradation of pharmaceuticals. Examples are given to illustrate their application.

Cost perspectives of laparoscopic and open appendectomy

BACKGROUND

Despite multiple studies comparing laparoscopic and open appendectomies, the clinically and economically superior procedure still is in question. A cost analysis was performed using both institutional and societal perspectives.

METHODS

A decision analytic model was developed to evaluate laparoscopic and open appendectomies. The institutional perspective addressed direct health care costs, whereas the societal perspective addressed direct and indirect health care costs. Baseline values and ranges were taken from randomized controlled trials, meta-analyses, and Medicare databases.

RESULTS

From the institutional perspective, open appendectomy is the least expensive strategy, with an expected cost of $5,171, as compared with $6,118 for laparoscopic appendectomy. The laparoscopic approach is less expensive if open appendectomy wound infection rates exceed 23%. From the societal perspective, laparoscopic appendectomy is the least expensive strategy, with an expected cost of $10,400, as compared with $12,055 for open appendectomy.

CONCLUSIONS

The decision analysis demonstrated an economic advantage to the hospital of open appendectomy. In contrast, laparoscopic appendectomy represents a better economic choice for the patient.

Identification and quantitation of sodium-thyroxine and its degradation products by LC using electrochemical and MS detection

High performance liquid chromatography (HPLC) was used in combination with an amperometric and mass spectrometric detection to elucidate and quantitate the degradation products and contaminants of the photo-sensitive Na-thyroxine. Using HPLC with amperometric detection, seven decomposition compounds were separated. These products, which occur mostly as contaminants, were then identified by a developed liquid chromatography-mass spectrometry technique. The same HPLC method was also employed to analyze Na-thyroxine and its degradation products in three commercially available brands of Na-thyroxine tablets.

Bacteria in the transfer catheter tip influence the live-birth rate after in vitro fertilization

OBJECTIVE

To assess the impact of individual bacteria isolated from the vagina and tip of the embryo transfer catheter on live-birth rates.

DESIGN

Prospective clinical study.

SETTING

Infertility outpatient clinic of a university hospital.

PATIENT(S)

Ninety-one women undergoing IVF-ET.

INTERVENTION(S)

Cultures were obtained from the vagina for aerobic and anaerobic bacteria at the time of both sonographic egg retrieval and embryo transfer and from the tip of the embryo transfer catheter. Doxycycline treatment was started after egg retrieval.

MAIN OUTCOME MEASURE(S)

The live birth of one or more neonates.

RESULT(S)

Doxycycline had no substantial impact on the recovery of individual vaginal bacteria or on bacterial vaginosis. An increase in live-birth rate was associated with the recovery of hydrogen peroxide-producing Lactobacillus from the vagina (P=0.01) and from the embryo transfer catheter (P=0.01). In contrast, a reduction in live-birth rate was associated with recovery of Streptococcus viridans (S. viridans) from the embryo transfer catheter tip (P=0.04).

CONCLUSION(S)

In the setting of IVF-ET, prophylactic doxycycline had little effect on vaginal bacteria. Specific bacteria recovered from the embryo transfer catheter appear associated with a detrimental or beneficial effect or with no effect on live-birth rates.

Photodegradation of amiloride in aqueous solution

The photodegradation of amiloride hydrochloride in deaerated aqueous solution at 30 degrees C in the pH range 4.5-11.0 was studied by spectrophotometry and reversed-phase HPLC. The neutral form of the drug present in alkaline solution degraded approximately 3-fold faster than the cationic form. The quantum yields for photodegradation of neutral amiloride and its conjugate acid were determined using ferrioxalate actinometry to be 0.023+/-0.002 and 0. 009+/-0.001, respectively. The initial photoreaction involves dechlorination of amiloride and the major product is N-amidino-3, 5-diamino-6-hydroxylpyrazine-carboxamide, established by UV, 1H and 13C NMR, and chemical ionization-mass spectrometry. The mechanism of photolysis is postulated to involve cation radical formation that facilitates the dechlorination step. The photosensitizing activity of amiloride hydrochloride was tested by measuring (a) the rate of oxygen uptake in the presence of singlet oxygen substrates, 2, 5-dimethylfuran or l-histidine, and (b) the rate of free radical polymerization of acrylamide, at 30 degrees C in aqueous solution. Photosensitization by amiloride was concluded to occur predominantly via singlet oxygen rather than a free radical mechanism. However, amiloride is a much weaker photosensitizer than other diuretics such as frusemide and hydrochlorothiazide, tested under the same experimental conditions.

Characterization of ciliary activity in distal Fallopian tube biopsies of women with obstructive tubal infertility

Biopsy specimens were obtained from the distal end of the Fallopian tubes of 62 women with tubal infertility and examined by light and electron microscopy. Ciliary beat frequency (CBF) measurements were obtained using laser light spectroscopy. Neither demographic nor behavioural characteristics nor serological evidence of past chlamydial infection were associated with CBF measurements. In contrast, CBF were significantly lower (P < 0.05) in tissues with oedema compared to tissues without oedema (6.7 versus 12.9) and in tissues with erythema compared to tissues without erythema (9.2 versus 13.7). Furthermore, CBF measurements did vary by chlamydial serotype pattern, with lower values observed among the tissues of women with antibodies to serotype C or E (without D) as compared to the tissues of women with other serotypes (P < 0.04). However, these data must be interpreted with caution as the numbers of subjects with chlamydial antibodies to serotype C (n = 3) or E without D (n = 5) were few in number and serotyping of IgG antibodies in blood is not as accurate as it is in bacterial isolates. Confirmation of the suggested association between chlamydial serotype and risk of adverse sequelae could indicate potential new avenues for vaccine research.

Electron transfer processes in the reactivity of nonsteroidal anti-inflammatory drugs in the ground and excited states

The nonsteroidal anti-inflammatory drugs (NSAID), naproxen, sulindac and indomethacin, were shown to donate electrons to nitro blue tetrazolium (NBT) when irradiated with UV light in deoxygenated aqueous buffer solution (pH 7.4, 30 degrees C). The reaction was monitored spectrophotometrically by the appearance of the diformazan reduction product from NBT. The electron transfer process facilitates the decomposition of the drugs. Naproxen in the presence of NBT is photodegraded principally to the alcohol (2-[1-hydroxyethyl]-6-methoxynaphthalene) at a rate approximately 20-fold faster than when irradiated alone in deoxygenated conditions. The photoproduct from naproxen also participates in the electron transfer to NBT but at a much slower rate than naproxen. Irradiation of sulindac or indomethacin in the presence of NBT caused the slow photoreduction of NBT to diformazan. In the absence of NBT, indomethacin and sulindac are essentially unreactive when irradiated in aqueous solution. The ability of a number of NSAID to act as electron donors in their ground state was studied by observing their oxidation by potassium peroxodisulfate in pH 7.0 phosphate buffer at 50 degrees C. The HPLC analysis of the drug remaining showed that the 2-arylpropionic acid NSAID (naproxen, ibuprofen, ketoprofen and suprofen) reacted at a rate equivalent to the thermal decomposition of peroxodisulfate. The major products were the same as detected in the photooxidation of these drugs, resulting from decarboxylation and oxygen addition but also included a dimeric compound. On the other hand, the NSAID that do not contain the propionic acid substituent all reacted more slowly with peroxodisulfate, enabling specific reaction rate constants to be evaluated.

Maternal factors and breast cancer risk among young women

The results from previous studies have provided evidence to support the hypothesised association between intrauterine oestrogen exposure and subsequent risk of breast cancer. Information has not been available to study this relationship for several perinatal factors thought to be related to pregnancy oestrogen levels. Data collected from the mothers of women in two population-based case-control studies of breast cancer in women under the age of 45 years (510 case mothers, 436 control mothers) who were diagnosed between 1983 and 1992 in three western Washington counties were used to investigate further the relationship between intrauterine oestrogen exposure and risk of breast cancer. A pregnancy weight gain of 25-34 pounds was associated with breast cancer risk (odds ratio [OR] = 1.5; 95% confidence interval [CI] 1.1, 2.0); however, women whose mothers gained 35 pounds or more were not at increased risk. Use of antiemetic medication in women with any nausea and vomiting (OR = 2.9; 95% CI 1.1, 8.1) and use of diethylstilboestrol (DES) (OR = 2.3; 95% CI 0.8, 6.4) appeared to be positively associated with breast cancer risk. The results from this study provide limited support for the hypothesis that in utero oestrogen exposure may be related to subsequent breast cancer risk among young women.

Electron-transfer mechanisms in photosensitization by the anti-inflammatory drug benzydamine

The novel anti-inflammatory drug benzydamine has been show to photosensitize the reduction of Nitro Blue Tetrazolium, ferricytochrome c and copper (II) bathocuproinedisulphonate in aqueous solutions (pH 7.4, 30 degrees C) when irradiated with UV light at its maximum absorption wavelength of 308 nm. The reduction reactions all proceed most efficiently when the solutions are deoxygenated, clearly indicating that direct electron transfer occurs from the excited state of the sensitizer to the substrate. In aerated solutions the reduction reactions are slower and are partially inhibited by superoxide dismutase, suggesting that superoxide anion could be involved as an intermediate when oxygen is present. Benzydamine also photosensitizes the oxidation of 1-histidine and 2,5-dimethylfuran by the singlet oxygen pathway in aerated solutions. The ability of benzydamine to participate as sensitizer in several types of photochemical reaction is relevant to the observed clinical photosensitivity of the drug.

Dramatic changes in oxidative tryptophan metabolism along the kynurenine pathway in experimental cerebral and noncerebral malaria

The pathogenesis of human cerebral malaria (CM) remains unresolved. In the most widely used murine model of CM, the presence of T lymphocytes and/or interferon (IFN)-gamma is a prerequisite. IFN-gamma is the key inducer of indoleamine 2,3-dioxygenase (IDO), which is the catalyst of the first, and rate-limiting, step in the metabolism of tryptophan (Trp) along the kynurenine (Kyn) pathway. Quinolinic acid (QA), a product of this pathway, is a neuro-excitotoxin, like glutamic acid (Glu) and aspartic acid (Asp). Kynurenic acid (KA), also produced from the Kyn pathway, antagonizes the neuro-excitotoxic effects of QA, Glu, and Asp. We therefore examined the possible roles of IDO, metabolites of the Kyn pathway, Glu, and Asp in the pathogenesis of fatal murine CM. Plasmodium berghei ANKA infection was studied on days 6 and 7 post-inoculation (p.i.), at which time the mice exhibited cerebral symptoms such as convulsions, ataxia, coma, and a positive Wooly/White sign and died within 24 hours. A model for noncerebral malaria (NCM), P. berghei K173 infection, was also studied on days 6 and 7 and 13 to 17 p.i. to examine whether any changes were a general response to malaria infection. Biochemical analyses were done by high-pressure liquid chromatography and gas chromatography/mass spectrometry/mass spectrometry (GC/MS/MS). IDO activity was low or absent in the brains of uninfected mice and NCM mice (days 6 and 7 p.i.) and was induced strongly in the brains of fatal murine CM mice (days 6 and 7 p.i.) and NCM animals (days 13 to 17 p.i.). This induction was inhibited greatly by administration of dexamethasone, a treatment that also prevented CM symptoms and death. Furthermore, IDO induction was absent in IFN-gamma gene knockout mice, which were also resistant to CM. Brain concentrations of Kyn, 3-hydroxykynurenine, and the neuro-excitotoxin QA were significantly increased in both CM mice on days 6 and 7 p.i. and NCM mice on days 13 to 17 p.i., whereas an increase in the ratio of brain QA to KA occurred only in the CM mice at the time they were exhibiting cerebral symptoms. Brain concentrations of Glu and Asp were significantly decreased in CM and NCM mice (days 13 to 17 p.i.). The results imply that neuro-excitation induced by QA may contribute to the convulsions and neuro-excitatory signs observed in CM.

Validity and reliability of subject and mother reporting of perinatal factors

The authors used data from a population-based case-control study of breast cancer in women aged < or = 44 years (cases, n = 975; controls, n = 866) conducted between 1994 and 1996 in three counties of western Washington state to assess the validity and reliability of reported perinatal factors. For a sample of participants, exposure information from self-administered questionnaires was validated with information from birth certificates (cases, n = 378; controls, n = 283). Detailed information regarding perinatal characteristics of their daughters was also collected from subjects' mothers (case mothers, n = 510; control mothers, n = 436) to assess the reliability of subjects' reporting of these events. Although reporting of birth weight by subjects (cases, r = 0.83; controls, r = 0.80) and their mothers (case mothers, r = 0.89; control mothers, r = 0.84) was highly correlated with the birth certificates, there was differential measurement error by subjects; cases reported birth weight accurately on average, but controls tended to underestimate their birth weight. Agreement between the subject and mother report was excellent for birth weight (cases, r = 0.85; controls, r = 0.87) and good for other perinatal factors, but birth order and maternal diethylstilbestrol use were underreported among cases and reported accurately among controls. Differential measurement error of birth weight by case-control status resulted in biased odds ratios for breast cancer risk.

Evaluation of amperometric detection for the liquid-chromatographic determination of tetracycline antibiotics and their common contaminants in pharmaceutical formulations

A sensitive high-performance liquid chromatographic technique with amperometric detection has been developed for the determination of seven commercially used tetracyclines in bulk powders and pharmaceutical preparations. The technique is based on the oxidation of these compounds and their contaminants at the glassy carbon electrode. The extraction procedures are simple and the HPLC conditions separate the tetracyclines from their major degradation products. The chromatography was performed using a commercially available octadecylsilane column, with a mobile phase: KH2 PO4 (pH = 2.5; 0.05 M) - acetonitrile (84:16, v/v) and detection at 1.2 V. The technique permits the simultaneous determination of trace amounts of chlortetracycline, demeclocycline, doxycycline, methacycline, minocycline, oxytetracycline and tetracycline as well as the separation of their common impurities (epi, anhydro and epianhydro contaminants) with detection limits of 0.1-1.0 ng microl(-1) and recoveries of 99.1-100.4%. No interference was observed from the commonly present excipients in pharmaceutical formulations.

Biological and lifestyle factors, and lipid and lipoprotein levels among Japanese Americans in Seattle and Japanese men in Japan

BACKGROUND

It has been previously shown that Japanese Americans in Seattle have significantly higher cholesterol levels than native Japanese. The present study examines the association of biological and lifestyle factors with plasma lipid and lipoprotein levels among Japanese Americans (JA) and native Japanese (NJ) to determine if these associations are consistent between these high and low cholesterol populations.

METHODS

Study samples consisted of 710 JA male and 728 JA female volunteers living in the Seattle area and a random sample of 3833 NJ male urban workers who participated in parallel cardiovascular disease screening and lifestyle surveys for 1989-1994. Multiple regression analysis was conducted to examine the association of lifestyle and biological factors with lipid and lipoprotein levels.

RESULTS

Alcohol consumption was positively and linearly associated with high density lipoprotein cholesterol (HDL-C) levels and negatively associated with both low density lipoprotein cholesterol (LDL-C) levels and the ratio of total cholesterol (TC)/HDL-C (P < 0.05 to P < 0.001) among JA males and JA females and NJ males. Current smoking habit was observed to be negatively associated with HDL-C levels and positively with TC/HDL-C ratio and log TG levels (logarithmic transformation of triglyceride values) (P < 0.05 to P < 0.001) among all three groups. Body mass index (BMI) was negatively associated with HDL-C levels and positively associated with log TG and TC/HDL-C ratio among all three groups (P < 0.05 to P < 0.001). Moderate alcohol consumption was negatively associated with log TG levels among JA males and females (P < 0.05), whereas heavy alcohol consumption was positively associated with log TG levels in NJ males (P < 0.001). Smoking was positively associated with TC and LDL-C levels (P < 0.05) among JA males, whereas a negative association (P < 0.05) was observed in NJ males.

CONCLUSION

Overall, the fitted models were consistent between JA males and females and NJ males with the exception of smoking on TC and LDL-C. The results suggest that moderate alcohol consumption favourably influences lipid profiles in both high and low cholesterol populations. The results also indicate that light alcohol consumption is associated with decreased triglyceride levels, whereas heavy alcohol consumption is associated with increased triglyceride levels.

Separation and characterization of cholesteryl oxo- and hydroxy-linoleate isolated from human atherosclerotic plaque

In previous work we demonstrated that up to 30% of cholesteryl linoleate in homogenates of advanced human plaque samples is present in oxidized forms. Here we show that the material from plaque hexane extracts which co-elutes with cholesteryl hydroxy-linoleate on reversed phase HPLC (Anal Biochem 1993;213:79), is composed of several isomers of cholesteryl hydroxy- and cholesteryl oxo-octadecadienoate. Enzymatic hydrolysis and measurement of liberated cholesterol and disappearance of the esters revealed that almost all of the material consisted of unoxidized cholesterol esterified to oxidized derivatives of octadecadienoate. Semi-preparative reversed-phase HPLC was used to obtain sufficient quantities of this co-eluting material to undertake normal phase HPLC separation of these components. The nature of such separated and isolated compounds was identified, by co-chromatography with authentic standards, UV spectroscopy and chemical ionization and electron impact mass spectrometry, as cholesteryl hydroxy- and cholesteryl oxo-octadecadienoate. These oxidized fatty acids have been observed previously in plaque, in agreement with our new unambiguous demonstration of their presence as cholesteryl esters. The application of the methods described for the separation of the various forms of oxidized cholesteryl octadecadienoate may aid mechanistic studies of in vitro and in vivo lipoprotein lipid oxidation.

Utility of follicle stimulating hormone (FSH), luteinizing hormone (LH), oestradiol and FSH:LH ratio in predicting reproductive age in normal women

The relative efficacy of follicle stimulating hormone (FSH), luteinizing hormone (LH), FSH:LH ratio and oestradiol is evaluated as a predictor of ovarian reserve (reproductive age) in normal women. Serum levels of FSH, LH, oestradiol and FSH:LH ratios were measured during menstrual cycle days 1-4 in younger (20-25 years; n = 23) and older (40-45 years; n = 32) reproductive age women with regular menstruation and normal reproductive function. On days 1-4, mean levels of FSH, oestradiol and FSH:LH ratios were significantly higher in older compared with younger women. FSH increased in concentration across cycle days in both age groups. A significantly lower LH value in younger versus older women was found only on day 1. Oestradiol showed no change across days in the younger group, but increased significantly from day 1 to day 4 in the older group. FSH values on days 1 or 2 were the best single predictor of age differences. However, the best prediction of age differences was obtained by using the combination of FSH and LH (as opposed to the FSH:LH ratio) on day 1 of the menstrual cycle.

Photosensitizing activity of the anti-bacterial drugs sulfamethoxazole and trimethoprim

The photochemical reactions in vitro of sulfamethoxazole alone and in combination with trimethoprim were studied to obtain information on the photosensitization mechanism. Sulfamethoxazole in aqueous solution, on exposure to UVB radiation, generates free radicals and singlet oxygen, with the neutral molecule being at least twice as active as the sulfamethoxazole anion. Photoexcited sulfamethoxazole can participate in electron transfer to cytochrome-c and nitro blue tetrazolium, and sensitizes the peroxidation of linoleic acid and the hemolysis of human erythrocytes, predominantly by a free radical mechanism. Trimethoprim is relatively inactive in the same photochemical systems.

Clinical value of radiologists' interpretations of perioperative radiographs of orthopedic patients

The content and accuracy of radiographic interpretations by radiologists was assessed to determine the reports' ability to provide sufficient information necessary to make clinical treatment decisions. A retrospective review was performed of 371 radiographic studies (211 consecutive patients) and their reports which had been generated by three Board-certified radiologists. Data were collected regarding fracture assessment and description as well as the description and assessment of orthopedic implants. These descriptions were categorized by their ability to be used clinically (precise) or not (general). Fracture descriptions were considered complete for 85% of reports, while their assessment of alignment and displacement (necessary to determine fracture care) was complete on only 9%. Orthopedic implants were described precisely on 12% of reports with 7% of the descriptions in error. The effect and position of orthopedic implants were described precisely for only 27% and 25% of cases, respectively, while implant stability was assessed precisely in only 4% of cases. For 61% of preoperative studies, the radiologist's report was not available until after the surgical procedure had already been performed. For all variables considered, an average of 3% of descriptions contained an error. Radiologists' reports of radiographs of these patients undergoing orthopedic procedures did not contain sufficient descriptive information to be used clinically, were not promptly available, and contained an error for 3% of variables studied. The attending orthopedic surgeon has traditionally interpreted such radiographs and should continue to do so to provide patients with more immediate and complete clinical evaluation and management.

Selective uptake of boronated low-density lipoprotein in melanoma xenografts achieved by diet supplementation

The lipid core of human plasma low-density lipoprotein (LDL) was extracted using hexane and the LDL reconstituted with the addition of n-octyl-carborane. Biodistribution studies of the boronated LDL were performed in BALB/c mice bearing subcutaneous Harding-Passey melanoma xenografts. When diet supplementation with coconut oil and cholesterol for 21 days and regular dosing with hydrocortisone for 7 days before the studies was used to down-regulate the liver LDL receptors and the adrenal receptors, respectively, the tumour-blood boron concentration ratio of 5:1 was achieved.

Risk of breast cancer in a cohort of infertile women

The purpose of this study was to assess: (1) the risk of breast cancer associated with use of ovulation-inducing agents (such as clomiphene citrate) as treatment for infertility; and (2) the risk associated with ovulatory abnormalities that result in infertility. We performed a case-cohort study among 3837 women evaluated for infertility at clinics in Seattle, Washington, at some time during 1974-1985. Computer linkage with a population-based tumor registry was used to identify women diagnosed with breast cancer before January 1, 1992. Data regarding infertility testing and treatment were abstracted from the infertility clinic medical records for women who developed breast cancer and a randomly selected subcohort. Twenty-seven women in the cohort developed in situ or invasive breast cancer, in comparison with an expected number of 28.8 cases (standardized incidence ratio, 0.9; 95% confidence interval (CI), ).6-1.4). Infertile women with evidence of an ovulatory abnormality were at a risk of breast cancer similar to that of women whose infertility was believed to be due to other causes. The risk among women who had taken clomiphene was reduced relative to infertile women who had not used this drug (adjusted relative risk, 0.5; 95% CI, 0.2-1.2), but the reduction in risk did not increase with duration of use. The possibility that use of clomiphene as treatment for infertility lowers the risk of breast cancer should be examined in other, larger studies.

In situ and invasive cervical carcinoma in a cohort of infertile women

OBJECTIVE

To assess the risk of cervical neoplasia associated with the use of ovulation-inducing agents such as clomiphene citrate (CC) DESIGN: Case-cohort study.

SETTING

Infertility clinics in Seattle, Washington.

PATIENTS

A cohort of 3,837 women evaluated for infertility at some time during 1974-1985.

MAIN OUTCOME MEASURE

Computer linkage with a population-based tumor registry was used to identify women diagnosed with cervical cancer before January 1, 1992. Data regarding infertility testing and treatment were abstracted from medical records for women who developed cancer and a randomly selected subcohort.

RESULTS

Thirty-six women in the cohort developed in situ or invasive cervical cancer in comparison with an expected number of 67.8 cases (standardized incidence ratio = 0.5, 95% confidence interval [CI] 0.4 to 0.7). Infertile women with fallopian tube abnormalities were at an increased risk of cervical cancer relative to women whose infertility was believed to be due to other causes. The risk among women who had taken CC was reduced relative to infertile women who had not used this drug (relative risk = 0.4, 95% CI 0.2 to 0.8). This association was present both in women with and without tubal abnormalities. However, the size of the reduction in risk was not influenced by duration of use.

CONCLUSIONS

The hypothesis that use of antiestrogenic agents, such as CC, can lead to a reduced risk of cervical neoplasia warrants testing in other studies.

Population-based study of tamoxifen therapy and subsequent ovarian, endometrial, and breast cancers

BACKGROUND

The success of tamoxifen in reducing the occurrence of contralateral breast cancer among breast cancer patients in clinical trials has prompted the study of its use in the primary prevention of breast cancer. Long-term risks associated with tamoxifen therapy, however, are still being evaluated, particularly with respect to subsequent cancer occurrence at sites other than the breast.

PURPOSE

This population-based, nested case-control study investigated the risks of second primary cancers of the ovary, endometrium, and contralateral breast among women receiving tamoxifen for breast cancer in conventional medical practice.

METHODS

A cohort of women diagnosed with breast cancer during 1978 through 1990 was identified from a population-based cancer registry. Case subjects included all women in the cohort who subsequently developed second primary ovarian (n = 39), endometrial (n = 42), or contralateral breast (n = 234) cancer prior to 1992. Control subjects were a random sample of the cohort who did not develop a second primary malignancy; they were matched to the case subjects on age, disease stage, and year of initial breast cancer diagnosis (approximately two control subjects per case subject). Information on tamoxifen use as well as on potential risk factors for the second primary cancers was obtained through medical record abstractions and physician questionnaires.

RESULTS

The percentage of women who had received tamoxifen was 18% and 20%, respectively, among ovarian cancer case subjects and control subjects; 26% and 31%, respectively, among endometrial cancer case subjects and control subjects; and 10% and 18%, respectively, among contralateral breast cancer case subjects and control subjects. The mean duration of tamoxifen use was less than 2 years for all groups. The relative risks for ovarian and endometrial cancers in women who took tamoxifen were relatively low but were consistent with no association (for ovarian cancer, matched odds ratio [mOR] = 0.6 and 95% confidence interval [CI] = 0.2-1.8; for endometrial cancer, mOR = 0.6 and 95% CI = 0.2-1.9). Tamoxifen therapy was associated with a decreased risk of contralateral breast cancer (mOR = 0.5; 95% CI = 0.3-0.9), especially if the drug had been taken for more than 1 year (mOR = 0.4; 95% CI = 0.2-0.9) or if the women were postmenopausal at initial breast cancer diagnosis (mOR = 0.4; 95% CI = 0.2-0.8).

CONCLUSIONS AND IMPLICATIONS

These data suggest that short durations of tamoxifen therapy are not associated with an increased risk of endometrial or ovarian cancer but are associated with a reduction in contralateral breast cancer risk. It would not be appropriate, however, to generalize these results to women who receive tamoxifen for longer periods.

Risk of cutaneous melanoma in a cohort of infertile women

We assessed the risk of cutaneous malignant melanoma associated with the presence of ovulatory abnormalities and with the use of ovulation-inducing agents (such as clomiphene citrate) in a cohort of 3,837 women evaluated at infertility clinics in Seattle, WA, between 1974 and 1985. Computer linkage with a population-based tumour registry was used to identify women diagnosed with melanoma before 1992. Data regarding infertility testing and treatment were abstracted from the infertility clinic medical records for women who developed cancer and a randomly selected subcohort. Twelve women in the cohort developed cutaneous malignant melanoma, in comparison with an expected number of 6.8 cases (standardized incidence ratio = 1.8; 95% confidence interval (CI) 0.9-3.1). Within the cohort, risk was increased among women who had used clomiphene during 12 or more menstrual cycles (relative risk = 2.2; 95% CI 0.5-10.2). All four of the women with this duration of clomiphene use who developed melanoma had ovulatory abnormalities, and three had also used human chorionic gonadotropin (HCG). No elevation in risk associated with the presence of ovulatory abnormalities was observed in the absence of at least 12 cycles of clomiphene exposure; also, there was no increased risk associated with long-term use of clomiphene among women without ovulatory abnormalities, but the number of such women was very small. Thus, it is not certain to what extent the observed increased risk of melanoma in this cohort (if not due to chance) may be attributable to the use of clomiphene or HCG, or is a reflection of some underlying hormonal abnormality for which the drug was administered.

Effect of L-10B-p-boronophenylalanine-fructose and the boron neutron capture reaction on mouse brain dopaminergic neurons

Radiation damage to the dopamine tracts caused by enriched L-10B-p-boronophenylalanine (L-10BPA)-fructose and the boron neutron capture reaction was investigated using the mouse model. Following various treatments with L-10BPA and neutron irradiation of the head, the brain was perfusion fixed and removed; 50-microns frozen sections were cut. Dopaminergic neurons were visualized using immunohistochemistry for tyrosine hydroxylase. The administration of L-10BPA had no permanent effect on dopaminergic tracts. Neutron capture therapy with L-10BPA caused a reduction in tyrosine hydroxylase immunohistochemical activity within 4 h of irradiation, but by 48 h, this reduction reversed. No damage was observed at 120 h postirradiation.

Photochemical sensitization by azathioprine and its metabolites. Part 3. A direct EPR and spin-trapping study of light-induced free radicals from 6-mercaptopurine and its oxidation products

Sunlight has been implicated in the high incidence of skin cancer found in patients receiving 6-mercaptopurine (PSH) in the form of its pro-drug azathioprine. In this study we have used EPR spectroscopy in conjunction with the spin-trapping technique to determine whether PSH and its metabolic or photochemical oxidation products generate highly reactive free radicals upon UV irradiation. When an aqueous anaerobic solution (pH 5 or 9) of PSH (pKa = 7.7) and either 2-methyl-2-nitrosopropane (MNP) or nitromethane (NM) were irradiated (lambda > 300 nm) with a Xe arc lamp, the corresponding purine-6-thiyl (PS.) radical adduct and the reduced form of the spin trap (MNP/H. or CH3NO2.-) were observed. However, no radical adducts were detected when PSH and 5,5-dimethyl-1-pyrroline-N-oxide (DMPO) were irradiated (lambda = 320 nm) in oxygen-free buffer. These findings suggest that PSH does not photoionize but that instead MNP and NM are reduced by direct electron transfer from excited state PSH, 1.3(PSH)*. In aerobic solution, oxygen can act as an electron acceptor and the O2.- and PS. radicals are formed and trapped by DMPO. 6-Mercaptopurine did photoionize when irradiated with a Nd:YAG laser at 355 nm as evidenced by the appearance of the DMPO/H.(eq- + H+) adduct, which decreased in intensity in the presence of N2O. 1.3(6-Mercaptopurine)* oxidized ascorbate, formate and reduced glutathione to the corresponding ascorbyl, CO2.- or glutathiyl radicals. The photochemical behavior of 6-thioxanthine and 6-thiouric acid was similar to PSH. However, the excited states of these metabolic oxidation products exhibited stronger reducing properties than 1.3(PSH)*.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian tumors in a cohort of infertile women

BACKGROUND

Case reports and the results of a recent case-control study have raised questions about the potential neoplastic effects of medications used as treatment for infertility.

METHODS

We examined the risk of ovarian tumors in a cohort of 3837 women evaluated for infertility between 1974 and 1985 in Seattle. Computer linkage with a population-based tumor registry was used to identify women in whom tumors were diagnosed before January 1, 1992. Data on infertility testing and treatment were abstracted from the medical records of women who had ovarian cancer and those of a randomly selected comparison group. The risk of ovarian tumors associated with exposure to ovulation-inducing medications was assessed through an age-standardized comparison with the rate of ovarian tumors in the general population, and Cox regression analysis was used to compare the risk of cancer among women who received these medications with the risk among infertile women who did not receive them.

RESULTS

There were 11 invasive or borderline malignant ovarian tumors, as compared with an expected number of 4.4 (standardized incidence ratio, 2.5; 95 percent confidence interval, 1.3 to 4.5). Nine of the women in whom ovarian tumors developed had taken clomiphene; the adjusted relative risk among these women, as compared with that among infertile women who had not taken this drug, was 2.3 (95 percent confidence interval, 0.5 to 11.4). Five of the nine women had taken the drug during 12 or more monthly cycles. This period of treatment was associated with an increased risk of ovarian tumors among both women with ovarian abnormalities and those without apparent abnormalities (relative risk, 11.1; 95 percent confidence interval, 1.5 to 82.3), whereas treatment with the drug for less than one year was not associated with an increased risk.

CONCLUSIONS

Prolonged use of clomiphene may increase the risk of a borderline or invasive ovarian tumor.

Reduction of Permeability in Granite at Elevated Temperatures

The addition of hydrothermal fluids to heated, intact granite leads to permeability reductions in the temperature range of 300 degrees to 500 degrees C, with the rate of change generally increasing with increasing temperature. The addition of gouge enhances the rate of permeability reduction because of the greater reactivity of the fine material. Flow rate is initially high in a throughgoing fracture but eventually drops to the level of intact granite. These results support the fault-valve model for the development of mesothermal ore deposits, in which seals are formed at the base of the seismogenic zone of high-angle thrust faults. The lower temperature results yield varying estimates of mineral-sealing rates at shallower depths in fault zones, although they generally support the hypothesis that such seals develop in less time than the recurrence interval for moderate to large earthquakes on the San Andreas fault.

Aedes albopictus distribution, abundance, and colonization in Lee County, Florida, and its effect on Aedes aegypti

In 1992 the known southern limit of Aedes albopictus in Florida was in Lee County. Through oviposition surveillance, the distribution of Ae. albopictus was determined, and its frequency relative to Aedes aegypti and colonization pattern of areas previously occupied by Ae. aegypti were examined in Lee County. The data collected in the first year of surveillance demonstrate the ability of Ae. albopictus to rapidly and preferentially colonize large expanses of rural southwest Florida. Urban and suburban areas of the county showed slower colonization rates. In suburban areas, Ae. albopictus became the dominant container-breeding mosquito species, whereas it did not become dominant in urban areas. During the study period, Ae. albopictus did not displace Ae. aegypti in urban or suburban habitats. The southern limit of Ae. albopictus moved a distance of 8.1 km (5 mi.) in 6 wk to the southern border of the county.

Fourier transform infrared (FTIR) spectrometry for the assay of polyhedral boron compounds in plasma and pharmaceutical formulations

The determination of polyhedral boron compounds such as sodium borocaptate directly in blood plasma is described using FTIR with computed nonlinear background subtraction of the water absorption band. The procedure can be performed in less than 15 min to a sensitivity level of 5 ppm boron (as a signal/noise ratio of 2.5), which is satisfactory in the clinical application of such compounds in neutron capture therapy of cancer. For boron compounds with suitable organic solubility, extraction from plasma into carbon tetrachloride is described as an alternative approach not requiring computed subtraction and capable of achieving a sensitivity level of 1 ppm. Both the boron and the lipid content of liposome formulations containing the polyhedral boron compounds can be measured simultaneously by FTIR. After extraction into CHCl3:CH3OH (1:1) or dispersion in ethanol, the extracts are evaporated to dryness and redissolved in carbon tetrachloride for FTIR assay.

Photodegradation of sulfamethoxazole: a chemical system capable of monitoring seasonal changes in UVB intensity

Sulfamethoxazole (SMX) in its nonionized form in aqueous solution has ultraviolet (UV) absorption that is maximal at 268 nm but extends through the ultraviolet-B (UVB) region. It was found to be extremely susceptible to photodegradation when exposed to artificial UV radiation through a Pyrex filter or to unfiltered natural sunlight. The SMX anion was more stable. The quantum yields of the photodegradation of both forms were determined by use of monochromatic light and ferrioxalate chemical actinometry, the values of 0.47 (pH 3.0) and 0.084 (pH 9.0) at the maximum absorption wavelengths (268 and 257 nm, respectively) being obtained. Using literature data on sunlight intensity, the photochemical shelf-life of SMX solutions exposed to direct sunlight was calculated for Sydney (latitude 33.5 degrees S) as a function of season of the year and verified experimentally. A fixed correlation was established between the rate constant for SMX degradation and UVB intensity measured by a radiometer, suggesting the capacity of this chemical system to monitor changes in the UVB region of sunlight.

Cigarette smoking and functional ovarian cysts

This population-based case-control study assessed the effect of current cigarette smoking on the risk of functional ovarian cyst development. Cases were all 15-39 year-old enrollees of Group Health Cooperative of Puget Sound (GHC) who had either an inpatient primary diagnosis of functional ovarian cyst in 1988 or 1989 (n = 61) or an outpatient primary diagnosis of functional ovarian cyst at five GHC primary care clinics (n = 37). Controls were randomly selected enrollees matched to cases on age, primary care clinic, and enrollment date (n = 239). A total of 36.7% of cases and 20.5% of controls were determined by medical record review to be current smokers. Compared with women who were not current smokers, the relative risk of a diagnosed functional ovarian cyst among smokers was 2.0 (95% confidence interval 1.1-3.5). This finding, in an area of little previous research, provides a promising lead in the investigation of the etiology of functional ovarian cysts and the effects of smoking on ovarian function in general.

The pharmacokinetics of p-Boronophenylalanine.fructose in human patients with glioma and metastatic melanoma

PURPOSE

To study the biodistribution of p-Boronophenylalanine in patients undergoing surgery for intracranial tumors or metastatic melanoma.

METHODS AND MATERIALS

D,L-p-Boronophenylalanine was administered as boronophenylalanine.fructose in an intravenous bolus 1-4 h before the operation. Blood samples were collected for 24 h from the time of administration of the compound, and the blood boron elimination parameters were determined. For the glioma patients tumor samples were obtained and skin, dura, periosteum, and surrounding brain samples were collected whenever possible. For the metastatic melanoma patients tumor, fat, skin, and muscle were collected. Determination of the boron content was performed using inductively coupled plasma-atomic emission spectrometry. Twelve melanoma patients and six glioma patients participated in the study. The melanoma patients included four cases of cutaneous metastatic melanoma, six cases of metastatic melanoma to the lymph nodes and two cases of cerebral metastasis.

RESULTS

The results for the metastatic melanoma patients are encouraging with an average tumor:blood boron concentration ratio and standard deviation of about 4.4 +/- 3.2 and a maximum value of 10 for the cerebral metastasis. The glioma patients involved high grade glioma for which the tumor:blood ratio was 2.2 +/- 1.2.

CONCLUSION

The tumor:blood ratios for melanoma fulfil requirements for epithermal boron neutron capture therapy for cerebral melanoma metastases, whereas those for high grade glioma do not.

The association between Chlamydia trachomatis serology and pelvic damage in women with tubal ectopic gestations

OBJECTIVE

To determine whether pelvic damage is associated with positive Chlamydia trachomatis serology in women with tubal ectopic pregnancy.

DESIGN

Cross-sectional retrospective study.

SETTING

A prepaid health maintenance organization.

PATIENTS

Two-hundred eighty-one women admitted with confirmed tubal ectopic pregnancy were interviewed for history of sexually transmitted diseases. Chlamydia serology was obtained for 135 subjects, and operative findings were available for 121 of these.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Pelvic damage, as determined by review of operative findings of the pelvis at the time of ectopic surgery.

RESULTS

Pelvic damage was associated with positive chlamydia serology with an adjusted odds ratio of 4.2 (95% confidence interval: 1.8 to 9.7). Moderate and severe pelvic damage were more strongly associated with positive serology than mild damage.

CONCLUSIONS

Women with ectopic pregnancies and antibodies to C. trachomatis are more likely to have damaged pelves than women with ectopic pregnancies without such antibodies. Prevention or early treatment of C. trachomatis infection may reduce pelvic damage and, therefore, reduce incidence of ectopic pregnancy.

Detection of Chlamydia trachomatis deoxyribonucleic acid in women with tubal infertility

OBJECTIVE

To determine the presence of Chlamydia trachomatis by in situ hybridization in fallopian tube tissues of women with distal tubal occlusion.

PATIENTS

Subjects were selected from a Seattle-based study of infertility in women with distally occluded fallopian tubes undergoing reconstructive surgery. For comparison, six specimens were obtained from women undergoing surgery for noninfertility-related conditions who had normal appearing tubes.

METHODS

Tissue specimens from 16 of these patients were selected for analysis by in situ hybridization and immunoperoxidase (IP) staining.

RESULTS

C. trachomatis was detected in 9 of 16 women by either in situ hybridization or IP. Six of the nine were seropositive with titers ranging from 1:16 to 1:64. Tissue from 6 women with normal appearing fallopian tubes were negative by in situ hybridization.

CONCLUSIONS

The demonstration of C. trachomatis deoxyribonucleic acid and/or antigens in fallopian tube tissue from infertile women with distal tubal disease suggests that C. trachomatis can persist in these tissues in an uncultivable state.

Hydrostatic pulmonary edema in sheep. Effects of bronchial artery embolization on the plain chest radiograph

RATIONALE AND OBJECTIVES

The bronchial circulation may influence pulmonary edema. This study evaluates possible effects of bronchoesophageal artery embolization on the plain film manifestations of hydrostatic pulmonary edema in sheep.

METHODS

Anteroposterior and lateral chest radiographs were obtained during the induction of pulmonary edema both before and after embolization of the bronchoesophageal artery in six adult sheep. Interstitial lines and perivascular, segmental bronchial, proximal bronchial, carinal, tracheal, and parenchymal edema were evaluated.

RESULTS

Only parenchymal edema was graded consistently. Though edema increased with left atrial pressure before embolization (P < .001), there was no similar change afterward. The embolized animals tended to be more edematous by the first film.

CONCLUSION

Rather than any protective effect, bronchoesophageal artery embolization may increase edema. This model may be inappropriate for further investigation of the bronchial circulation in the development of human pulmonary edema.

Local control of subcutaneous murine melanoma xenografts in nude mice by neutron capture therapy

The systemic administration of enriched [10B]D,L-p-boronophenylalanine results in the selective uptake of boron by Harding-Passey melanoma xenografts in the nude mouse model. The boron-10 located in the tumour cells acts as a radiation sensitizer for thermal neutron irradiation. The nude mouse model can be successfully used to demonstrate that regression and local control of melanoma can be achieved by neutron capture therapy. Control is a manifestation of the high linear energy transfer radiation released after neutron capture by boron-10, and does not result from an equal fluence of neutrons alone. Histological examination of remnant tumour beds 300 days after treatment shows the presence of isolated melanoma cells. However, these cells are few in number and appear incapable of division.

Early luteal progesterone supplementation during in vitro fertilization cycles. A randomized trial

The effects of early luteal phase progesterone (P) supplementation were studied in women with endogenous serum P levels less than or equal to 12 ng/mL prior to embryo transfer. From a total of 129 cycles that received the same ovarian hyperstimulation protocol, 72 cycles were characterized by levels less than 12 ng/mL on the day prior to embryo transfer. Of those women, 42 (group B) were started on P supplementation one day prior to embryo transfer, and 30 (group C) were started according to the standard protocol after embryo transfer. The clinical course and outcomes in both groups were compared with 57 cycles that had P levels greater than or equal to 12 ng/mL (group A). The early P supplementation in group B resulted in a transient increase in P levels on the morning of embryo transfer as compared with group C. It did not, however, approach the levels seen in group A, which had higher P levels from the early luteal phase through embryo transfer and more favorable oocyte recovery, fertilization and cleavage rates. We were unable to improve the clinical outcome in group B as compared with group C by providing earlier P supplementation.

Risk factors for tubal infertility. Influence of history of prior pelvic inflammatory disease

In order to explore possible etiologic differences between tubal infertility in women who had been physician-diagnosed as having pelvic inflammatory disease ("overt" PID) and in women who had not ("silent" pelvic inflammatory disease), we made use of self-reported data from a large, population-based, case-control study of infertility in King County, Washington. Responses from 33 infertile women with no history of physician-reported PID and 129 infertile women with such a history were compared to those of 501 fertile women. No cultures or blood for antibody titers were obtained. Logistic regression was used to compute the relative risks for silent and overt PID-related tubal dysfunction associated with various lifestyle and contraceptive habits in an effort to identify practices that potentially affect these outcomes. In general, practices associated with an increased risk of overt tubal disease, such as use of Dalkon Shield and other types of intrauterine devices, were also associated with an increased risk of silent tubal disease, but to a lesser extent. Women who used oral contraceptives for longer than three years had a decreased risk for silent disease (relative risk = 0.5, 95% confidence interval = 0.3-0.8), but their risk for overt disease did not decrease to the same extent (relative risk = 0.9, 95% confidence interval = 0.3-2.5). These results suggest that silent and overt tubal disease share many common lifestyle risk factors.

Medical treatment of endometriosis: a comparison of the suppressive effects of danazol and nafarelin on reproductive hormones

OBJECTIVE

Patients with endometriosis were studied to investigate hormonal suppression by the gonadotropin-releasing hormone against nafarelin acetate compared with danazol. We hypothesized that the pattern, time course, and degree of gonadotropin and ovarian suppression would be different.

DESIGN

The study included 16 patients who were randomized into one of three 6-month treatment protocols.

SETTING

Patients were recruited from a university hospital setting.

PATIENTS

Eligible candidates were 18 to 45 years of age, with regular menses and documented pelvic endometriosis.

INTERVENTION

Six-month treatment protocols included nafarelin 800 or 400 micrograms/d, or danazol 800 mg/d.

MAIN OUTCOME MEASURES

Serum estradiol (E2), progesterone (P), luteinizing hormone (LH), and follicle-stimulating hormone were determined before treatment and then monthly. Thirteen patients consented to a 12-hour hospital admission during the 5th and 6th month of treatment to determine LH pulse frequency and amplitude.

RESULTS

Estradiol and P were suppressed in all groups, but E2 significantly more by nafarelin than danazol (P less than or equal to 0.01). Nafarelin, 800 micrograms, significantly depressed LH pulse amplitude compared with danazol (P less than or equal to 0.05). Two patients in the nafarelin group had the administration of their medication observed, and both demonstrated single, high-amplitude pulses immediately after administration.

CONCLUSION

Nafarelin is a more potent LH and E2 suppressor than danazol, and the agonist effect of nafarelin may continue to provoke transient gonadotropin responses despite long-term therapeutic suppression.

Moving from "small qa" to "large qa". An outcomes framework for improving quality management

In this article we describe an "outcomes framework" for planning and analyzing quality management systems in relation to their ultimate purpose, enhancing the wide range of health care benefits. "Small qa" includes those methods that focus on structure or process and induce improvement of outcomes. These methods are essential but, predictably, often involve minimal improvement of health care. "LARGE QA" is defined as those methods that focus on unacceptable outcomes and deduce processes and structures to be changed to enhance outcomes. These methods focus on either "problems" or "opportunities" that predict substantial improvement in health care benefits. We briefly describe and analyze this outcomes framework for quality management in terms of its conceptual factors and its current and future emphasis. We then describe several major national program developments and resources that will facilitate moving the balance of quality management effort from small qa to LARGE QA.

Selective fallopian tube canalization

Infertility is an increasingly common problem. Occlusion of the fallopian tubes is one of the principal causes, and until recently surgery was the only available treatment. The success rate of surgery is often low, particularly with occlusion of the proximal tube. Selective fallopian tube canalization under fluoroscopic guidance has been successful in alleviating proximal tubal obstruction. This procedure may be performed in the outpatient setting and is a safe, cost-effective alternative to surgery.

Comparison of nonionic and ionic contrast agents in the rabbit lung

The objective of this study was to determine the short- and long-term radiographic, physiologic and histologic changes elicited in the lung of rabbits following the aspiration of commonly used radiographic contrast agents. All agents used, including nonionic agents, caused radiographically evident pulmonary edema which cleared by 24 hours. The contrast materials with higher osmolality, viscosity, and iodine content elicited the greatest physiologic and pathologic changes. No differences were found between an ionic and a nonionic agent with similar viscosities and iodine content, despite a lower osmolality in the nonionic agent. No contrast agent is innocuous when introduced into the lung.

Liquid chromatography with amperometric detection for the determination of non-steroidal anti-inflammatory drugs in plasma

A simple and sensitive liquid chromatographic method with electrochemical detection is described for the quantitative determination of the non-steroidal anti-inflammatory drugs diflunisal, indomethacin, naproxen, piroxicam and sulindac in human plasma. Isolation of the drug from the biological fluid is achieved using a Sep-pak RP18 cartridge. Separation of plasma components occurs on a reversed-phase C18 column with a mobile phase consisting of methanol-water-phosphate buffer. For the amperometric detection the potential of +0.9 V was set on the working electrode. The detection limit of the assay is 10-20 ng/ml. The method showed good concordance for plasma samples containing the drugs (r = 0.999) and can be readily utilized for clinical pharmacokinetic studies.

Photochemical studies on the anti-inflammatory drug diclofenac

Irradiation with UVA light of the anti-inflammatory drug diclofenac [2-(2,6-dichloroanilino)phenylacetic acid] in aqueous buffer or methanol solution leads to sequential loss of both chlorine substituents and ring closure to carbazole-1-acetic acid as the major product. Minor products result from substitution by the solvent. The photosensitizing properties of diclofenac and its major photoproduct were tested with singlet oxygen substrates and in the free radical polymerization of acrylamide. Although the major carbazole product is a weakly phototoxic agent, able to generate singlet oxygen more efficiently than diclofenac, the free radical photodechlorination process is postulated as the probable initiation step of in vivo photosensitivity responses.