Zuclopenthixol, D1/D2 antagonist, for treatment of chronic aggressive schizophrenia and psychotic oligophrenic patients

An open label trial was conducted to study the efficacy of zuclopenthixol decanoate, a D1/D2 antagonist, in the treatment of chronic (> 10 years) neuroleptic-resistant aggressive schizophrenia (n = 10) and psychotic oligophrenic patients (n = 6). A significant reduction was noted in the Brief Psychiatric Rating Scale score, especially in the clusters of hostility-suspiciousness and excitement. After many years of seclusion, ten of the 16 patients were transferred to an open psychiatric department and were allowed to visit their families.

Outcomes of a prospective multi-center trial of a second-generation composite mesh for open ventral hernia repair

PURPOSE

Composite mesh prostheses incorporate properties of multiple materials for use in open ventral hernia repair (OVHR). This study examines clinical outcomes in patients who underwent OVHR with a polypropylene/expanded polytetrafluoroethylene (ePTFE) composite graft containing a novel polydioxanone (PDO) absorbable ring to facilitate placement and graft positioning.

METHODS

Data were prospectively collected on consecutive patients undergoing OVHR using a synthetic composite mesh. Seven centers enrolled patients during the study period. All patients underwent a standardized surgical procedure consisting of OVHR with sublay intraperitoneal placement of mesh. Mesh fixation was accomplished with peripheral tacks and transfascial sutures.

RESULTS

One hundred and nineteen patients underwent OVHR with the composite mesh. Average age was 55.8 years; there were 71 (59.7 %) females and 48 (40.3 %) males with mean BMI of 33.5 ± 7.1 kg/m(2). One hundred and two (85.7 %) patients presented with primary ventral hernias. Mean defect size was 13.6 cm(2), and mean mesh size was 113.6 cm(2). Most patients (67 %) were discharged the day of surgery. Twelve patients (10.1 %) experienced complications in the perioperative time period primarily consisting of seroma (4.2 %) and ileus (1.7 %). Two patients required reoperation and mesh removal in the early postoperative period for infection and herniorrhaphy site pain, respectively. There was a decline in pain and movement limitation scores between baseline and 1-year follow-up. Six-month (n = 109) and twelve-month (n = 99) follow-up revealed no hernia recurrences (95 % CI 0-3 %, and 0-4 %, respectively).

CONCLUSIONS

The use of this second-generation composite mesh was associated with no hernia recurrences and a low complication rate after open ventral hernia repair.

Influence of age on Medicare expenditures and medical care in the last year of life

CONTEXT

Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain.

OBJECTIVES

To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon.

DESIGN, SETTING, AND PATIENTS

Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996.

MAIN OUTCOME MEASURE

Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services.

RESULTS

For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states.

CONCLUSIONS

Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Risk adjustment for measuring health outcomes: an application in VA long-term care

An empirically derived risk adjustment model is useful in distinguishing among facilities in their quality of care. We used Veterans Affairs (VA) administrative databases to develop and validate a risk adjustment model to predict decline in functional status, an important outcome measure in long-term care, among patients residing in VA long-term care facilities. This model was used to compare facilities on adjusted and unadjusted rates of decline. Predictors of decline included age, time between assessments, baseline functional status, terminal illness, pressure ulcers, pulmonary disease, cancer, arthritis, congestive heart failure, substance-related disorders, and various neurologic disorders. The model performed well in the development and validation databases (c statistics, 0.70 and 0.68, respectively). Risk-adjusted rates and rankings of facilities differed from unadjusted ratings. We conclude that judgments of facility performance depend on whether risk-adjusted or unadjusted decline rates are used. Valid risk adjustment models are therefore necessary when comparing facilities on outcomes.

Postmenopausal estrogen use, type of menopause, and lens opacities: the Framingham studies

BACKGROUND

Previous studies of estrogen replacement therapy and lens opacities have not reported consistent findings.

OBJECTIVE

To investigate whether postmenopausal estrogen use is associated with the occurrence of age-related lens opacities (nuclear, cortical, and posterior subcapsular).

METHODS

Surviving members of the original cohort of the Framingham Heart Study who also participated in the Framingham Eye Study (1986-1989) were examined for the absence or presence of lens opacities. Data from the Framingham Heart Study, including information on menopausal status (collected biennially from approximately 1948) and use of estrogen replacement therapy (collected biennially from approximately 1960) were used to examine associations between lens opacities and duration of postmenopausal estrogen use, type of menopause, and age at menopause. Five hundred twenty-nine women, aged 66 to 93 years, were included. Multivariable-adjusted odds ratios of specific types of lens opacities were calculated for (1) duration of estrogen use (never and 1-2, 3-9, and >/=10 years), (2) surgical vs natural menopause, and (3) age at menopause.

RESULTS

Longer duration of postmenopausal estrogen therapy was inversely associated with the presence of nuclear lens opacities in an adjusted model. Women who had taken estrogen for 10 years or longer had a 60% reduction in risk compared with nonusers (odds ratio, 0.4; 95% confidence interval, 0.2-1.01). Longer duration of estrogen use was associated with fewer posterior subcapsular opacities at a borderline level of significance. No association was noted for cortical opacities. The risk of posterior subcapsular opacities was significantly increased for women who had undergone surgical menopause compared with women with natural menopause (odds ratio, 2.2; 95% confidence interval, 1.1-4.3). No association was noted for lens opacities and age at menopause.

CONCLUSION

Data from our study and other studies suggest that a reduction in the risk of lens opacities may be an additional benefit of postmenopausal estrogen use.

Structural and functional disruption of vascular smooth muscle cells in a transgenic mouse model of amyloid angiopathy

The deposition of amyloid Abeta peptide in the wall of cerebral vessels (cerebral amyloid angiopathy), can lead to weakness and rupture of the vessel wall, resulting in hemorrhagic stroke. The Tg2576 transgenic mouse line, overexpressing mutant amyloid precursor protein in an age-dependent manner, forms amyloid angiopathy morphologically similar to that seen in the human. We report here the structural and functional disruption of smooth muscle cells (SMCs) in the walls of pial vessels affected by amyloid deposition in the Tg2576 mouse. We demonstrate, using multiphoton imaging, that the arrangement of SMCs becomes disorganized before the onset of cell death, and that these disorganized SMCs are unable to respond appropriately to application of endothelial-dependent and endothelial-independent vasodilators in a closed-cranial window preparation.

Three-year update of sildenafil citrate (Viagra) efficacy and safety

In the three years since its launch, sildenafil citrate (Viagra), an oral agent for the treatment of erectile dysfunction (ED), has been prescribed to more than 10 million patients worldwide and has been further evaluated in clinical studies in diverse patient populations. Significant improvements in erectile function have been demonstrated in double-blind, placebo-controlled trials in patients with ED and underlying diabetes, cardiovascular disease, minor depression, spinal cord injury and multiple sclerosis. Promising results have also been reported for patients with treated prostate cancer, end-stage renal failure, Parkinson's disease, and spina bifida and in multiple organ transplant recipients. Accounts of sildenafil use in clinical practice and postmarketing data reflect clinical trial findings of effectiveness in a broad spectrum of ED aetiologies and overall good tolerability. As in the clinical trials, most adverse events associated with sildenafil use have been transient, mild or moderate effects that rarely lead to treatment discontinuation.

Beneficial effect of the addition of the 5-HT 2A/2C and alpha2 antagonist mianserin to ongoing haloperidol treatment in drug-resistant chronically hospitalized schizophrenic patients

Atypical neuroleptics that block serotonin 2A (5-HT 2A) and dopamine 2 (D2) receptors have been shown to possess efficacious antipsychotic activity. We assessed the efficacy of the addition of the 5-HT 2A/2C and alpha2 antagonist mianserin to ongoing haloperidol treatment in chronically hospitalized (> 10 years) drug-resistant schizophrenic patients (N = 12). The patients were assessed at baseline and every three months for one year with the Brief Psychiatric Rating Scale and the Clinical Global Impression. Results showed a significant (but < 10%) improvement in the core symptoms of schizophrenia; however, only the reduction (by 43%) in anxiety was clinically relevant (P < 0.0001). The beneficial effect of mianserin may be related to the combined blockade of 5-HT 2A and histamine (H1) receptors.

Cyclosporin for severe ulcerative colitis

BACKGROUND

About one-third of patients with severe ulcerative colitis do not respond to conventional therapy and require urgent colectomy. It was recently shown that cyclosporin is effective in some of these patients.

OBJECTIVES

To review the current experience of six hospitals in central Israel that used cyclosporin in patients with severe ulcerative colitis.

METHODS

The files of all 32 patients treated with cyclosporin for corticosteroid-resistant ulcerative colitis were reviewed. Activity of disease was measured by a clinical activity, index colonoscopy and laboratory tests.

RESULTS

The average duration of treatment with intravenous cyclosporin was 12.7 days (range 9-28) after which the disease activity index dropped from an average of 14.22 to 4.74. The mean time for response was 7.5 days (4-14). Twelve patients (40%) required surgery within 6 months and another 6 patients (18.8%) were operated on after more than 6 months. Twelve patients (37%) maintained remission for at least 6 months and did not require surgery. In one patient treatment was stopped because of non-compliance and one was lost to follow-up. There were numerous side effects, but in only one case with neurotoxicity was treatment withdrawn.

CONCLUSIONS

Cyclosporin is a relatively safe and effective treatment for severe ulcerative colitis. It induced long-term remission in 37% of the patients, and in those who required surgery the treatment resulted in an improved clinical condition before the operation.

The optimal outcomes of post-hospital care under medicare

OBJECTIVE

To estimate the differences in functional outcomes attributable to discharge to one of four different venues for post-hospital care for each of five different types of illness associated with post-hospital care: stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fracture, and to estimate the costs and benefits associated with discharge to the type of care that was estimated to produce the greatest improvement.

STUDY SETTING/DATA SOURCES

Consecutive patients with any of the target diagnoses were enrolled from 52 hospitals in three cities. Data sources included interviews with patients or their proxies, medical record reviews, and the Medicare Automated Data Retrieval System.

ANALYSIS

A two-stage regression model looked first at the factors associated with discharge to each type of post-hospital care and then at the outcomes associated with each location. An instrumental variables technique was used to adjust for selection bias. A predictive model was created for each patient to estimate how that person would have fared had she or he been discharged to each type of care. The optimal discharge location was determined as that which produced the greatest improvement in function after adjusting for patients' baseline characteristics. The costs of discharge to the optimal type of care was based on the differences in mean costs for each location.

DATA COLLECTION/EXTRACTION METHODS

Data were collected from patients or their proxies at discharge from hospital and at three post-discharge follow-up times: six weeks, six months, and one year. In addition, the medical records for each participant were abstracted by trained abstractors, using a modification of the Medisgroups method, and Medicare data were summarized for the years before and after the hospitalization.

PRINCIPAL FINDINGS

In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost.

CONCLUSIONS

Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities.

New four-stitch sleeve anastomosis: an experimental study in rats with reports of clinical use

A new technique for microvascular four-stitch sleeve anastomosis of arteries is described. Modifications from previously described techniques include absence of suture material within the arterial lumen, and a decreased proximal to distal artery overlap. In 40 rat arterial anastomoses, 100% patency without evidence of stenosis or early aneurysm formation was seen up to 6 weeks postoperatively by in vivo observation, arteriography and Doppler flow study. This new anastomosis was also successful in repairing two clinical cases of complete radial artery transection as evident from physical examination and doppler flow study. We believe that this new four-stitch sleeve anastomosis is faster and easier to perform and has patency and flow characteristics similar to those of the conventional end-to-end anastomosis.

Does diagnostic information contribute to predicting functional decline in long-term care?

BACKGROUND

Compared with the acute-care setting, use of risk-adjusted outcomes in long-term care is relatively new. With the recent development of administrative databases in long-term care, such uses are likely to increase.

OBJECTIVES

The objective of this study was to determine the contribution of ICD-9-CM diagnosis codes from administrative data in predicting functional decline in long-term care.

RESEARCH DESIGN

We used a retrospective sample of 15,693 long-term care residents in VA facilities in 1996.

METHODS

We defined functional decline as an increase of > or =2 in the activities of daily living (ADL) summary score from baseline to semiannual assessment. A base regression model was compared to a full model enhanced with ICD-9-CM codes. We calculated validated measures of model performance in an independent cohort.

RESULTS

The full model fit the data significantly better than the base model as indicated by the likelihood ratio test (chi2 = 179, df = 11, P <0.001). The full model predicted decline more accurately than the base model (R2 = 0.06 and 0.05, respectively) and discriminated better (c statistics were 0.70 and 0.68). Observed and predicted risks of decline were similar within deciles between the 2 models, suggesting good calibration. Validated R2 statistics were 0.05 and 0.04 for the full and base models; validated c statistics were 0.68 and 0.66.

CONCLUSIONS

Adding specific diagnostic variables to administrative data modestly improves the prediction of functional decline in long-term care residents. Diagnostic information from administrative databases may present a cost-effective alternative to chart abstraction in providing the data necessary for accurate risk adjustment.

In vivo potentiostatic studies at the electrode tissue interface: filter properties of the monophasic action potential (Ag/AgCl) electrode in living rat heart

The monophasic action potential (Franz) catheter is regarded as the criterion standard for high fidelity recording of a class of physiological signals. However, its signal modulation characteristics have never been reported. Broadband impedance spectroscopy was performed in perfused living rat heart in a three-electrode potentiostatic configuration to determine the filtering characteristics of the MAP and model Ag/AgCl electrode-tissue interfaces. The filter transfer function H(f) (attenuation [dB] vs log(f) [log(Hz)]) was derived for the frequency range 10 Hz-10(6) Hz. As a filter, the MAP interface is characterized by two ranges of filtering behavior. At high frequency the MAP interface is a high-pass filter with passband frequency 54 kHz-549 kHz (median 321 kHz) and with -3 dB cutoff points ranging from 10 kHz to 302 kHz. In this high frequency range the transfer function is characterized by decreasing attenuation per decade. However, in the lower frequency range relevant to physiological signals (the monophasic action potential, 0.1-40 Hz), it is a severely attenuating nondiodic high-pass filter element with an average attenuation of 16.87 dB relative to passband. In this physiological range, rolloff is nonlinear with increasing attenuation per decade. While the MAP electrode and model Ag/AgCl electrodes are high-pass filters with robust transfer functions for high frequency signals in the living heart, the attenuation of signals in a frequency range relevant to in vivo physiological recording imparts extreme attenuation that may distort physiological signals unpredictably. This disadvantage may be mitigated by amplitude scaling to a calibrated pure tone signal within the physiological frequency band to recover a reproducible signal.

Morphometric analysis of the extramacular retina from postmortem eyes with retinitis pigmentosa

PURPOSE

To evaluate the degree of inner retinal preservation in the extramacular regions of postmortem retinitis pigmentosa (RP) eyes.

METHODS

Eighteen RP retinas and 11 age-matched healthy retinas were sectioned for morphometric analysis by light microscopy. The 18 RP retinas were classified by disease severity and mode of inheritance. Cell nuclei in the outer nuclear layer (ONL), inner nuclear layer (INL), and ganglion cell layer (GCL) were counted in adjacent 125-microm segments from an area spanning the region between 4 mm and 10 mm from the fovea.

RESULTS

A mixed-effects model showed a decrease in mean cell counts for each of the cell layers when the severity groups and inheritance types compared with those of control retinas. There was no statistically significant difference in the number of nuclei preserved in the INL and GCL in the moderate group compared with the severe group. Results from the INL counts for the different inheritance types of RP showed a higher overall mean percentage of cells was preserved for the autosomal dominant RP (ADRP) group when compared with the X-linked (XLRP) and simplex RP groups. Analysis of the GCL counts revealed significantly more counts only in the ADRP group compared with the XLRP group; the other group comparisons were not significant.

CONCLUSIONS

Retinitis pigmentosa results in cell loss in all retinal layers, with the most profound loss in the ONL, followed by the GCL and then the INL. The preservation of the INL and GCL in the extramacular region is less than that previously reported for the macular region of the same retinas.

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.

METHODS

Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA).

RESULTS

In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.

CONCLUSIONS

The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty

A 2.8-year prospective multicenter trial was conducted to evaluate the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. A total of 441 inguinal hernias were repaired in 351 patients (326 male; 25 female). Two hundred twenty-six of the hernias were direct, 185 indirect, 4 femoral, 26 pantaloon, 90 bilateral, and 92 recurrent. Standardized data collection forms were used and submitted for centralized data analysis. For the hernioplasty, Cooper's ligament was exposed and an 8 cm x 12 cm x 1 mm GORE-TEX Soft Tissue Patch was stapled circumferentially to Cooper's ligament and the endoabdominal fascia. Patients were followed at 1 week, 6 months, 1 year, and then annually. Three-month intervals were used as needed. There was a mean follow-up of 447 days, with 21% of the total repairs followed for more than 2 years and 56% for more than a year. The overall follow-up rate was 95.5%. The operative and postoperative complication rates were 0.45% and 8%, respectively. There were 17 recurrent hernias (3.8%). The range of experience among the investigators was 13 to 168 hernioplasties. With the completion of 25 cases per investigator, the recurrence rate fell to 0.39%. Postoperative analgesia averaged a 24-hr supply of medication; 12.2% of patients required no analgesia. Convalescence averaged 5.4 days, and return to work averaged 7.7 days. This multicenter trial demonstrates that the ePTFE laparoscopic peritoneal onlay inguinal hernioplasty is a safe and dependable repair, especially after the initial learning curve is surmounted.

Characteristics of gallbladder bile of infants and children

In the past, biliary lipids of infants and children were studied in duodenal aspirates. This study was performed on original bile aspirated from the gallbladder. The analysis of lipids in bile demonstrated a significantly lower total lipid content in the bile of infants than in children (3.3 g/dl vs. 9.1 g/dl). The most prominent difference was demonstrated in the bile salt concentration (43.2 mM vs. 126.7 mM) and thereafter in the phospholipid content. Infants had a shorter nucleation time and a higher cholesterol saturation index than did children. These results may explain the increased tendency of infants to produce sludge and gallstones during total parenteral nutrition.

Use of post-hospital care by Medicare patients

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post-hospital care. Medicare coverage provides for various types of post-hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post-hospital care.

METHODS

A Total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988-1989, were enrolled in the study. These DRGs comprised approximately one-eighth of all Medicare hospital discharges and 40% of all Medicare-paid post-hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation.

RESULTS

Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often.

CONCLUSIONS

Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients.

Effects of CPAP on cardiac output in pigs with pacing-induced congestive heart failure

Continuous positive airway pressure (CPAP) may improve left ventricular (LV) function in patients with congestive heart failure (CHF). To understand mechanisms involved, in nine sedated, unanesthetized pigs with pacing-induced CHF we measured cardiac index (CI), heart rate (HR), LV pressures and volumes, ejection fraction (LVEF), and maximal rate of LV pressure rise (dp/dtmax). LV end-systolic transmural pressure (afterload) was estimated as LV end-systolic pressure (LVESP)-CPAP. Measurements were taken at CPAP 0, 5, 10, and 15 cm H2O and during recovery. At CPAP 5 cm H2O, CI increased from 4.23 +/- 1.00 to 4.99 +/- 0.88 L/min/m2 (p < 0.005), LV end-systolic volume decreased from 82.3 +/- 32.1 to 72.7 +/- 30.3 ml (p < 0.04) and LVEF increased from 0.30 +/- 0.09 to 0.36 +/- 0.12 (p < 0.02), and dp/dtmax increased. LVESP-CPAP was unchanged. After CPAP was discontinued, there was a rise in CI (p < 0.03), HR (p < 0.03), LVESP (p < 0.02), dp/dtmax (p < 0.02) and a decrease in total peripheral resistance (p < 0.03). We conclude that in CHF, low levels of CPAP improved CI, at least partly by improving contractility. Increased CI after discontinuing CPAP may be due to sympathoadrenal stimulation or withdrawal of alpha-adrenergic tone.

Methods of automatically acquiring images from digital medical systems

Automated image acquisition plays an important role in a picture archiving and communication system (PACS). However, there is no single solution for automated data acquisition from existing digital medical imaging systems. We have gained a great deal of experience on automatic acquiring data by interfacing imaging scanners of major manufacturers. In this paper, we categorize the interface methods supported by the current image scanners. This categorization consists of five architectural models: (a) sequential chain; (b) direct interface; (c) memory access; (d) shared disk; and (e) interconnected network. The cost, rate of data transfer, and ease of implementation of each model are discussed. To ensure the integrity and availability of patient images in a PACS system, automated fault tolerance design in image acquisition is required. Based upon our field data, we report common scenarios which cause the acquisition to fail. We also describe techniques employed to automatically restart the operations which include recovery from acquisition processes' errors and traps, image acquisition computer down-time occurrence, and shutdown occurrence of medical imaging system.

Effects of continuous positive airway pressure on cardiac output in normal and hypervolemic unanesthetized pigs

Continuous positive airway pressure (CPAP) has been used to increase cardiac index (CI) in patients with congestive cardiomyopathy in the presence of elevated pulmonary wedge pressure. We hypothesized that with normovolemia, CPAP would decrease CI because of decreased left ventricular (LV) preload, whereas in hypervolemia CPAP would increase CI because of a decrease in afterload. We tested this hypothesis on nine sedated, unanesthetized pigs instrumented 5 to 10 d before study. We measured CI, heart rate, stroke volume, LV end-diastolic and end-systolic pressures, and LV dimensions at CPAP levels 0, 5, 10, 15, and 20 cm H2O before and after volume expansion with hetastarch (35 ml/kg). From LV dimensions, LV end-diastolic (LVEDV) and LV end-systolic volumes (LVESV) and LV ejection fraction (LVEF) were calculated. With normovolemia, CI and LVEDV decreased with increased CPAP. Volume infusion produced mild cardiac dysfunction as evidenced by increased LV volumes, decreased LVEF, and decreased contractility. With hypervolemia, CPAP produced an increase in CI, decrease in LVEDV and LVESV, and an increase in LVEF. At higher values of CPAP, we observed decreased CI and LVEDV as with normovolemia. We conclude that with normovolemia, CPAP's effects are mainly related to changes in preload. Hypervolemia produced mild cardiac dysfunction. The improvement in CI with CPAP appears predominantly to be secondary to decrease in LV afterload, but a mild preload effect, which parallels the effect seen with normovolemia, was superimposed on afterload changes at higher CPAP values.

Extended duration of vertical position might impair bone metabolism

Bone-remodelling is markedly influenced by vectors of gravitational forces. Sleep-deprivation, common during military training, involves a change in the normal balance between horizontal and vertical forces enacting on the skeleton. Stress fractures are likewise prevalent among army recruits. In order to investigate the impact of sleep-deprivation on bone-metabolism, three groups of young, healthy volunteers were selected to exercise the following: 63 h of sleeplessness (17 participants, group A); vertical sleep in a seated position for three consecutive nights (9 participants, group B); controls who slept 6 h a night horizontally (14 participants, group C). During periods of wakefulness, all participants were kept in an upright position. Twenty-four hours' urine collection was strictly observed from two days prior to the experiment until two days after it (1 week). Changes in levels of the most characteristic bone-metabolites, calcium and hydroxyproline indicate an increased bone-resorption in the two experimental groups, but not in controls. The calcium excreted in the fasting urine peaked significantly at 72 h after the beginning of the experiment (+ 170% in group A; + 68% in group B, relative to the basal level). Qualitatively, similar results were obtained with hydroxyproline. On an individual basis, approximately 40% of the participants in either group responded by exceeding urinary-calcium elevation. A comparison of pre-test bone-density between responders and non-responders, reveals a significantly lower bone-density (-5%) in calcium and hydroxyproline excretors. These results suggest a pre-disposition to bone-resorption associated with responsiveness to changes in the balance between gravitational forces.

Post-hospital home health care for Medicare patients

Medicare patients in five diagnosis-related groups (DRGs) associated with heavy use of post-hospital care discharged from 52 hospitals in 3 cities were followed up at 6 weeks, 6 months, and 1 year to determine the factors associated with their being discharged home with or without home health care and the correlates of improvement in their functional status. Models correctly predicted those discharged home from those going to institutions in a range from 54 to 82 percent of cases. The amount of the variance in the change in function for those who went home (with or without home health care) explained by the models tested ranged from 19 percent to 73 percent. Total Medicare costs for the patients who went home were considerably less in the year subsequent to the hospitalization compared with those discharged to institutional care.

Effect of inoculum size on antimicrobial susceptibility of Helicobacter pylori

An agar dilution assay was used to assess the effect of inoculum size and culture period on the susceptibility of 15 clinical isolates of Helicobacter pylori to ampicillin, erythromycin, tetracycline, chloramphenicol, metronidazole and tinidazole. The mean MIC of the isolates increased 2.2- to 21.2-fold as the inoculum size progressed from 10(3) to 10(7) cfu/spot. Identical results were noted when isolates were maintained for two or four days prior to testing. Inoculum size should be carefully controlled when assessing the in vitro susceptibility of Helicobacter pylori.

Effects of lead time, length bias, and false-negative assurance on screening for breast cancer

This article presents a model of breast cancer screening programs. The model shows the effects of the screening threshold, screen sensitivity, and false-negative assurance on the cumulative mortality rate in the screened population. It shows that factors of screen design and a penalty associated with false-negative assurance can result in excess mortality rates in screened populations--especially in those age classes in which the incidence of rapidly growing tumors is high. Factors related to the magnitude of this effect are described.

Maintenance of a low-fat diet: follow-up of the Women's Health Trial

This report examines the maintenance of a low-fat diet 1 year on average after the completion of intervention sessions among participants in the Women's Health Trial (WHT). The WHT was a randomized controlled trial of the feasibility of adoption of a low-fat diet among women of moderate or increased risk of breast cancer, conduced in Seattle, Houston, and Cincinnati in 1985-1988. The women randomized to the low-fat diet attended an intensive dietary intervention program for 5-37 months. Intervention women were highly successful in reducing their dietary fat intake from 40.0% of energy intake at baseline to 26.3% by the end of the trial, based on a food frequency questionnaire (or an estimated 24% adjusted for the inaccuracies of a food frequency questionnaire versus a 4-day diet record). During 1989, 1 year on average after the WHT ended, 448 intervention women and 457 control women (87% of eligibles) completed a follow-up survey to determine the degree of maintenance of the diet. The intervention women maintained the low-fat diet with an increase of only 1.4 percentage points of energy from fat, despite the fact that they had attended no further intervention sessions and had made no commitment to maintain the diet beyond the end of the WHT. Furthermore, the degree of maintenance of the low-fat diet was not dependent on the length of time in the intervention, which suggests that intervention led to a sustained change in eating habits after as little as 5-9 months (8-13 classes).(ABSTRACT TRUNCATED AT 250 WORDS)

Overview of guidelines for screening

Controlled trials of screening for breast cancer have proven that (1) for women older than 50 years of age, screening with single-view or two-view mammography, at intervals of 1 to 3 years, with or without clinical examination reduces mortality; (2) annual screening with two-view mammography and clinical examination and emphasis on breast self-examination (BSE) can reduce mortality for women from 40 to 49 years of age; (3) screening this age group with single-view mammography, at intervals of 20 months or longer, without clinical or BSE results in excess mortality in women screened; (3) screening this age group annually with poor quality mammography, weakly interpreted, with some clinical examination results in excess deaths in screened women. If screening women 40 to 49 years of age is to be suggested there is no reason to suggest a model that has been proven to be counterproductive.

Guidelines for screening for breast cancer. Is a revision in order?

Screening women over the age of 50 for breast cancer has clearly been proven to be capable of reducing population mortality from breast cancer. Population based screening for women aged 40 to 49 has not been shown to be effective, and in several trials there is an early excess breast cancer mortality in the screened population. Because tumors tend to grow more rapidly in younger women than in older women, those trials performed at biannual intervals will detect only the intermediate and slower growing lesions. The more rapidly growing tumors will occur between screens. Furthermore, maintaining a high positive predictive value will lead to a lower sensitivity rate. If the screening interval is too long or the positive predictive value too high, the reassuring effect of a false-negative screening examination may contribute to delay in diagnosis beyond even the usual clinical detection threshold. This may cause more deaths in the study population than in the control population. Guidelines that take the various factors into account have been proposed.

Expert learning system network for diagnosis of breast calcifications

Breast calcification diagnosis was studied by using clinical findings and computerized image processing of a mammogram in a network of trained expert learning systems (Outcome Advisor [OA]). The system was tested with records not used for training and performance was compared with radiologist. The network was 72% accurate in classifying clusters of calcifications as malignant or benign over a set of test cases radiologists had considered "hard-to-diagnose calcifications," and referred for biopsy. The radiologists had decided to conduct biopsy by selecting an equal number of positive and negative cases for the test group; thus the radiologists' performance with respect to categories of benign versus malignant was constrained to be 50/50. Statistical analysis shows only a 2% probability that the observed accuracy of 72% was a chance performance in recognizing whether a cluster is benign or malignant. The feasibility of developing a network of OAs for diagnosing breast cancer integrating digital image processing of mammograms is promising.

Growth factor expression after stroke

Fibroblast growth factors are polypeptides with potent trophic effects on central nervous system cells. Both acidic and basic forms of fibroblast growth factor are found in the mammalian brain. We have examined the expression of these factors after focal brain injury or stroke. After infarction of the lateral cerebral cortex in the mature rat brain, we found a twofold to threefold increase during the first 3 weeks after stroke in levels of fibroblast growth factors in tissue surrounding infarcts. This increase persisted for at least 2 months and appeared mainly to be due to increased levels of basic, but not acidic, fibroblast growth factor. Because of its gliotrophic, angiogenic, and neuronotrophic properties, basic fibroblast growth factor may play an important role in the cascade of cellular reactions that contributes to wound healing and functional recovery after stroke.

Canadian National Breast Screening Study: assessment of technical quality by external review

Mammograms from the Canadian National Breast Screening Study (NBSS) were reviewed by three external experts to provide an objective evaluation of their technical quality, to establish a model for auditing mammograms in a screening program, and to assess whether NBSS mammograms improved over time. The sample reviewed included 10 randomly chosen mammograms from each of 15 screening centers for each calendar year of their operation between 1980 and 1987. All 830 mammograms were reviewed on two consecutive days in randomized sequence by each reader, and rated 0-3 for each of four criteria including positioning and image quality, with a total possible score of 0-12. Although the mammograms were not in temporal sequence when reviewed, the scores assigned by each reader were significantly higher for mammograms dating from later years. Subjects' ages at entry (40-49 vs 50-59 years) did not affect the score. The largest increase in scores was associated with a 1985 protocol change in which mediolateral oblique positioning replaced straight mediolateral positioning. This study reinforces the importance of monitoring technical quality in screening programs and establishes that the NBSS benefited from technical improvements during its operation. A retrospective review of NBSS mammography by three external reviewers confirmed that technical quality improved from 1980 to 1987. This improvement was associated with improved technology (film, processing, and units) and with the quality assurance programs operating during the NBSS, which identified problems and offered remedies.

Feasibility of a randomized trial of a low-fat diet for the prevention of breast cancer: dietary compliance in the Women's Health Trial Vanguard Study

The Women's Health Trial Vanguard Study was conducted to examine the feasibility of a nationwide, randomized multicenter intervention trial to test the hypothesis that a low-fat diet followed for a period of 10 years will reduce breast cancer risk. Women ages 45-69 years at increased risk of breast cancer were randomized into intervention (low-fat diet, n = 184) and control (usual diet, n = 119) groups. On the basis of 4-day food records, baseline fat intakes were comparable in the two groups, averaging 1,718 kcal with 39% of energy as fat. Intervention women reported substantially lower fat intake at 6 (20.9% kcal), 12 (21.6%), and 24 months (22.6% kcal). In contrast, control women reported only slight reductions in fat intake (37.3% kcal at 12 months and 36.8% kcal at 24 months). Evidence that these women were indeed complying with the low-fat dietary intervention comes from (a) the reasonable nature of reported nutrient changes within food groups in the intervention women and (b) agreement between observed and expected differences in plasma total cholesterol between the control and the intervention groups. At 12 months, the observed control - intervention plasma cholesterol difference was 13.1 +/- 4.6 mg/dl while the expected difference based on the Keys equation was 15.1 +/- 1.1 mg/dl; at 24 months, the observed difference was 15.5 +/- 4.3 mg/dl and the expected difference was 12.0 +/- 1.2 mg/dl. These analyses indicate that the intervention women made substantial dietary changes and have successfully maintained these changes over a 2-year period. This study thus demonstrates the feasibility of a randomized trial with an intensive low-fat dietary intervention.

Results of a randomized feasibility study of a low-fat diet

A 2-year randomized clinical trial was conducted to test whether free-living women aged 45 to 69 years can reduce the fat content of their diet from the typical US level of approximately 39% to 20% of energy from fat, using readily available foods, when given nutritional and behavioral counseling and social support. Three clinical units randomized 303 selected volunteers into intervention (low-fat eating plan) or control (customary diet) groups. The two groups were comparable at baseline. The intervention group received nutrition instruction and behavioral counseling largely in permanent groups of 12 to 15 participants meeting weekly, then biweekly, and finally monthly. At 6 months, they had substantially reduced the mean proportion of total energy from fat from 39.1% to 20.9%, compared with the control group's nonsignificant reduction from 39.0% to 38.1%. At 12 and 24 months, they sustained the reduction of energy from fat. Weight loss and plasma cholesterol level changes in the intervention group supported the self-recorded dietary intake changes. Attendance at intervention sessions averaged 75% during the first 6 months and, subsequently, 60% to 70%. Four-day food records for the randomized women were obtained at 6 and 12 months from approximately 95% and at 24 months from 87%. A clinical trial of a low-fat diet is feasible in women.

[Massive pericardial effusion following minoxidil]

Minoxidil is a potent antihypertensive which is reserved for severe cases. A 58-year-old man admitted for evaluation of progressive dyspnea and peripheral edema had been taking Minoxidil, Normiten and Lasix for severe hypertension. Echocardiography disclosed a massive pericardial effusion but there were no signs of tamponade. Discontinuation of Minoxidil resulted in complete clearance of the pericardial fluid within 3 months. Awareness of this potentially fatal side-effect of Minoxidil is mandatory.