Proregenerative extracellular matrix hydrogel mitigates pathological alterations of pelvic skeletal muscles after birth injury

Pelvic floor disorders, including pelvic organ prolapse and urinary and fecal incontinence, affect millions of women globally and represent a major public health concern. Pelvic floor muscle (PFM) dysfunction has been identified as one of the leading risk factors for the development of these morbid conditions. Childbirth, specifically vaginal delivery, has been recognized as the most important potentially modifiable risk factor for PFM injury; however, the precise mechanisms of PFM dysfunction after parturition remain elusive. In this study, we demonstrated that PFMs exhibit atrophy and fibrosis in parous women with symptomatic pelvic organ prolapse. These pathological alterations were recapitulated in a preclinical rat model of simulated birth injury (SBI). The transcriptional signature of PFMs after injury demonstrated an impairment in muscle anabolism, persistent expression of genes that promote extracellular matrix (ECM) deposition, and a sustained inflammatory response. We also evaluated the administration of acellular injectable skeletal muscle ECM hydrogel for the prevention of these pathological alterations. Treatment of PFMs with the ECM hydrogel either at the time of birth injury or 4 weeks after injury mitigated PFM atrophy and fibrosis. By evaluating gene expression, we demonstrated that these changes are mainly driven by the hydrogel-induced enhancement of endogenous myogenesis, ECM remodeling, and modulation of the immune response. This work furthers our understanding of PFM birth injury and demonstrates proof of concept for future investigations of proregenerative biomaterial approaches for the treatment of injured pelvic soft tissues.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures.

RECENT FINDINGS

Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Pulmonary Veno-Occlusive Disease

Pulmonary hypertension is a well-known though poorly characterized disease in veterinary medicine. In humans, pulmonary veno-occlusive disease (PVOD) is a rare cause of severe pulmonary hypertension with a mean survival time of 2 years without lung transplantation. Eleven adult dogs (5 males, 6 females; median age 10.5 years, representing various breeds) were examined following the development of severe respiratory signs. Lungs of affected animals were evaluated morphologically and with immunohistochemistry for alpha smooth muscle actin, desmin, CD31, CD3, CD20, and CD204. All dogs had pulmonary lesions consistent with PVOD, consisting of occlusive remodeling of small- to medium-sized pulmonary veins, foci of pulmonary capillary hemangiomatosis (PCH), and accumulation of hemosiderophages; 6 of 11 dogs had substantial pulmonary arterial medial and intimal thickening. Ultrastructural examination and immunohistochemistry showed that smooth muscle cells contributed to the venous occlusion. Increased expression of CD31 was evident in regions of PCH indicating increased numbers of endothelial cells in these foci. Spindle cells strongly expressing alpha smooth muscle actin and desmin co-localized with foci of PCH; similar cells were present but less intensely labeled elsewhere in non-PCH alveoli. B cells and macrophages, detected by immunohistochemistry, were not co-localized with the venous lesions of canine PVOD; small numbers of CD3-positive T cells were occasionally in and around the wall of remodeled veins. These findings indicate a condition in dogs with clinically severe respiratory disease and pathologic features resembling human PVOD, including foci of pulmonary venous remodeling and PCH.

Role of routine chest radiographs in the evaluation of patients with stable blunt chest trauma--a prospective analysis

OBJECTIVE

The study sought to assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury.

METHODS

We prospectively enrolled all adult patients (older than 16years) who were considered to have stable blunt chest trauma over a six-month period (May 1-October 31, 2009). We defined the latter as patients who were unintubated, normotensive (systolic blood pressure > 90 mm Hg) and without hypoxia (oxygen saturation> 95% at room air). Patients eligible for the study were sent for anteroposterior (AP) CXRs which were then interpreted by the same consultant radiologist throughout the study period. Both test (clinical judgement) and disease status (CXR) were assigned and correlated as binary measures. We compared the test performance characteristics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic likelihood ratios of clinical judgement to CXR findings in the determination of significant intra-thoracic injury.

RESULTS

During the six-month period, data were collected from 77 eligible stable blunt chest trauma patients (age over 16 years). Fifty-nine patients (76.6%) were male. Nine patients (11.7%) were radiologically confirmed to have significant blunt chest injuries including rib fractures, pneumothorax and an isolated case of pulmonary contusion. All nine (11.7%) patients had a positive (abnormal) radiograph for rib fractures. In addition, three (3.9%) of them also had both rib fracture and pneumothoraces and one (1.3%) had both a rib fracture and pulmonary contusion. Clinical judgementfor the diagnosis of significant blunt chest injuries matched with the CXR finding with 95% confidence intervals (CIs): sensitivity 100% (95% CI 66.4, 100), specificity 32.4% (95% CI 21.5, 44.8), prevalence 11.7%, PPV 16.4% (95% CI 7.77, 28.8), NPV100% (95% CI 84.6, 100), DLR+ 1.48 (95% CI 1.25, 1.74).

CONCLUSION

The majority ofpatients who sustained blunt chest injuries and were assessed as stable patients do not require CXR routinely. This study revealed that physicians in the local Emergency Department may be over-utilizing CXRfor patients who have stable blunt chest trauma.

[The chronic patient and the nurse-managed hospital unit]

In this article we discuss the implementation of a hospital nursing care unit in a local health authority in Rome (Italy), The hospital involved provides a wide range of healthcare and social services. The project is a very innovative one at the national level, with respect to healthcare services offered to patients with chronic disorders and associated disabilities. Starting from the concept of "centrality of the patient" in the area of healthcare services, we developed an organizational model where nursing care represents one of the basic elements.

Can a participatory approach contribute to food chain risk analysis?

We consider food chain risks and specifically address stakeholder participation in the risk analysis process. We combine social and natural science perspectives to explore the participation process in relation to food risks and, in particular, to consider how some specific participation processes might be scientifically evaluated and how stakeholder participation in general might be incorporated into food risk decision making. We have built considerations based on three large integrative case studies that examine aspects of participatory processes. Here we use the case studies collectively to illustrate observations and beliefs concerning the nature of the interaction of stakeholders with established quantitative risk methodologies. This account is not supported by any large volume of analysis. The views in the report are expressed in relation to an accepted risk analysis framework and also with respect to probabilistic modeling of risks and are illustrated where possible with anecdotal reports of actual case study events.

[In the heart of the district. 50 interviews with the health professionals of the Lazio Region districts, Italy]

This article aims to explore some key issues relating to the health districts of the Lazio Region, in particular the major critical aspects as well as some strengths highlighted by the operators. In the Lazio Region there are 12 Local Health Units, divided into 55 health districts. In recent years, the majority of the authors analized theoretical models proposed by regional standards, while the strengths and weaknesses of the district, as well as the organizational difficulties and problems experienced daily by the operators have not been investigated. It was decided to use qualitative methods of research, through open interviews with 50 operators in 15 health districts of the Region. Interviews were analysed utilizing software Nvivo. Some codes were identified to guide interviews. We can summarize the emergency issues at least in three major areas: 1) the organization of the district, 2) the management of personnel and resources, 3) the care pathways. It is hoped that, during next years, the research directed at health district analysis will grow, with particular reference to quantitative and qualitative investigations, in order to build a body of knowledge from practical experience of health professionals.

Staining for intracytoplasmic lumina and CAM5.2 increases the detection rate for bile duct cancers

BACKGROUND AND STUDY AIMS

Endoscopic biopsies have a low sensitivity for diagnosing malignant bile duct strictures. Tumor markers detected by mucin staining and immunohistochemistry may help to determine the malignancy of a biopsy specimen where histologic evaluation alone is nondiagnostic.

PATIENTS AND METHODS

61 patients who underwent forceps biopsies were retrospectively identified, yielding 49 and 40 biopsy specimens for strictures finally diagnosed as benign and malignant, respectively. Biopsy specimens were histologically evaluated and stained for p53, Ki-67, carcinoembryonic antigen (CEA), CA19-9, CAM5.2, and presence of intracytoplasmic lumina (ICL). Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (PLR and NLR) were calculated to evaluate the performance of each test.

RESULTS

Histology alone provided sensitivity and specificity of 53 % and 100 %. Addition of ICL or CAM5.2 increased sensitivity to 73 % or 60 %, respectively, and provided excellent specificity, PPV, and PLR (ICL, 98 %, 97 %, and 36; CAM5.2, 100 %, 100 %, and infinite). Both stains in combination increased the sensitivity to 75 %. Staining for Ki-67, p53, CEA, and CA19-9 increased the sensitivity to detect malignancy (range 60 % to 83 %), but significantly reduced the specificity, PPV and PLR (ranges 73 % to 90 %, 72 % to 86 %, and 3 to 7, respectively). Markers in all combinations performed poorly as a negative test (NPV 69 % to 87 %, and NLR 0.19 to 0.55).

CONCLUSIONS

Staining for tumor markers ICL and CAM5.2 can improve the diagnostic value of endoscopic biopsies, and may change the course of management for patients with indeterminate histological findings.

Delays in presentations of stroke patients at the University Hospital of the West Indies

Thrombolytic therapy has been proven to be beneficial in selected patients with ischaemic strokes. Early diagnosis is paramount because there is a narrow therapeutic window for these patients to derive benefit from thrombolytics. We sought to evaluate the timing of stroke presentations at the University Hospital of the West Indies (UHWI) in order to assess the potential eligibility for definitive therapy A retrospective audit of all consecutive patients who had emergent computed tomographic (CT) scans for suspected ischaemic stroke at the UHWI was performed over a six-month period between February 2006 and July 2006. Data were extracted from the hospital records and analysed using SPSS version 12. There were 331 patients evaluated with brain CT for a clinically suspected stroke during the study period. Complete time documentation and CT scans were available for analysis in 171 patients with ischaemic strokes. The average age was 64.5 years (range +/- SD: 3-98 +/- 19.9 years) with a slight male preponderance (58% vs. 42%). There was considerable pre-hospital delay with 63% of patients presenting more than 12 hours after the onset of symptoms. There were also long inhospital delays. Only 52% of patients were assessed by a physician within an hour of presentation to hospital and only 55% of patients had CT scans completed within three hours of a physician s request. Although thrombolysis is not routinely performed for ischaemic strokes at our institution, sensitization of physicians and the general public in our setting to symptoms and signs of this disease is urgently needed to improve stroke management, whereby definitive treatment can be considered for selected patients.

Pilot series of radiofrequency ablation of Barrett's esophagus with or without neoplasia

BACKGROUND AND STUDY AIMS

Radiofrequency ablation is a rapidly evolving therapeutic modality for Barrett's esophagus. The aim of this ongoing 12-month trial is to assess Barrett's esophagus eradication after radiofrequency ablation using a balloon-based (HALO-360) and a plate-based (HALO-90) device. We report here our experience with the first 10 patients (out of 40) who have completed 12 months of follow-up.

PATIENTS AND METHODS

Following radiofrequency ablation using the HALO-360 device all patients were maintained on double-dose proton pump inhibitor therapy. Endoscopic evaluation was performed at 3 and 12 months postablation. Patients with residual Barrett's esophagus at 3 months underwent repeat ablation. Ten patients, seven with nondysplastic Barrett's esophagus, two with low-grade and one with high-grade dysplasia have completed the study to date.

RESULTS

Complete Barrett's esophagus eradication was achieved in seven patients, and partial eradication was achieved in three. There were no major complications. One case of buried Barrett's metaplasia was encountered and successfully re-ablated, with complete Barrett's esophagus eradication achieved at 12 months.

CONCLUSIONS

In this study, Barrett's eradication rates were comparable to previously published reports. One case of buried Barrett's metaplasia was identified out of 247 biopsies and was eradicated with repeat ablation.

The evolution of emergency medicine in Jamaica

Emergency Medicine in Jamaica has evolved rapidly over the past 20 years and has gained recognition as a specialty. A residency training programme has been established, trademark life support courses are now available, moves to develop areas of sub-specialization have begun and an emergency medicine association has been formed. There has been an increase in the diagnostic modalities in the main teaching institution, the University Hospital of the West Indies (UHWI). There is an urgent need for improvements in pre-hospital care. This will require the development of an efficient Emergency Medical Service (EMS). More emphasis and attention is required on disaster medicine, toxicology and trauma. Increased training of emergency physicians and nurses, advances in academia and research, and greater advocacy by local emergency physicians will further advance the specialty.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims--a hospital review

OBJECTIVE

Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents.

METHODS

Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle.

RESULTS

Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61).

CONCLUSION

It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

What young Dutch adults say they do to keep from gaining weight: self-reported prevalence of overeating, compensatory behaviours and specific weight control behaviours

OBJECTIVE

The aim of this study was to explore the prevalence of and differences in self-reported occasions of overeating (such as at celebrations and other parties), compensatory behaviours and specific weight gain prevention strategies among young Dutch adults according to sociodemographics and overweight status.

DESIGN AND SUBJECTS

Cross-sectional data were analysed from Dutch adults aged 20-40 years, recruited from an Internet research panel (n = 857, response rate = 76.6%). Using electronic questionnaires, self-report data were collected on sociodemographics, body mass index (BMI), occasions of overeating, compensatory behaviours, and diet and physical activity used as weight gain prevention strategies. Associations were tested using multiple linear and logistic regression analyses.

RESULTS

Of the participants, 48.6% reported occasions of overeating at least once a week during the 4-week period, 44.6% reported compensating for these occasions and 72.9% reported engaging in dietary and physical activities specifically for weight gain prevention purposes. Only 32.1% of the respondents reported using the recommended combination of diet and physical activity as a weight gain prevention strategy. In addition, results showed that overweight people (BMI > or = 25 kg m-2) and women were more likely to report overeating than people with healthy body weights (odds ratio (OR) = 1.79; 95% confidence interval (CI) 1.32-2.42) and men (OR = 1.50; 95% CI 1.14-1.97). Overweight people, women and people who regularly reported overeating were also significantly more likely to report compensatory behaviours by eating less and to report specific weight gain prevention strategies using diet and physical activity.

CONCLUSION

The present study suggests that people experience frequent occasions of overeating and try to compensate for such occasions in different ways. However, the combination of dietary changes and physical activity recommended by experts was seldom reported.

Are current processes for nuclear emergency management in Europe adequate?

We describe the results of process mapping of nuclear emergency management procedures in four European countries. We find clear differences and explore these in relation to their suitability for building a shared understanding across the emergency management team of the evolving situation and a balanced appreciation of the uncertainties. Our findings indicate that there are some issues that cause concern in that the procedures may run smoothly and efficiently but they may also risk underestimating uncertainty or ignore key issues that have only been identified by a minority of experts or models. We are concerned that they do not facilitate the building of shared mental models that the literature such as that on highly reliable organisations has shown is important.

The effect of hurricane Ivan on emergency department operations at the University Hospital of the West Indies

The objective of this study was to determine the impact of Hurricane Ivan on the operations of the Emergency Department (ED) at the University Hospital of the West Indies (UHWI). Hurricane Ivan,--a category four Hurricane--traversed the south coast of the island of Jamaica on September 10, 2004, causing damage to several parishes. The study design is a descriptive retrospective record-based incidence study of all admissions to the ED commencing at 8:00 am September 10, 2004 and ending at 12 midnight September 11, 2004, covering the period of the entire duration of the hurricane as well as immediately after. Injuries that took place during the hurricane, inclusive of gun-shot wounds (GSWs) represented 40% of the total patients seen. The types of admission are listed categorically as well as specific items to be considered in planning for potential disasters of higher magnitude. Overall, the coping mechanism of the ED at UHWI was adequate for this magnitude of disaster.

To determine the effect of metoclopramide on gastric emptying in severe head injuries: a prospective, randomized, controlled clinical trial

To determine the effect of 8-hourly administration of 10 mg intravenous metoclopramide, over a 48-h period on gastric emptying in severe head injury (SHI), 22 patients were prospectively randomized (Glasgow Coma Score of 3-8) to receive 2 ml of intravenous metoclopramide or 2 ml of 5% saline 8-hourly for 48 h. Baseline and serial blood paracetamol absorption assays were performed at time (t) = 0, 15, 30, 45, 60, 90 and 120 min on day 0 and day 2. The area under the curve between the day 0 and day 2 was used to measure the degree of gastric emptying. In SHI, sequential doses of metoclopramide did not appear to improve gastric motility within subject comparisons (p = 0.65) and between subject comparisons (placebo p = 0.4 and drug p = 0.12). Metoclopramide has no significant prokinetic effect on gastric emptying in SHI patients when given in the early postinjury period.

Effect of health lifestyle pattern on dietary change

PURPOSE

To examine the effect of lifestyle on the effectiveness of a low-intensity dietary intervention.

DESIGN

A secondary data analysis was performed using data from the Eating Patterns Study, a randomized controlled trial that found that self-help materials with physician advice was effective in changing dietary intake and behavior.

SETTING

Primary care clinics in a large health maintenance organization.

SUBJECTS

A total of 2111 patients with a routine scheduled appointment with their primary care physicians.

MEASURES

Participants were grouped into one of six health lifestyle patterns based on similarities in baseline measures of alcohol intake, smoking, diet quality, and exercise. Within each lifestyle pattern, changes from baseline in usual fat and fiber intake (based on a food frequency) and a fat and fiber behavior score were compared at 3 months and 12 months for intervention vs. control participants.

INTERVENTION

Self-help materials delivered by a physician with advice to change diet.

RESULTS

Intervention participants in the fitness lifestyle group made the largest changes relative to controls for each dietary outcome at 3 and 12 months. For intervention participants defined by their alcohol intake or current smoking, either no changes in diet were observed compared with controls, or early changes were not sustained over time. Intervention-control comparisons within the remaining lifestyle patterns showed smaller dietary changes compared with the fitness lifestyle. This finding was similar to previously published results.

CONCLUSIONS

This randomized controlled trial had limited power to detect subgroup differences; however, these results suggest that lifestyle patterns may be useful in the development of effective, targeted interventions to change behavior.

Inhibition of intra-abdominal adhesions: a comparison of hemaseel APR and cryoprecipitate fibrin glue

Our previous studies demonstrated fibrin glue (FG) prepared from cryoprecipitate (cryo) inhibits intra-abdominal adhesions in rats. A new FG, Hemaseel APR, is Food and Drug Administration (FDA) approved for hemostasis during cardiac surgery and splenic trauma. This study was undertaken to determine if Hemaseel FG prevents intra-abdominal adhesions, and to compare it to cryo FG. Forty-five rats underwent laparotomy. Bilateral peritoneal-muscular defects were created. Polypropylene mesh was sewn into each defect with a running silk suture. The bowel was abraded with gauze. The rats were then randomized to mesh covered with Hemaseel FG, cryo FG, or control. On postoperative day 7, the severity of adhesions were graded by percentage of mesh covered by adhesion (0-100%) and degree of adhesion (0-3). The mean percentage of mesh covered by adhesion was 9% for Hemaseel FG, 43% for cryo FG (p = .005), and 65% for the controls (p < .0001). The mean density adhesion score was 0.5 for Hemaseel FG, 1.2 for cryo FG (p = .04), and 2.1 for the controls (p < .0001). In the Hemaseel FG group, 77% of patches had no adhesions, compared with 37% in the cryo FG group (p = .004) and 13% in the controls (p < .0001). Thus, Hemaseel FG significantly decreases intra-abdominal adhesions, and is more effective than cryo FG.

Nitric oxide synthase in porcine heart mitochondria: evidence for low physiological activity

The capacity of isolated porcine heart mitochondria to produce nitric oxide (NO) via mitochondrial NO synthase (NOS) was evaluated. The mitochondrial NOS content and activity (0.2 nmol NO x mg mitochondrial protein(-1) x min(-1)) were approximately 10 times lower than previously reported for the rat liver. No evidence for mitochondrial NOS-generated NO was found in mitochondrial suspensions based on the lack of NO production and the lack of effect of either L-arginine or NOS inhibitors on the rate of respiration. The reason that even the low mitochondrial NOS activity did not result in net NO production and metabolic effects is because the mitochondrial metabolic breakdown of NO (1-4 nmol NO x mg mitochondrial protein(-1) x min(-1)) was greater than the maximum rate of NO production measured in homogenates. These data suggest that NO production at the mitochondria via NOS is not a significant source of NO in the intact heart and does not regulate cardiac oxidative phosphorylation.

Binge and purge behavior among adolescents: associations with sexual and physical abuse in a nationally representative sample: the Commonwealth Fund survey

OBJECTIVES

(1) To examine associations between binge and purge behavior and sexual and physical abuse among adolescents; (2) to determine if these associations remain significant after controlling for sociodemographic and anthropometric characteristics; and (3) to identify aspects of abuse associated with binge and purge behavior.

METHOD

A nationally representative sample of 6728 adolescents in 5th-12th grades completed the Commonwealth Fund Survey of the Health of Adolescent Girls and Boys.

RESULTS

Binge and purge behavior was nearly twice as prevalent among girls (13%) as boys (7%), and was significantly associated with all abuse types (physical, sexual, or both). Associations were strongest among individuals who had experienced both physical and sexual abuse [odds ratios 4.28 (girls) and 8.25 (boys)]. Differences in binge and purge behavior by gender and type of abuse across abuse characteristics were limited. A higher percentage of abused youth that did not discuss their abuse reported binge-purge behavior than those who did discuss their abuse. Abused girls and boys who did talk to someone about the abuse most often discussed the abuse with their best friend (42.5% and 18.0%, respectively), their mother (38.8% and 32.2%, respectively), and their friends (27.2% and 19.5%, respectively).

DISCUSSION

Being physically and/or sexually abused was associated with greater likelihood for engaging in binge and purge behaviors. Discussing the abuse experience with another person may help to reduce binge-purge behavior, as abused adolescents who did not discuss the abuse were more likely to report binge-purge behavior than those who did discuss their abuse.

Performance-related pay in health care

OBJECTIVE

Performance-related pay (PRP) has been widely extended within the British public sector in the last 15-20 years, mostly because of pressure from central government. Its penetration in the National Health Service (NHS) has not so far been very deep but it has been sufficient to permit preliminary judgements on its likely impact.

METHODS

Review of published accounts of the extent of use of PRP in the NHS and its impact, plus two case studies.

RESULTS

There have been few rigorous studies reported. PRP has been introduced for a variety of reasons: an incentive to motivate staff; to enhance staff recruitment and retention; to signal a change in organizational culture; to control staff costs; to reduce the power of trades unions; to reinforce staff development policies. Very few NHS provider organizations have implemented PRP. Despite this, senior managers see real merit in it in improving staff performance and delivering a clear message about the importance of organizational performance. Employees are much more skeptical, seeing PRP as having no effect or being detrimental.

CONCLUSIONS

PRP has had, at most, only a very modest beneficial impact in the British NHS. In the absence of better evidence, it would be sensible for government to continue to encourage local initiatives rather than propose a mandatory national scheme. It would also be prudent to subject local schemes to rigorous evaluation.

Regulation of peroxisome proliferator activated receptor alpha-mediated pathways in alcohol fed cytochrome P450 2E1 deficient mice

Fatty acids are substrates and inducers for cytochrome P450 2E1 (CYP2E1) and peroxisome proliferator activated receptor alpha (PPARalpha). Previously, we have shown that the ethanol-induced CYP2E1 expression in rat is accompanied by the inhibition of the expression of the PPARalpha gene and the reduction in polyunsaturated fatty acid content. To further analyze the effect of CYP2E1 and ethanol in PPARalpha-mediated fatty acid homeostasis, the expression of PPARalpha and retinoid x receptor alpha (RXRalpha) and their target genes was examined in ethanol fed CYP2E1 deficient mice. Our data demonstrated that the expression of PPARalpha and RXRalpha genes was activated in the livers of CYP2E1-null mice suggesting a compensatory effect for the absence of CYP2El. In addition, the expression of PPARalpha target genes, which included the liver fatty acid-binding protein, malic enzyme, and CYP4A1 genes, was induced indicating the activation of PPARalpha-mediated pathways in CYP2E1 deficient mice. Ethanol inhibited the expression of some of the PPARalpha target genes in wild-type mouse livers, and the inhibitory effect of ethanol was particularly prominent in the CYP2E1-null mice. Morphologically, centrilobular fat accumulation was detected in the ethanol fed CYP2E1-null mouse livers suggesting that inhibition of PPARalpha-mediated pathways might be responsible for the ethanol-induced fatty liver in CYP2El-null mice. In addition, the expression of CYP2E1 was not changed in the PPARalpha-null mice. These data suggest that CYP2E1 and ethanol can regulate PPARalpha-mediated fatty acid homeostasis. CYP2E1-induced lipid peroxidation might play a major role in lipid metabolism, PPARalpha only becomes important when the CYP2E1 level is low and polyunsaturated fatty acids increase.

Surgical treatment of severe colonic inertia with restorative proctocolectomy

Patients with severe constipation due to colonic inertia who remain symptomatic after extensive medical therapy or partial colonic resection have occasionally been treated with ileostomy as a last resort. The hospital records of five patients with persistent symptomatic idiopathic colonic inertia were reviewed. Each of the patients had undergone extensive medical management, and eventually four underwent one or more colonic resections to relieve the recurrent abdominal distention and pain. Three of the patients eventually received a distal ileostomy, which functioned well. Anorectal manometric studies were within normal range for each of the five patients. Restorative proctocolectomy (J pouch) was therefore performed for each. With a mean follow-up of 42 months after restorative proctocolectomy each of the five patients was relieved of constipation and small bowel distention. The average number of bowel movements per 24 hours at 6 months was 4.8. All patients were able to discriminate flatus from stool, could hold back for up to 1.5 hours after the initial urge to defecate, and had total daytime continence. Each returned to work or school within 3 months, and each reported greater satisfaction with bowel function than with the ileostomy. Restorative proctocolectomy with a J pouch provides a satisfactory option for the management of patients with persistent abdominal distention and pain due to idiopathic colonic inertia.

Chronic daily low dose of 4-methyl-5-(2-pyrazinyl)-1,2-dithiole-3-thione (Oltipraz) in patients with previously resected colon polyps and first degree female relatives of breast cancer patients

The chemoprevention agent oltipraz, one of the most active chemopreventive compounds in preclinical studies, has been shown to induce glutathione-S-transferase (GST) activity in animals. Oltipraz was evaluated in a Phase I trial at daily oral doses of 20 mg (L1), 50 mg (L2), and 100 mg (L3) and twice weekly doses of 125 mg (L4) taken for 6 months with 6 patients entered at L1 and L2 and 7 patients entered at L3 and L4 (26 subjects: 19 females and 7 males). The subject population included patients with previously resected colon polyps and first-degree female relatives of breast cancer patients. Patients with resected colon polyps underwent rectal biopsy for GST and glutathione (GSH) analyses. Of the 26 subjects, the following completed 6 months of therapy: 4 of 6 patients (L1), 4 of 6 patients (L2), 5 of 7 patients (L3), and 4 of 7 patients (L4). Toxicities were mild to severe and included: gastrointestinal symptoms, photosensitivity/heat intolerance, and neurological symptoms. Monthly plasma samples were obtained 2-3 h after oltipraz ingestion with minimally detectable plasma concentrations at L1. There was a significant difference in mean oltipraz concentration across the four doses, with no significant differences in mean oltipraz concentration over time. Rectal tissue and lymphocyte GSH and GST were variable, with no significant difference in mean levels across doses. At the 100-mg/day dose (L3), 1 patient experienced significant increase in rectal tissue GSH and GST activity, whereas 3 additional patients (L1 and L4) had >50% increase in tissue GSH. Lymphocyte GSH level was significantly related to plasma oltipraz concentration. There were no significant correlations between plasma oltipraz concentration and lymphocyte GST level nor any significant correlation between plasma concentration and percentage of change in tissue GSH or GST. Further investigation of dose/schedule and biological end points is ongoing.