Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding

BACKGROUND: Measurement of the hepatic venous pressure gradient may identify a sub-optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined. METHODS: A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta-blockers alone, beta-blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta-blockers plus isosorbide mononitrate or beta-blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non-responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years. RESULTS: The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost-effectiveness ratio of the latter strategy was 136,700 dollars per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re-bleeding were increased. CONCLUSIONS: The cost-effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re-bleeding rates.     

Restoration of wild-type conformation to full-length and truncated p53 proteins: specific effects of ATP and ADP

Mutations in the core domain of the tumour suppressor p53 gene occur in over 50% of human cancers and are not present in normal cells hence p53 protein is a prime target for anti-cancer therapy. In full-length p53 protein, mutations have been shown to destabilize protein structure from wild-type to mutant conformation resulting in differential exposure of conformational epitopes PAb1620, PAb240 and PAb246 in murine p53 protein. In recent studies, putative anti-cancer agents have been designed for rescuing wild-type p53 conformation and function. Using full-length and truncated murine p53 proteins derived from the baculoviral system, we analyzed the recovery of PAb246 and PAb1620 epitopes and have identified regions of p53 required for optimal renaturation in vitro to wild-type. The influence of ATP and ADP on the process was also determined. We demonstrate a difference in the dose-dependent effect of ATP and ADP on renaturation of full-length wild-type and monomeric p53 proteins. Putative ATP binding sites were identified at residues 1-67 and 98-303 in conjunction with a putative ADP binding site at residues 98-303 and negative regulation of ATP/ADP binding by the proline-rich region. Improved efficacy and reduced toxicity of anti-cancer therapy may depend upon compounds engineered to rescue hot-spot core mutations in the context of full-length p53.     

Modulation of GABA(A) receptor function by nonhalogenated alkane anesthetics: the effects on agonist enhancement,direct activation,and inhibition

At clinically relevant concentrations, ethers, alcohols, and halogenated alkanes enhance agonist action on the gamma-aminobutyric acid(A) (GABA(A)) receptor, whereas nonhalogenated alkanes do not. Many anesthetics also directly activate and/or inhibit GABA(A) receptors, actions that may produce important behavioral effects; although, the effects of nonhalogenated alkane anesthetics on GABA(A) receptor direct activation and inhibition have not been studied. In this study, we assessed the abilities of two representative nonhalogenated alkanes, cyclopropane and butane, to enhance agonist action, directly activate, and inhibit currents mediated by expressed alpha(1)beta(2)gamma(2L) GABA(A) receptors using electrophysiological techniques. Our studies reveal that cyclopro- pane and butane enhance agonist action on the GABA(A) receptor at concentrations that exceed those required to produce anesthesia. Neither nonhalogenated alkane directly activated nor inhibited GABA(A) receptors, even at concentrations that approach their aqueous saturated solubilities. These results strongly suggest that the behavioral actions of nonhalogenated alkane anesthetics do not result from their abilities to enhance agonist actions, directly activate, or inhibit alpha(1)beta(2)gamma(2L) GABA(A) receptors and are consistent with the hypothesis that electrostatic interactions between anesthetics and their protein binding sites modulate GABA(A) receptor potency. IMPLICATIONS: When normalized to either their in vivo anesthetic potencies or hydrophobicities, cyclopropane and butane are 1-1.5 orders of magnitude less potent enhancers of agonist action on alpha(1beta2gamma2L) GABA(A) receptors than isoflurane. Additionally, cyclopropane and butane fail to directly activate or inhibit receptors, even at near aqueous saturating concentrations. Thus, it is unlikely that either enhancement or inhibition of the most common GABA(A) receptor subtype in the brain accounts for the behavioral activities of cyclopropane and butane.     

Relationship of peripheral arterial compliance and standard cardiovascular risk factors

Abnormalities of peripheral arterial compliance are clinically useful markers of atherosclerosis and risk of vascular events. Local peripheral arterial compliance can be easily and accurately assessed in the clinic by computer-controlled pulse volume recordings (air plethysmography). The purpose of this study was to investigate the relationship between clinical cardiovascular risk factors, a surrogate of atherosclerotic burden, and peripheral arterial compliance in the thigh and calf determined by quantification of local pulse volume recordings in patients undergoing coronary angiography. Peripheral arterial compliance in the thigh and calf was measured in 346 patients undergoing diagnostic cardiac catheterization at 4 centers. Demographic and cardiovascular risk factor data were collected, and their relationship to local arterial compliance examined using a new device that assesses maximal local arterial volume change in an extremity segment. Pulse volume recordings detected decreased local arterial compliance in the thigh associated with a history of hypertension (p < 0.0001), diabetes mellitus (p = 0.0001), and hyperlipidemia (p = 0.0007). In the calf, this arterial compliance measure was associated with a history of hypertension (p < 0.0001) and diabetes mellitus (p = 0.002). Females had lower arterial compliance than males in the thigh (p = 0.003) and calf (p < 0.0001). Limited evidence of lower arterial compliance in the thigh was found for those with obesity (p = 0.07). This procedure also demonstrated that subjects with multiple cardiovascular risk factors had lower arterial compliance in the thigh than subjects with no or 1 risk factor (p = 0.0001). Peripheral arterial compliance determined by air plethysmography is strongly associated with standard cardiovascular risk factors. The noninvasive measurement of local arterial compliance by regional pulse volume recording may be a useful adjunct for cardiovascular risk stratification early in the course of the disease as well as for monitoring vascular response to therapy.     

Does indermil glue improve success rates in myringoplasty? Interim analysis of a prospective trial

The success rates of myringoplasty vary in the literature from 65 to 97.5 percent. Various reasons for failure are cited, one being failure of the graft to act as an adequate scaffold due to its falling away from the edge of the perforation. The potential role of adhesives in myringoplasty has been described but not objectively assessed. A group of 15 patients with a perforation of the tympanic membrane present for at least 6 months was prospectively recruited. All patients underwent myringoplasty using underlayed temporalis fascia. In each case the graft was spot welded to the edge of the perforation using Indermil (n-butyl cyanoacrylate) glue. At mean 7.7 months post operatively 14 grafts are intact (93%) and all patients have audiometric improvement (p < 0.01). These results are better then those from national audit statistics in the UK using conventional methods suggesting this technique is very promising. The technique and results are described.     

Nursing Practice Competency of Accelerated Bachelor of Science in Nursing Program Students

The purposes of this study were to quantify the perception of nursing practice competency by students in an accelerated bachelor of science in nursing program at the beginning and the end of the program of study and to compare the student's perception of their competency at the end of the program of study with the unit-based nurses expert's perception of the students nursing practice competency. A quantitative pre–post intervention design was used to measure the perception of students at the beginning (T-1) and the end (T-2) of their program of study in nursing. Using Benner's domains of nursing practice, there was a significant difference in self-perception at the beginning and the end of the program. At the end of the program, the unit-based nurse expert rated the student's nursing practice higher on all domains, as compared to the student self-rating. The nursing practice competency of these students was quantified. It is interesting to note that self-rating at the end of the program of study were just below the midpoint of the scale. However, the scoring on a global item of how competent are you to begin practicing as a professional nurse was scored higher than any of the individual domains of practice.     

Stereoelectronic and steric effects in side chains preorganize a protein main chain

Preorganization is shown to endow a protein with extraordinary conformational stability. This preorganization is achieved by installing side-chain substituents that impose stereoelectronic and steric effects that restrict main-chain torsion angles. Replacing proline residues in (ProProGly)₇ collagen strands with 4-fluoroproline and 4-methylproline leads to the most stable known triple helices, having T_m values that are increased by > 50 °C. Differential scanning calorimetry data indicate an entropic basis to the hyperstability, as expected from an origin in preorganization. Structural data at a resolution of 1.21 Å reveal a prototypical triple helix with insignificant deviations to its main chain, even though 2/3 of the residues are nonnatural. Thus, preorganization of a main chain by subtle changes to side chains can confer extraordinary conformational stability upon a protein without perturbing its structure.     

Development of a novel probe for measuring drug binding to the F1*S variant of human alpha 1-acid glycoprotein.

A novel probe was developed to measure drug association with the F1*S variant of the human serum protein alpha 1-acid glycoprotein (AGP). The molecule 2-hydroxy-3,5-diiodo-N-[2(diethylamino)ethyl]benzamide (DEDIC) binds to AGP, quenching its native fluorescence. This quenching was fitted to a two-site model giving apparent dissociation constants of 0.049 +/- 0.005 and 12 +/- 2 microM (mean +/- SEM). Quenching of each of the separate variants of AGP by DEDIC was itself described by a two-site model, giving for the F1*S variant K(D)(1)((F1*S)) = 0.041 +/- 0.010 microM and K(D)(2)((F1*S)) = 29 +/- 7 microM; and for the A variant K(D)(1)((A)) = 0.31 +/- 0.18 microM and K(D)(2)((A)) = 8.8 +/- 0.7 microM. The utility of DEDIC in probing drug interactions with isolated variants was demonstrated in competition experiments with the model drugs amitriptyline and bupivacaine. In addition, the selectivity of DEDIC for variant F1*S rendered it capable of probing the binding of drugs (including the variant A-selective drug amitriptyline) to F1*S in a mixture of variants, such as occurs naturally in whole AGP. DEDIC is unique as an F1*S variant-selective probe of drug binding to whole AGP that is also sufficiently soluble to serve as a probe of drug binding to the lower affinity sites on isolated A and F1*S variants.