Characterization of a paradoxical post-operative increase in serum cortisol in Cushing disease

Pituitary - In Cushing disease, early post-operative serum cortisol fluctuations have not been adequately characterized, and their association with initial remission and recurrence is unclear. A...     

A minimum data set prevalence of pain quality indicator: is it accurate and does it reflect differences in care processes?

BACKGROUND: A new prevalence of pain quality indicator based on the Minimum Data Set (MDS) has been developed for the purpose of providing nursing home (NH) consumers with information that would allow them to compare the quality of pain care between facilities. The purpose of this study was to compare pain-related care processes between NHs that scored in the lower 25th percentile (low pain prevalence) or upper 75th percentile (high pain prevalence) based on this indicator. METHODS: Care processes related to pain assessment, documentation, and treatment were independently evaluated using standardized resident interview and medical record review protocols for 255 residents in 16 NHs that reported MDS pain prevalence of less than 15% (8 NHs in lower 25th percentile) or greater than 30% (8 NHs in upper 75th percentile). RESULTS: A significantly greater proportion of participants in the high pain prevalence NHs reported symptoms indicative of chronic pain during interview. The standardized pain interview revealed a significantly higher prevalence of pain among participants in the lowest quartile NH group compared to the MDS pain prevalence quality indicator, but the pain prevalence according to both MDS and interview were comparable in the higher quartile NHs. Medical record review showed that a significantly greater proportion of participants in upper quartile NHs had pain assessments documented by licensed nurses and physicians, received pain medication, and had documentation of treatment response. CONCLUSIONS: An MDS pain quality indicator accurately discriminates prevalence of pain between facilities. However, interpretation of the pain indicator requires caution. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes.     

Growth factors essential for self-renewal and expansion of mouse spermatogonial stem cells

Spermatogonial stem cells (SSCs) self-renew and produce large numbers of committed progenitors that are destined to differentiate into spermatozoa throughout life. However, the growth factors essential for self-renewal of SSCs remain unclear. In this study, a serum-free culture system and a transplantation assay for SSCs were used to identify exogenous soluble factors that promote proliferation of SSCs. Mouse pup testis cells were enriched for SSCs by selection with an anti-Thy-1 antibody and cultured on STO (SIM mouse embryo-derived thioguanine and ouabain resistant) feeders in a serum-free defined medium. In the presence of glial cell line-derived neurotrophic factor (GDNF), SSCs from DBA/2J strain mice formed densely packed clumps of cells and continuously proliferated. However, other strains of mice required the addition of soluble GDNF-family receptor alpha-1 and basic fibroblast growth factor to support replication. The functional transplantation assay proved that the clump-forming cells are indeed SSCs. Thus, GDNF-induced cell signaling plays a central role in SSC self-renewal. The number of SSCs in culture doubled every 5.6 days, and the clump-forming cells strongly expressed Oct-4. Under these conditions, SSCs proliferated over 6 months, reconstituted long-term spermatogenesis after transplantation into recipient testes, and restored fertility to infertile recipients. The identification of exogenous factors that allow continuous proliferation of SSCs in vitro establishes the foundation to study the basic biology of SSCs and makes possible germ-line modification by sophisticated technologies. Moreover, the ability to recover, culture indefinitely, and transplant SSCs will make the germ-line of individual males available for periods extending beyond a normal lifetime.     

Influence of heart failure etiology on the prognostic value of peak oxygen consumption and minute ventilation/carbon dioxide production slope

BACKGROUND: Peak oxygen consumption (V(O2)) and minute ventilation (V(E))/carbon dioxide production (V(CO2)) slope have been widely demonstrated to have strong prognostic value in patients with heart failure (HF). In the present study, we investigated the effect of HF etiology on the prognostic applications of peak V(O2) and Ve/V(CO2) slope. METHODS: Two hundred sixty-eight subjects underwent symptom-limited cardiopulmonary exercise testing (CPX). The population was divided into ischemic (115 men and 22 women) and nonischemic (108 men and 23 women) subgroups. The occurrence of cardiac-related events over the year following CPX was compared between groups using receiver operating characteristic curve (ROC) analysis RESULTS: Mean age +/- SD was significantly higher (61.0 +/- 10.0 years vs 50.3 +/- 16.2 years) while mean peak V(O2) was significantly lower (15.0 +/- 5.2 mL/kg/min vs 17.5 +/- 6.7 mL/kg/min) in the ischemic HF group (p < 0.05). ROC curve analysis demonstrated that both peak V(O2) and V(E)/V(CO2) slope were significant predictors of cardiac events in both the ischemic group (peak V(O2), 0.74; V(E)/V(CO2) slope, 0.76; p < 0.001) and the nonischemic group (peak V(O2), 0.75; V(E)/V(CO2) slope, 0.86; p < 0.001). Optimal prognostic threshold values for peak V(O2) were 14.1 mL/kg/min and 14.6 mL/kg/min in the ischemic and nonischemic groups, respectively. Optimal prognostic threshold values for the V(E)/V(CO2) slope were 34.2 and 34.5 in the ischemic and nonischemic groups, respectively. CONCLUSIONS: Baseline and exercise characteristics were different between ischemic and nonischemic patients with HF. However, the prognostic power of the major CPX variables was strikingly similar. Different prognostic classification schemes based on HF etiology may therefore not be necessary when analyzing CPX responses in clinical practice.     

Approach to the patient with recurrent neprolithiasis

Although recurring nephrolithiasis may not be as common as single-episode disease, it poses greater problems to the patient's daily lifestyle and general future health status. The general need for an adequate history, examination, and radiological assessment is acknowledged, but a more intensive investigative and management approach is required. Investigations for secondary causes are paramount and may lead to identification of unusual metabolic abnormalities and specific therapies. Such medical approaches entail consideration of dietary adjustments to lower the urinary excretion of components of the renal stones, pharmacological therapies to modulate urinary constituents and limit renal stone risk, and monitoring efficacy of the therapy over time. This approach will prevent significant deterioration of renal function and other serious metabolic consequences.     

A clinic-based mammography intervention targeting inner-city women

OBJECTIVE: The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women. DESIGN: A randomized controlled trial employing firm system methodology was conducted. SETTING: The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle. PARTICIPANTS: Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314). INTERVENTIONS: The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care. MEASUREMENTS AND MAIN RESULTS: Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation. CONCLUSIONS: A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.     

DNA探针用于中华按蚊和嗜人按蚊的分类研究

本项研究首次报道了我国中华按蚊和嗜人按蚊DNA基因库的建立,并从中华按蚊DNA基因库中筛选出一特异的DNA片段,以此为DNA探针,分别与中华按蚊DNA和嗜人按蚊DNA进行斑点杂交试验,其结果证明该DNA探针可与任何发育期的中华按蚊DNA杂交而不与嗜人按蚊DNA杂交,该探针敏感性高,可检测出7.5ng的中华按蚊DNA,大约相当于1个蚊虫总DNA的1/150,可用于区别中华按蚊和嗜人按蚊。     

BNP as discharge criteria for heart failure

BACKGROUND: Heart failure (HF) is a significant clinical and economic burden in the industrialized world. Advances in pharmaceutical compounds and various medical device technologies along with the use of sophisticated HF clinics have enhanced HF treatment and improved morbidity, mortality, and quality of life. However, hospital readmission rates remain stubbornly high. B-type natriuretic peptide (BNP) levels provide valuable information about a patient's chance of readmission within 30 days of discharge, making BNP a potentially useful tool for making discharge decisions and possibly reducing readmissions. METHODS: This review examines the strength and level of evidence in key areas to determine if BNP levels could be used as a guide for discharge of HF patients. Although most of the literature describes nonrandomized studies, there is general agreement that BNP levels can be measured accurately and precisely, that BNP levels reflect varying physiologic states, and that they predict outcomes. CONCLUSIONS: More studies are needed to determine extent of biologic variability. The further use of BNP as a potential discharge marker is promising but awaits additional randomized study that reflects use in a broad-based population.