A defect in the oxidative metabolism of human polymorphonuclear leukocytes that remain in circulation early in hemodialysis

Human granulocytes harvested from uremic volunteers 15 min after the initiation of dialysis (at the nadir of neutropenia) were compared to predialysis controls. These intradialysis cells had a significant defect in peak luminol-enhanced chemiluminescence in response to opsonized zymosan, f-Met-Leu-Phe, and phorbol myristate acetate relative to predialysis control cells from the same patients. This defect could not be explained by a decrease in PMN myeloperoxidase concentration. H2O2 secretion by intradialysis cells (2 patients) was also depressed relative to predialysis controls. The ability to perform an independent function, orientation (polarization), was normal in both pre- and intradialysis cells relative to control. Whereas 125I-labeled formyl peptide binding studies demonstrated identical values for affinity and receptor number for predialysis and normal control cells, intradialysis cells displayed a 27% decrease in receptor number. This decrease in available receptor number. This decrease in available receptors may be related to the decreased chemiluminescence observed in response to f-Met-Leu-Phe. Furthermore, the results are consistent with the hypothesis that a defective PMN population remains in the circulation during the neutropenia of hemodialysis.     

Improved exercise performance after exchange transfusion in subjects with sickle cell anemia

Ten patients with sickle cell anemia underwent partial exchange transfusion with hemoglobin-A-containing cells using a technique that allowed hemoglobin concentration and blood volume to remain constant. The mean fraction of hemoglobin-A in these patients increased from 9% to 55%, but the mean hemoglobin concentration increased by only 1.44 g/dl. The exchange resulted in a large improvement in submaximal exercise capacity: the mean of the anaerobic threshold (the work at which lactic acid begins to accumulate in the blood) increased from 68 to 114 W. The mean work performed at a heart rate of 170/min, an estimation of maximal work capacity, increased from 128 to 187 W. Improved exercise performance after partial exchange transfusion may result from the superior flow properties of hemoglobin-A-containing red cells. Furthermore, we believe that exercise testing in sickle cell anemia has great potential utility as a means to monitor therapy and to evaluate the benefits of exchange transfusion.     

Analysis of the origin of marrow cells in bone marrow transplant recipients using a Y-chromosome-specific in situ hybridization assay

A Y-chromosome-specific in situ hybridization assay was used to assess the frequency with which host bone marrow cells are retained after marrow grafting. The majority of patients (74%) showed the presence of both host and donor marrow cells when assayed 14 days after transplant. By 84 days posttransplant only 4% of the patients retained host marrow cells. Only 1 of 19 evaluable patients analyzed over 1 year posttransplant showed minimal retention of host cells. No statistical correlation was found between retention of host cells posttransplant and the development of relapse or acute or chronic graft-versus-host disease. Pretransplant conditioning regimen, HLA-matching, diagnosis, disease status at transplant, ABO-matching, and patient age also showed no correlation with the retention of host cells posttransplant.     

Unusual Coarctation—the PHACE Syndrome: Report of Three Cases

Objectives. To report the clinical features, nature of vasculopathy observed and the management instituted in three cases of PHACE syndrome. Results. All three patients were noted to have diffuse vasculopathy and aortic arch hypoplasia in addition to aortic coarctation adding substantial surgical risk or making surgery palliative. Conclusion. PHACE syndrome should be considered in the differential diagnosis of aortic coarctation associated with aortic arch hypoplasia.     

Drivers of overall satisfaction with primary care: evidence from the English General Practice Patient Survey

Background/objectives

To determine which aspects of primary care matter most to patients, we aim to identify those aspects of patient experience that show the strongest relationship with overall satisfaction and examine the extent to which these relationships vary by socio‐demographic and health characteristics.

Design/setting

Data from the 2009/10 English General Practice Patient Survey including 2 169 718 respondents registered with 8362 primary care practices.

Measures/analyses

Linear mixed‐effects regression models (fixed effects adjusting for age, gender, ethnicity, deprivation, self‐reported health, self‐reported mental health condition and random practice effect) predicting overall satisfaction from six items covering four domains of care: access, helpfulness of receptionists, doctor communication and nurse communication. Additional models using interactions tested whether associations between patient experience and satisfaction varied by socio‐demographic group.

Results

Doctor communication showed the strongest relationship with overall satisfaction (standardized coefficient 0.48, 95% CI = 0.48, 0.48), followed by the helpfulness of reception staff (standardized coefficient 0.22, 95% CI = 0.22, 0.22). Among six measures of patient experience, obtaining appointments in advance showed the weakest relationship with overall satisfaction (standardized coefficient 0.06, 95% CI = 0.05, 0.06). Interactions showed statistically significant but small variation in the importance of drivers across different patient groups.

Conclusions

For all patient groups, communication with the doctor is the most important driver of overall satisfaction with primary care in England, along with the helpfulness of receptionists. In contrast, and despite being a policy priority for government, measures of access, including the ability to obtain appointments, were poorly related to overall satisfaction.