Inorganic sulfate metabolism in the very low birthweight infant

The effect of vitamin D supplementation on inorganic sulfate metabolism was examined in very low birth weight (less than 1,500 g) infants at biweekly intervals after birth until 6 weeks of postnatal age. Baseline serum sulfate concentrations were significantly higher in all infants (471 +/- 24 mumol/l, n = 80) than in adults (299 +/- 25 mumol/l, n = 17). In controls, the levels did not change significantly over the ensuing 6 weeks, although serum creatinine declined. Urinary sulfate excretion rose significantly to near adult levels by 2 weeks. Both urine and serum sulfate were correlated with weight gain but not with estimated glomerular filtration rate, suggesting that factors other than renal clearance have a preponderant influence on serum sulfate in these infants. At 6 weeks, the mean serum sulfate in the high-dose group (receiving 2,170 +/- 23 U/day of vitamin D, n = 41) was significantly higher than in controls (receiving 360 +/- 22 U/day, n = 40). In all infants, there was a significant correlation (r = 0.36, p less than 0.001) between serum sulfate and 25(OH)-vitamin D concentrations, but not other analytes or clinical variables, suggesting that vitamin D may be one of the factors modulating sulfate metabolism in the newborn period.     

Randomized controlled trial of anterior-chamber intraocular lenses in Nepal: long-term follow-up

Most of the estimated 20 million people who are blind with cataracts live in rural areas of developing countries, where expert surgical resources are scarce. We have studied the use of multiflex open-loop anterior-chamber intraocular lenses (ACIOL) in high-volume low-cost surgery. Between 1992 and 1995, a total of 2000 people attending Lahan Eye Hospital, Nepal, with bilateral cataracts reducing vision to < or = 6/36 were randomly allocated to receive intracapsular extraction (ICCE) with aphakic spectacles, or ICCE with an ACIOL. We re-examined the cohort (1305/2000, 65%) between November 1996 and April 1997 and report the findings in this article. There were 13 new cases of poor visual outcome (best corrected vision < 6/60) arising after one year: 9 in the ACIOL group and 4 in the control group; odds ratio 2.1 (95% confidence interval, 0.59-9.55). The causes of poor outcome were as follows: ACIOL group--retinal detachment (4 cases), cystoid macular oedema (2), epiretinal membrane (1), age-related macular degeneration (1), and late endophthalmitis (1); control group--retinal detachment (2 cases), late endophthalmitis (1), and primary open-angle glaucoma with age-related macular degeneration (1). In rural areas of developing countries, well-manufactured multiflex open-loop ACIOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction.     

Breast cancer: better care for less cost. Is it possible?

OBJECTIVES: To estimate the potential for cost reduction in the acute care setting and the required investment in the home care setting of implementing an outpatient/early discharge strategy for operable (stages I and II) breast cancer in Canada. METHODS: Data from a community hospital were augmented by expert knowledge and incorporated into the breast cancer submodel of Statistics Canada's Population Health Model. For the estimated 90% of patients for whom this approach was assumed to be appropriate, the resource utilization for outpatient breast-conserving surgery and 2 days of hospitalization for those women undergoing mastectomy was quantified and costed, as were the appropriate home care services. A 5% readmission rate for complications was assumed. Cost per case, total cost burden, investment in home care, savings in acute care, and net savings were calculated. Sensitivity analyses were performed around readmission rates and home care/surgical follow-up costs. All costs were determined in 1995 Canadian dollars. RESULTS: The cost of initial treatment for the 15,399 women diagnosed with stages I and II breast cancer in 1995 in Canada was estimated to be $127.6 million. Hospitalization made up 53% of these costs. Under the outpatient/early discharge strategy, the acute care cost of initial breast cancer management could be reduced by $47.2 million, with an investment in home care of $14.5 million ($453 per patient), resulting in an overall net saving of $33 million. Under this strategy, hospitalization would contribute only 21% to the total care cost. CONCLUSIONS: If Canadian surgeons and healthcare administrators were to work together to put in place processes to support ambulatory breast cancer surgery and if resources were redirected to the provision of home-based post-operative care, there would be potential for a large net healthcare saving and preservation of high-quality patient care.     

Prevalence and disabilities in 4 to 8 year olds with cerebral palsy.

A register of children born between 1970 and 1979 in the South East Thames Regional Health Authority, and diagnosed as having pre-, peri-, and postnatal cerebral palsy, was set up between 1978 and 1981. We report the 527 children born between 1970 and 1974 for whom ascertainment is virtually complete. The estimated prevalence was 2.2 per 1000, with 7.4% multiple births, and 58% boys. Birthweight distribution is as expected, with 35% weighing less than 2500 g at birth. Parental permission for release of detailed medical information was sought, and the clinicians responsible gave us data on the type of cerebral palsy; details of impairments, disabilities, and anticipated future prospects; and an opinion on the probable timing of the cause. There was a high incidence of orthopaedic defects which must represent a considerable use of resources, although the prevalence of hearing and vision defects suggested that some of these may be undetected.     

Clearance of 3H-dopamine from the amniotic fluid in the rhesus monkey

Previous studies have suggested that dopamine is the major catecholamine in the amniotic fluid; however, there are few data available concerning the metabolism of this hormone in the amniotic fluid compartment. With the use of acute 3H-dopamine injection studies into the amniotic sac of pregnant rhesus monkeys, the dopamine half-life was observed to be 29 minutes, the amniotic fluid volume was 113 ml, the metabolic clearance rate was 164 ml/hr, and the calculated production rate was 436 ng/hr. The biphasic pattern of dopamine clearance from this compartment suggests that it is cleared from the amniotic sac by mechanisms similar to those used in the intravascular compartment.     

Technical aspects of multifocal ERG recording

There are a wide range of variables which can influence the quality of the multifocal response. It is possible to place these variables into one of four categories. First, the method of stimulus delivery will determine the field of view, interference levels and the duration of on-state stimulation. Second, data acquisition variables such as electrode type and placement, amplifier specifications and filter bandwidth settings will have a direct impact on waveform shape and on the topographic distribution of signal amplitudes. Third, patient variables such as fixation, pupil dilation and refractive error will also contribute to the multifocal response. Fourth, there are many measurements that can be taken from multifocal recordings. In addition to standard amplitude and implicit time measures (the implicit time measure in the multifocal response is becoming increasingly important particularly in early stages of disease processes), the scalar product measure provides information on waveform shape. The conventional impulse and higher order responses will be different for different modes of stimulation such as Cathode Ray Tube (CRT) and Liquid Crystal Display (LCD) systems and latency shifts will be introduced if not corrected in software. Procedures which could lead to misleading interpretation include artefact rejection, averaging with neighbours and summing of responses. These procedures should be handled with caution. This revised version was published online in July 2006 with corrections to the Cover Date.     

Development and evaluation of a decision aid for patients with stage IV non‐small cell lung cancer

Although guidelines for treating stage IV non‐small cell lung cancer suggest that the patient’s values should be considered in decision‐making, there are no practical tools available to assist them with their decision‐making.

Objective

To develop and evaluate a decision aid that incorporates patient values.

Design and sample

(1) Before/after evaluation with patients referred to a regional cancer centre. (2) Mailed survey of thoracic surgeons and respirologists in Ontario.

Intervention

An audio‐tape guided individuals to review a booklet describing stage IV non‐small cell lung cancer, its impact and possible coping strategies, treatment options, benefits and risks, and examples of the decision‐making of others. Patients then used a worksheet to consider and communicate personal issues involved in the choice, including: personal values using a ‘weigh‐scale’; questions; preferred role in decision‐making; and predisposition.

Measures

(1) Patient questionnaires eliciting knowledge, the decision, decisional conflict and acceptability of the decision aid. (2) Physician questionnaires eliciting attitudes toward the decision aid.

Results

(1) Twenty of 30 patients used the aid in decision‐making. Users thought that the aid was acceptable and significantly improved their knowledge about options and outcomes (P < 0.001), and reduced their decisional conflict (P < 0.001). (2) The majority of the 29 physicians who reviewed the decision aid found it acceptable, were comfortable providing it to patients and said that they were likely to use it.

Conclusion

The decision aid is a useful and acceptable adjunct to personal counselling.

     

Treatment-independent pregnancies after cessation of gonadotropin ovulation induction in women with oligomenorrhea and anovulatory menses

Life-table analysis was performed for the cumulative spontaneous pregnancy rate (CSPR) of 56 patients with oligomenorrhea and anovulatory cycles who had been treated with gonadotropin for ovulation induction between 1963 and 1985. Twenty-seven had at least one spontaneous pregnancy, giving rise to a CSPR of 66.4% (95% confidence limit [CL] 42.4% to 90.4%) at 115 months for the first spontaneous pregnancy, which is significantly lower than the cumulative induced pregnancy rate (CIPR) of 88.6% at 23 months for the first course of gonadotropin therapy (P less than 0.0001). This fertility potential was not affected by the baseline estrogen and follicle-stimulating hormone levels, diagnosis, result of gonadotropin therapy, and age and menstrual pattern during exposure to spontaneous pregnancy by Cox regression analysis. More multiple births occurred in the induced pregnancies than in the spontaneous pregnancies (P = 0.005).