A cluster randomized controlled trial of a behavioral intervention to facilitate the development and implementation of clinical practice guidelines in Latin American maternity hospitals: the Guidelines Trial: Study protocol [ISRCTN82417627]

Background  

A significant proportion of the health care administered to women in Latin American maternity hospitals during labor and delivery has been demonstrated to be ineffective or harmful, whereas effective interventions remain underutilized. The routine use of episiotomies and the failure to use active management of the third stage of labor are good examples.     

Adult T-cell acute lymphoblastic leukemia: biologic profile at presentation and correlation with response to induction treatment in patients enrolled in the GIMEMA LAL 0496 protocol

Between 1996 and 2000, 90 newly diagnosed adult patients with T-acute lymphoblastic leukemia (T-ALL) were registered in the Gruppo Italiano Malattie Ematologiche dell'Adulto (GIMEMA) Leucemia Acuta Limfoide (LAL) 0496 protocol. Cases were centrally processed for morphology, immunophenotype, cytogenetics, molecular biology, and multidrug resistance (MDR). Twenty-two patients were females and 68 were males. Four percent of cases were pro-T, 47% pre-T, 39% cortical T, and 10% mature T-ALL. Fifty-six percent of patients with pro-T + pre-T-ALL achieved complete remission (CR) compared with 91% for cortical + mature cases (P = .002). CD34 expression was associated with a significantly lower CR rate: 54% versus 84% (P = .009). Thirty-one (36.5%) of 85 patients had an abnormal karyotype, the most common abnormality (15%) being a partial del(6q). The cytogenetic profile did not impact on CR achievement. MDR1 function, present in 26% of cases, correlated significantly with CR achievement (P = .004). A highly significant (P = .001) difference in CR rate was observed between patients who did not express the CD13/CD33/CD34 antigens and were MDR functionally negative (96%) compared with patients positive for at least one of these markers (57%). Multivariate analysis showed an impact on CR achievement for CD33 expression and MDR1 function. An extensive biologic workup of adult T-ALL cases at presentation is recommended in order to design tailored therapeutic strategies aimed at improving CR rates.     

Alcohol related conditions represent a major psychiatric problem in emergency departments

Background

Alcoholism represents a huge socioeconomic burden in most developed societies.

Methods

In order to determine the impact of conditions associated with alcohol abuse on emergency care, in 2002 all patients with alcohol related pathology presenting to the emergency department (ED) of a large urban university hospital in Germany were assessed.

Results

Of 2194 patients seen by psychiatrists in the ED, the 613 cases associated with alcohol abuse represented the largest diagnostic group (30.7%). Within this group, alcohol intoxication was the most frequent diagnosis (71.4%). Patients with an alcohol related condition needed treatment by different medical specialities and required diagnostic procedures significantly more often and consequently stayed significantly longer in the ED than patients with other psychiatric presentations.

Conclusions

The generally underestimated problem of alcohol abuse in Germany demands an excessive amount of manpower and resources in EDs, where a high yet expensive standard of care is provided. Against this background, how far this burden can be reduced, both in EDs and in society in general, is discussed.     

Subjective and objective perception of upper incisors

The purpose of this study was to evaluate the subjective judgment (SJ) of patients on their own dental appearance and to correlate the results with objective measurements (OM) of their dentition concerning the appearance of the upper incisors. Seventy-five participants (30 men and 45 women) with normal well-being were included in the study. In a questionnaire they judged the appearance of their upper incisors. Furthermore, OM were evaluated by the investigator with regard to the following points: (i) absolute length of the upper central incisors, (ii) their length exposed during laughing, (iii) width-to-length ratio of central incisors and (iv) the proportion between the width of the lateral and central incisors. The subjective results were registered on visual-analogue scales. For the objective results standardized photographs were taken. No gender dependent differences could be found for the objectively measured parameters (median): OM1, 10.7 mm; OM2, 8.1 mm; OM3, 0.81; OM4, 0.79. However, significant correlations between subjective and objective results (SJ1/OM1, SJ2/OM2, SJ3/OM3) could be shown for men, but not for women. The maximum of the calculated regression-curves for men reflect 'golden standard values' well known from the literature. The degree of satisfaction concerning appearance of anterior incisors in accordance with golden standard values is higher for men than for women.     

Incentives for retention of pregnant substance users: A secondary analysis

Retention of pregnant substance users in treatment is challenging. In a multisite clinical trial, 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus nonincentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention.     

Outcomes of a headache-specific cross-sectional multidisciplinary treatment program

Aim.— Chronic headache is a disabling disorder that is frequently poorly managed in general clinical practice. Objectives.— To investigate primary (headache frequency in days/month) and secondary (headache‐related disability, lost work/school time, anxiety and depression, amount and intake frequency of acute medication) 12‐month outcomes of a headache‐specific cross‐sectional outpatient and inpatient multidisciplinary treatment program using a dedicated computer system for data collection and corresponding between integrated care team in a tertiary headache center and practicing headache specialists. Background.— A need for integrated headache care using comprehensive and standardized assessment for diagnosis of headache, psychiatric comorbidity, and burden of disease exists. There are little published data on long‐term efficacy of multidisciplinary treatment programs for chronic headache. Design.— A prospective, observational, 12‐month, follow‐up study. Subjects and Methods.— Prospectively recruited consecutive patients with frequent difficult‐to‐treat headaches (n = 201; 63 migraine, 11 tension‐type headache, 59 combined migraine/tension‐type headache, and 68 medication overuse headache) were enrolled. Outcome measures included prospective headache diaries, a medication survey, Migraine Disability Assessment, 12‐item short form health survey, and the Hospital Anxiety and Depression Scale. Results.— The primary outcome of a reduction of ≥50% of headache frequency (days/month) was observed in 62.7%. Mean headache frequency decreased from 14.4 ± 8.2 to 7.6 ± 8.3 days/month, P < .0001. Secondary outcomes improved significantly in the total cohort and all headache subgroups. Predictors for good outcome were younger age, few days lost at work/school, and familiarity with progressive muscle relaxation therapy at baseline. Conclusions.— The present analysis provided support for a cross‐sectional multidisciplinary integrated headache‐care program.     

Increased bladder permeability in interstitial cystitis/painful bladder syndrome

The definition of interstitial cystitis (IC) has evolved over the years from being a well-defined entity characterized by diagnostic lesion (Hunner’s ulcer) in the urothelium to a clinical diagnosis by exclusion [painful bladder syndrome (PBS)]. Although the etiology is unknown, a central theme has been an association with increased permeability of the bladder. This article reviews the evidence for increased permeability being important to the symptoms of interstitial cystitis/painful bladder syndrome (IC/PBS) and in treating the disorder. Recent work showing cross-communication among visceral organs is also reviewed to provide a basis for understanding IC/PBS as a systemic disorder of a complex, interconnected system consisting of the bladder, bowel and other organs, nerves, cytokine-responding cells and the nervous system.     

Dual-label studies with [125I]-3(R)/[131I]-3(S)-BMIPP show similar metabolism in rat tissues.

Biodistribution studies with the radioiodinated 3(R)- and 3(S)-isomers of 15-(p-iodophenyl)-3-methylpentadecanoic acid (BMIPP) in rats have shown that 3(R)-BMIPP has 20%-25% higher heart uptake than 3(S)-BMIPP (15-180 min). In contrast, the 3(S)-isomer has slightly higher liver uptake, and uptake in other tissues examined is similar. METHODS: To evaluate the possible differences in metabolic fate of the two isomers, a mixture of [125I]-3(R)/[131I]-3(S)-BMIPP was administered to fasted female Fisher rats. Groups of rats (3 per group) were killed 15, 60 and 180 min after administration. Urine and feces were collected from a fourth group (n = 3) over 7 d. Samples of blood, heart, liver, lungs, kidney and urine were Folch extracted. The distributions of 125I and 131I in the organic (lipid), aqueous and pellet samples were determined. The lipid samples as well as the organic fractions from base-hydrolyzed triglyceride (TG) fractions and acid-hydrolyzed urine samples were then analyzed by thin-layer chromatography (TLC) and high-performance liquid chromatography (HPLC). RESULTS: The relative distributions of 125I and 131I in the lipid, aqueous and pellet samples were similar for both isomers. Distribution of 125I and 131I in the various components of the lipid extracts observed by TLC (hexane:ether:HOAc, 70:30:1) was also similar, with principal incorporation into the free fatty acid (FFA) and TG pools. HPLC analyses (C18) of the FFA fraction showed similar 125I and 131I profiles, corresponding to BMIPP, and the alpha-methyl-C14 (14-(p-iodophenyl)-3-(R,S)-methyltetradecanoic acid) and C12, C10 and C6 carbon chain-length catabolites. By TLC, radioactive components of 125I and 131I in the urine had the same TLC mobility as hippuric acid. HPLC analyses (C18) of acid-hydrolyzed urine gave a single 125I/131I component with the same relative retention time as 2-(p-iodophenyl)acetic acid, which is the final alpha/beta-oxidative BMIPP catabolite. Unexpectedly, HPLC of lipids from base-hydrolyzed TG from the heart tissue showed 125I/131I components with the same retention times as shorter-chain fatty acids, similar to the FFA fraction, with only low levels of activity detected in BMIPP. CONCLUSION: These results show that 3(R)-BMIPP and 3(S)-BMIPP are metabolized similarly in rat tissues and that higher myocardial extraction observed for 3(R)-BMIPP may reflect differences in the relative membrane transport of the two isomers.     

Improved radioiodination of 1,2-dipalmitoyl-3-IPPA via a tributyltin intermediate.

1,2-Palmitoyl-3-[15-(4-iodophenyl)pentadecan-3-oyl]-rac-glycerol (MIPAG) is a new agent for the clinical evaluation of pancreatic lipase activity and has demonstrated promise in preliminary clinical studies with patients affected with pancreatic insufficiency. Iodine-131-MIPAG was initially prepared via thallium-iodide displacement. Because of the need for a simple method which is amendable for the routine clinical use of MIPAG we have investigated the preparation and radioiodination of MIPAG utilizing the tributyltin precursor, 1,2-palmitoyl-3-[15-(4-tributylstannylphenyl)pentadecan-3-oy l]-rac-glycerol (TBT-MIPAG, 2). Compound 2 was prepared via the condensation of 1,2-palmitoyl-rac-glycerol with 15-(4-tributylstannylphenyl)pentadecanoic acid (TBT-PPA) prepared from 4-bromophenylacetylene. Electrophilic radioiodination using peracetic acid with sodium iodide-125 in ethanol at 80 degrees C for 60 min afforded I-125-MIPAG in 65.9% (+/- 11.5%) yield and radiochemical purity of 94% (+/- 3.0%) after C-18 Sep-Pak purification (n = 6). This improved method for radioiodination utilizing TBT-MIPAG now provides radioiodinated MIPAG for routine clinical evaluation.