How I was almost aborted: reflections on a prenatal brush with death.

After recently meeting with his biological parents, the author--a 29-year-old-married male--learned he had been an hour away from being aborted, being 'saved' only by extraordinary circumstances. In the paper the author reflects upon previous strong pro-choice beliefs and reasserts his commitment to a pro-choice philosophy, integrating his new personal experience. The paper pays particular attention to the biological mother's experience and how her fresh insights have reinforced the author's views on abortion.     

Reversed vein graft stenosis: early diagnosis and management.

Conscientious surveillance of intrainguinal bypass grafts is mandatory to detect vein graft stenoses, which, if uncorrected, can lead to graft occlusion. It is now widely accepted that noninvasive vascular laboratory studies are the best way to detect these lesions. However, controversy still exists over treatment, specifically whether balloon angioplasty is an acceptable substitute for surgery (patch angioplasty or short jump grafts) in the treatment of these lesions. We have always favored balloon angioplasty as primary treatment and have summarized our experience with treating 72 stenotic reversed femoropopliteal and femorotibial vein grafts, which represent 12% of 521 bypass grafts performed at our institution. Prosthetic and in situ grafts are specifically excluded from this report, as well as occluded grafts, found to have stenotic lesions after lytic therapy. The most common stenotic lesion occurred within 4 cm of the proximal anastomosis (29/72 = 40%). The other sites were near the distal anastomosis (7/72 = 10%), and in the middle of the graft (15/72 = 12%). Eighty-one percent (58/72) of the lesions were treated initially by balloon angioplasty with a 31% recurrence. Twenty-nine percent of the 14 grafts treated surgically by vein patch angioplasty or short jump grafts experienced recurrence. Overall 61% (44/72) of the stenotic grafts were treated by balloon angioplasty alone. The 5-year life-table assisted primary patency after correction of the stenotic lesion was 61%. The patency of the grafts from the time of initial bypass surgery, however, was 80%. Location of the stenosis within the graft was a major determinant of patency. Lesions in the proximal graft, proximal anastomosis, and distal graft taken as a group had significantly better patency than the midgraft and distal anastomotic lesions (5-year patency, 65% vs 48%, p less than 0.001 log rank test). We continue to recommend balloon angioplasty as primary therapy for vein graft stenosis except for those occurring in the midgraft and distal anastomosis. Fortunately, this group accounts for only 36% of lesions seen with reversed veins. Recurrent stenosis after balloon angioplasty should be repaired surgically.     

A Bayesian approach to aid in formulary decision making: incorporating institution-specific cost-effectiveness data with clinical trial results.

Pharmacy and therapeutics committees commonly cite a lack of generalizability as a reason for not incorporating cost-effectiveness information into decision making. To address this concern, many committees undertake site-specific economic evaluations, which are often limited by small sample sizes and nonrandomized designs. We show how 2 complementary approaches were used to minimize these limitations in an economic evaluation of abciximab at 1 institution. Using a propensity score methodology, we selected patients who did not receive abciximab for the comparison cohort. Then, we adopted a Bayesian, hierarchical, random-effects model to integrate site-specific and clinical trial data. We applied the posterior distributions of effectiveness with local cost data in a traditional decision-analytic model. In 74% of the simulations, abciximab was cost-effective at 1 institution at the $50,000 per life year saved threshold, assuming a 50:50 split of patients undergoing coronary stenting and angioplasty. Among patients undergoing coronary stenting, the cost-effectiveness ratio of the addition of abciximab was at or below the $50,000 per life year saved threshold in 66.0% of the simulations.     

Decrements in vigilance and cognitive functioning associated with ragweed-induced allergic rhinitis.

BACKGROUND AND OBJECTIVE: The adverse effects of untreated seasonal allergic rhinitis (AR) on performance in the workplace, school, and home are poorly understood. To delineate more clearly the impact and consequences of the disease on performance, the effect of symptomatic AR on vigilance and a wide range of cognitive functions was investigated. METHODS: A battery of automated neuropsychological tests was administered to asymptomatic adult subjects with histories of AR. Subjects were randomized to either a symptomatic or to an asymptomatic group. Subjects in the symptomatic group were exposed to ragweed pollen in a controlled exposure setting until they demonstrated predetermined severities of AR symptoms. Subjects in the asymptomatic group were not exposed to ragweed pollen in the environmental unit and retained a minimum symptom profile. The battery of cognitive measures was re-administered to both groups. RESULTS: AR had major adverse impacts on measures of vigilance. Further, AR adversely affected a broad range of cognitive functions. Specifically, subjects with AR symptoms demonstrated longer response times and decreased efficiency on measures of working memory, psychomotor speed, reasoning/computation, and divided attention as compared with asymptomatic subjects. CONCLUSIONS: In addition to decreased vigilance, AR was associated with decrements in speed and efficiency across several cognitive domains. This is similar to findings in research on medications and medical conditions that cause sedation. Findings may represent a link between AR and poor productivity/personal safety among AR sufferers. This suggests that these results have implications with regard to public health.     

Effect of ibuprofen and interleukin 2 on transfusion-induced suppression of cell-mediated immunity

Transfusion-induced immunosuppression has been associated with excessive production of prostaglandin E and decreased interleukin 2 (IL-2) production. In the present study, allogeneic blood-transfused mice were tested for cell-mediated immunity with the use of a delayed-type hypersensitivity assay. In vivo administration of a cyclo-oxygenase inhibitor, ibuprofen, and murine recombinant IL-2 was initiated on day 0 and continued daily throughout the delayed-type hypersensitivity assay. The results indicate that prostaglandin E may play a primary role in allogeneic blood transfusion-induced suppression, as manifest by normal responses in ibuprofen-treated mice. Supplementation of transfused mice with recombinant IL-2 also preserved immune response, indicating inadequate IL-2 production after transfusion, while receptor expression appears to remain intact.     

Noninvasive assessment of metabolism in wounded skin by 31P-NMR in vivo.

Phosphorus-31 nuclear magnetic resonance techniques using shallow penetrating coils have been used to noninvasively monitor severity and metabolic changes over time in skin wounds in rats. Ratios of phosphocreatine (PCr) to inorganic phosphate (Pi) indicate energy status in both thermal wounds and surgical flaps. In partial and full-thickness scald wounds, reductions in PCr/Pi ratios correlated with burn depth and improved over time postinjury, suggesting wound revascularization. No decrease in intracellular pH was noted in these wounds; the phosphate shifts may be primarily the result of tissue degradation followed by restoration of the microvasculature. Distal regions of caudally based dorsal 3 x 10 cm full-thickness skin flaps reveal progressively lower PCr/Pi ratios to 3-6 hours after elevation as well as drops in pH up to 0.5 units, presumably as a result of anaerobic glycolysis in these tissues. After 24 hours, the intracellular pH returned to normal (7.1-7.2) and the PCr/Pi ratios approached 70%-90% of the well-perfused proximal regions within 3-7 days. These results indicate the establishment of a microvasculature from the underlying bed as the distal regions survive as free grafts. The data demonstrate the potential usefulness of the technique in noninvasive measurement of the biochemical response to injury and wound healing in living organisms.