Vaginal microbiome and metabolome highlight specific signatures of bacterial vaginosis.

In this study, we sought to find novel bacterial and metabolic hallmarks for bacterial vaginosis (BV). We studied the vaginal microbiome and metabolome of vaginal fluids from BV-affected patients (n = 43) and healthy controls (n = 37) by means of an integrated approach based on quantitative polymerase chain reaction (qPCR) and proton nuclear magnetic resonance ((1)H-NMR). The correlations between the clinical condition and vaginal bacterial communities were investigated by principal component analysis (PCA). To define the metabolomics signatures of BV, 100 discriminant analysis by projection on latent structure (PLS-DA) models were calculated. Bacterial signatures distinguishing the health condition and BV were identified by qPCR. Lactobacillus crispatus strongly featured the healthy vagina, while increased concentrations of Prevotella, Atopobium and Mycoplasma hominis specifically marked the infection. (1)H-NMR analysis has led to the identification and quantification of 17 previously unreported molecules. BV was associated with changes in the concentration of metabolites belonging to the families of amines, organic acids, short chain fatty acids, amino acids, nitrogenous bases and monosaccharides. In particular, maltose, kynurenine and NAD(+) primarily characterised the healthy status, while nicotinate, malonate and acetate were the best metabolic hallmarks of BV. This study helps to better understand the role of the vaginal microbiota and metabolome in the development of BV infection. We propose a molecular approach for the diagnosis of BV based on quantitative detection in the vaginal fluids of Atopobium, Prevotella and M. hominis, and nicotinate, malonate and acetate by combining qPCR and (1)H-NMR.

The effect of uncertainty on the demand for medical care, health capital and wealth.

We analyze the effect of the uncertainty of the incidence of illness on the demand for medical care and on the accumulation of health capital and wealth over the retirement years. We use a simplified version of a dynamic Grossman household production model to characterize patterns of an individual's precautionary behavior. Elderly individuals respond to uncertainty by smoothing their expected utility over time by making specific patterns of purchases of medical care and consumption. We examine these patterns for individuals with different degrees of risk aversion.

Hospital ownership and cost and quality of care: is there a dime's worth of difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.

Angiosuppression and chemotherapy: strategies aimed at their integration in cancer patients.

A number of antiangiogenic agents have been developed as pharmaceuticals and are currently being tested in clinical studies. Potential strategies to enhance the activity of angiogenesis inhibitors could be to combine them, or better still, to administer them either sequentially or concurrently with cytotoxic drugs. Chemotherapy would be a more appropriate initial choice for patients with advanced disease since cytostatic agents can induce a fast regression of the tumor and cancer-related symptoms. Antiangiogenic treatment could be used after chemotherapy in patients who achieve disease remission to prolong the time to progression, the symptom-free interval and the overall survival. Antiangiogenic treatment is likely to attain an important role in the adjuvant setting. In fact, it could be used for prolonged periods after radical surgery to maintain dormancy of residual tumor cells. In spite of these promising preclinical data, several points need to be clarified before the initiation of clinical trials. In fact, certain misconceptions may interfere with their optimum design and result analysis.

Medicare home health agency utilization, 1984-1994.

This study analyzes the determinants of Medicare home health agency (HHA) use in 1984, 1989, and 1994. We estimated a two-part model, modified to adjust for heteroskedasticity, using data from the National Long-Term Care Surveys and the sample members' Medicare claim files. We found an evolving pattern of determinants of Medicare HHA utilization. The rapid increase in use after HHA guideline revisions in 1989 was associated closely with rising importance of limitations in activities of daily living and instrumental activities of daily living as determinants of expected utilization. Our results show little evidence that Medicare home health services substitute for informal home care, though they may reduce the use of skilled nursing facility care.

[Cellular adaptation and cancerogenesis]. / Adattamento cellulare e cancerogenesi.

The paper describes the main adaptive mechanisms involved in the carcinogenic process. As a result of the action of carcinogenic agents (physical, chemical, biological), and in relation to the functional status of the affected cells, a number of systems are triggered off: detoxification and conjugation systems, the metabolisation of the said agents, DNA repairing enzymes, increased shock proteins (HSP), the induction of clonal proliferation. All these systems are valuable to the survival of the body and the species and culminate in the apoptosis of damaged cells as the last attempt at adaptation of a social kind for the good of the body. When these compensation mechanisms prove ineffective, imprecise or are exceeded by cell adaptive capacity, the resulting structural and functional alterations trigger off (induction) a very long process which often lasts between one and two thirds of the body's life, in various stages, multistep and multifactorial: this neoplastic transformation leads to a purposeless, egoistic, anarchic proliferation of cells which wish to survive at all costs, even to the detriment of the body of which they form part. Following the exhaustion of cell adaptive defences, there is an accumulation of additional genetic alterations (promotion and progression), the cells become manifestly neoplastic and continue their egoistic adaptation, according to the laws of natural selection: the cells which survive are those which adapt best to the hostile environment of the host's body, which are unaffected by proliferation control mechanisms (contact inhibition, differentiation factors, apoptosis, etc.), which make the best of the growth factors present in their microenvironment, which accomplish the so-called decathlon of the metastatization process, namely acquiring new capacities which can overcome the basal membrane, invade tissues to which they are attracted and continue to proliferate. Manifestly neoplastic cells become not self at a later stage, managing to escape the immune system using various adaptive mechanisms which induce immune tolerance/anergy. From this point of view, cancer may be regarded as an incidental factor in the host's cell adaptation processes; the latter are much more important from a biological point of view and their absence is incompatible with life: cancer might therefore be regarded as a cell adaptation pathology.

[Malignant lymphoma. Epidemiologic review of 150 cases]. / Linfomi maligni. Revisione epidemiologica di 150 casi.

In the present paper the incidence of lymphomatous disease in Messina and its province, with growing urbanization and rural limiting areas, is discussed: by analysing 150 cases of malignant lymphoma observed at our Institute from 1990 to 1995. The method proposed, based on data obtained from the medical files of these patients, took into consideration various parameters such as age, sex, residence, profession, clinical and bioptic diagnosis, LDH and disease presentation. The final results showed an increase of the risk for NHL in the rural province where the main profession is agriculture or handicraft (ceramics, forged iron, glasswork, refinery), in subjects above 60 years of age; for the HL instead, over the years, a minor incidence of risk has been observed. The data obtained were partially similar to those reported in the international literature. The most present form in NHL was the lymphocytic and the centrocytic follicular form, while for HL it was the mixed cells form. The relationship between the two sexes was higher in males with HL and almost equal in NHL. The age range mostly affected by HL was between 25 and 65 years of age.

The lived experience of adolescents who transfer from a pediatric to an adult hemodialysis centre.

The transition experience of adolescent patients who transfer from pediatric to adult hemodialysis centres has not received attention in the pediatric nephrology literature. In order for health care professionals from both pediatric and adult hemodialysis centres to positively influence the quality of life during this transition, an understanding of the meanings adolescents attach to their transition experience must be explored. Phenomenology as a research paradigm was employed for this study. Phenomenology provides a method from which to study human experience as it is lived, including the meanings that individuals attach to the experience. This qualitative research study was designed to describe the meanings adolescents attached to their transition experience. Subsequent objectives of the study were: to identify implications for professional practice in both pediatric and adult hemodialysis centres; to positively influence the quality of life for adolescent hemodialysis patients during their transition; and to identify and define potential areas for further research related to the holistic needs of adolescent hemodialysis patients. A sample of three English-speaking adults between the ages of 18 and 22 years who were receiving hemodialysis treatments in an adult centre following transfer from a pediatric centre within one year were interviewed. The tape-recorded interviews were transcribed into verbatim text. In addition, field notes provided investigators with the supplemental information about the meaning and the context of the interview that the audiotape may have missed. The data were analyzed using a step-by-step procedure adapted from Colaizzi (1978). In the final step, the investigators integrated and synthesized the analysis into a descriptive meaning of the transition experience of adolescents who transferred from a pediatric to an adult hemodialysis centre. The findings of the study revealed a major theme of ownership that the adolescents described as being achieved in the adult hemodialysis centre through their increased knowledge of dialysis technology, through being held accountable for their dialysis care and through increased feelings of independence.

Home nocturnal hemodialysis in children.

OBJECTIVE: To describe the effect of home nocturnal hemodialysis (NHD) in North American children. STUDY DESIGN: Four teenagers underwent NHD for 8 hours, 6 to 7 nights/week, using either central venous lines or fistulae for periods of 6 to 12 months. Blood flow approximated 200 mL/min, and dialysate flow was 300 mL/min; the dialysate contained potassium and phosphate. The procedure was remotely monitored. RESULTS: The children had unrestricted diets and fluid allowance and did not require phosphate binders. Persistent relative hypotension developed in 2 of 4 children. Weekly Kt/V urea values were consistently >10; other biochemical measures varied. Quality of life and school attendance improved in 3 of 4 children. The workload and reported emotional burden of NHD was substantial. No significant complications occurred. Dialysate losses of calcium, phosphate and carnitine required supplementation. The annual cost per patient was dollar 64,000 Canadian, which represented a 27% savings compared with thrice weekly in-center hemodialysis. CONCLUSIONS: NHD is feasible in selected children, allows free dietary and fluid intake, and improves patient wellbeing. The burden on the family is substantial, and NHD requires support of a dedicated multidisciplinary team.

Costs and outcomes of hip fracture and stroke, 1984 to 1994.

OBJECTIVES: This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994. METHODS: We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status. RESULTS: Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P < .001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status. CONCLUSIONS: During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes.

The team approach to the management of children on chronic peritoneal dialysis.

The diagnosis of chronic renal failure has a profound and lasting impact on a child and family, with the potential for impairment of the child's physical, mental, and social development. To achieve an ideal outcome, the peritoneal dialysis (PD) team must focus on preparing the child and family to perform home dialysis, prescribe the dialysis regimen most compatible with the patient's lifestyle and clearance requirements, ensure optimal nutrition, and facilitate psychosocial adaptation to PD. Close follow-up is essential for early detection, prevention, and treatment of potential complications of dialysis. A multidisciplinary team approach encompassing nursing, medicine, nutrition, and social work best suits the needs of the child and family.

Serum uric acid and insulin secretion in diabetes mellitus.

In order to define the relationship, if any, between serum uric acid and insulin pattern in different types of diabetes mellitus, 4 groups of subjects (controls, and affected by type 1 and type 2 diabetes mellitus, with and without obesity) were considered. In each group, successively cleared of the long-term and complicated diabetic patients, serum and urinary uric acid and insulin secretion (serum C-peptide values) were determined. Serum uric acid and C-peptide values were higher in type 2 obese diabetic subjects vs the other groups of patients and controls (p < 0.001). No difference was found, on the contrary, between creatinine clearance and urinary excretion of uric acid among the groups. Moreover, serum uric acid values were in positive correlation (p < 0.02) with serum C-peptide values considering, among the diabetic subjects, only those with duration of diabetes less than 5 years and without micro-macrovascular complications. In conclusion, these data lead to presume that diabetic patients with short duration of disease and without complications show a different serum uric acid pattern, strictly related to beta-cellular secretion.

[Usefulness of color echo Doppler with power Doppler in the diagnosis of hypoechoic thyroid nodules: work in progress]. / Utilità dell'eco color Doppler con power Doppler nella diagnostica dei noduli tiroidei ipoecogeni: work in progress.

The aim of this study was twofold: first, to improve the predictive value of ultrasonography (US) in differentiating benign from malignant thyroid nodules and, second, to investigate whether color Doppler and power Doppler can distinguish different morpho-hemodynamic patterns of hypoechoic thyroid nodules according to their vascularity. Twenty-nine patients with hypoechoic thyroid nodule(s) were entered into this work in progress. Three typical power Doppler patterns were recorded and compared with color Doppler patterns and with cytologic and/or histologic findings. Power Doppler patterns were classified as follows: type A, a perilesional vascular halo; type B, a peri- and intralesional vascular halo, subdivided into: 1) with moderate intralesional vascularization, homogeneous structure and regular vessel caliber and 2) with rich intralesional vascularization, anarchical structure and winding vessel caliber and flow; type C, a perilesional vascular halo with a characteristic peripheral large afferent vessel characterized by winding caliber and flow. Of 29 patients, 21 had type A power Doppler (benign nodular goiter at cytology, in 4 of them with regressive phenomena); seven patients had type B power Doppler patterns-4 had a subtype 1 pattern (3 with nodular hyperplasias and 1 with a papillary adenoma), 3 had a subtype 2 (two had a follicular adenoma and one had a final diagnosis of angioinvasive follicular carcinoma). The patient with undifferentiated carcinoma had a type C power Doppler pattern. In conclusion, according to our early results, PD seems to be more sensitive and reliable than CD in the screening of thyroid nodules, and to yield better vascular information.

Power Doppler sonography to evaluate response to percutaneous ethanol injection in hepatocellular carcinoma.

BACKGROUND AND AIMS: The aim of the present study was to compare power Doppler imaging with traditional color Doppler imaging and with contrast enhanced computer tomography in the evaluation of intratumoral vascularity of hepatocellular carcinomas at diagnosis and in response to percutaneous ethanol injection. PATIENTS AND METHODS: Sixteen patients with hepatocellular carcinoma underwent colour Doppler, power Doppler and computed tomography at diagnosis. Seventeen patients were studied by the three techniques one month after percutaneous ethanol injection treatment. RESULTS: At baseline evaluation, power Doppler and color Doppler were always in agreement and, with the exception of one case, were also in agreement with the computerized tomography scan. On the contrary, power Doppler and computerized tomography are more sensitive than color Doppler in the evaluation of residual vascularized tumoral tissue after percutaneous ethanol injection. In 3 patients, residual vascularity was demonstrated only by computerized tomography while color and power Doppler were negative. In another 3 cases, a positive power Doppler signal, with a typical arterial Doppler spectrum, was observed while color Doppler and computerized tomography were negative. In these patients, cancer relapse was clinically evident after a few months and treatment was repeated to obtain complete necrosis. CONCLUSIONS: We conclude that only the integration of the results of all these techniques can reliably evaluate tumoral vascularity after percutaneous ethanol injection.

A combination of a fixed dose rate infusion of gemcitabine associated to a bolus 5-fluorouracil in advanced pancreatic cancer, a report from the Italian Group for the Study of Digestive Tract Cancer (GISCAD).

BACKGROUND: Laboratory evidences suggest the possibility that an infusion rate of 10 mg/m2/min may be more effective than the standard 30-min infusion of Gemcitabine (GEM). PATIENTS AND METHODS: Thirty-four patients with histologically verified locally unresectable and/or metastatic pancreatic carcinoma received GEM at the dose of 1,500 mg/m2 with an infusion rate of 10 mg/m2/min, associated to 5-fluorouracil (5-FU) at the dose of 600 mg/m2. Both drugs were administered weekly for two consecutive weeks out of every three weeks. RESULTS: One complete and five partial responses have been observed for an overall response rate of 17% (95% CI: 3%-27%). The time to progression was 3.7 months with a median survival of 5.7 months. A clinical benefit was obtained in 5 of 29 patients (17%). Grade 3-4 WHO toxicities included neutropenia (35%) and thrombocytopenia (10%). CONCLUSION: It is unlikely that a fixed dose rate infusion of GEM, at least with this dose, can improve palliation in comparison with the standard 30-min infusion schedule in advanced pancreatic cancer.