Association of selenium and copper with lipids in umbilical cord blood.

Altered levels of selenium and copper have been linked with altered cardiovascular disease risk factors including changes in blood triglyceride and cholesterol levels. However, it is unclear whether this can be observed prenatally. This cross-sectional study includes 274 singleton births from 2004 to 2005 in Baltimore, Maryland. We measured umbilical cord serum selenium and copper using inductively coupled plasma mass spectrometry. We evaluated exposure levels vis-à-vis umbilical cord serum triglyceride and total cholesterol concentrations in multivariable regression models adjusted for gestational age, birth weight, maternal age, race, parity, smoking, prepregnancy body mass index, n-3 fatty acids and methyl mercury. The percent difference in triglycerides comparing those in the highest v. lowest quartile of selenium was 22.3% (95% confidence interval (CI): 7.1, 39.7). For copper this was 43.8% (95% CI: 25.9, 64.3). In multivariable models including both copper and selenium as covariates, copper, but not selenium, maintained a statistically significant association with increased triglycerides (percent difference: 40.7%, 95% CI: 22.1, 62.1). There was limited evidence of a relationship of increasing selenium with increasing total cholesterol. Our findings provide evidence that higher serum copper levels are associated with higher serum triglycerides in newborns, but should be confirmed in larger studies.

Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond.

CONTEXT: A high homocysteine level has been identified as an independent modifiable risk factor for coronary heart disease (CHD) events and death. Since January 1998, the US Food and Drug Administration has required that all enriched grain products contain 140 microg of folic acid per 100 g, a level considered to decrease homocysteine levels. OBJECTIVES: To examine the potential effect of grain fortification with folic acid on CHD events and to estimate the cost-effectiveness of additional vitamin supplementation (folic acid and cyanocobalamin) for CHD prevention. DESIGN AND SETTING: Cost-effectiveness analysis using the Coronary Heart Disease Policy Model, a validated, state-transition model of CHD events in adults aged 35 through 84 years. Data from the third National Health and Nutrition Examination Survey (NHANES III) were used to estimate age- and sex-specific differences in homocysteine levels. INTERVENTION: Hypothetical comparison between a diet that includes enriched grain products projected to increase folic acid intake by 100 microg/d with the same diet without folic acid fortification; and a comparison between vitamin therapy that consists of 1 mg of folic acid and 0.5 mg of cyanocobalamin and the diet that includes grains fortified with folic acid. MAIN OUTCOME MEASURES: Incidence of myocardial infarction and death from CHD, quality-adjusted life-years (QALYs) saved, and medical costs. RESULTS: Grain fortification with folic acid was predicted to decrease CHD events by 8% in women and 13% in men, with comparable reductions in CHD mortality. The model projected that, compared with grain fortification alone, treating all patients with known CHD with folic acid and cyanocobalamin over a 10-year period would result in 310 000 fewer deaths and lower costs. Over the same 10-year period, providing vitamin supplementation in addition to grain fortification to all men aged 45 years or older without known CHD was projected to save more than 300 000 QALYs, to save more than US $2 billion, and to be the preferred strategy. For women without CHD, the preferred vitamin supplementation strategy would be to treat all women older than 55 years, a strategy projected to save more than 140 000 QALYs over 10 years. CONCLUSIONS: Folic acid and cyanocobalamin supplementation may be cost-effective among many population subgroups and could have a major epidemiologic benefit for primary and secondary prevention of CHD if ongoing clinical trials confirm that homocysteine-lowering therapy decreases CHD event rates.

Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education.

CONTEXT: Academic medical centers are under enormous pressure to improve quality and cut costs while preserving education. OBJECTIVE: To determine whether a reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively in care, would lower costs without compromising quality and education. DESIGN: Alternate-day controlled trial. SETTING: Inpatient academic general medical service. PATIENTS: The 1623 patients discharged from the Moffitt-Long medical service between July 1, 1995, and June 30, 1996. INTERVENTIONS: We divided our 4-team inpatient general medical service into 2 managed care service (MCS) teams and 2 traditional service (TS) teams. The MCS faculty served as attending physicians more often and were required to provide early input into clinical decisions. Patients were assigned to teams based on alternate days of admission. MAIN OUTCOME MEASURES: Outcome measures included resource use and outcomes for MCS vs TS patients, and for MCS patients vs patients seen the previous year, adjusted for demographic characteristics and case mix. Satisfaction of patients, house staff, and faculty was also assessed, as was educational emphasis. RESULTS: A total of 806 patients were admitted to the MCS and 817 to the TS. Demographic characteristics and case mix were similar. Clinical outcomes, including mortality and readmission rates, were also similar, as was patient satisfaction. Resident and faculty satisfaction were high on both services. The average adjusted length of stay of patients on the MCS was 4.3 days vs 4.9 days on the TS and 5 days in 1994-1995 (adjusted P=.01 for MCS vs TS; MCS vs 1994-1995, P<.001). Average adjusted hospital costs were $7007 on the MCS vs $7777 on the TS and $8078 in 1994-1995 (adjusted P=.05 for MCS vs TS; MCS vs 1994-1995, P=.002). CONCLUSIONS: A reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively, resulted in significant resource savings with no changes in clinical outcomes or patient, faculty, and house staff satisfaction.

The relationship of postoperative delirium with psychoactive medications.

OBJECTIVE: To examine the role of medications with known psychoactive properties in the development of postoperative delirium. DESIGN: Nested case-control study within a prospective cohort study. SETTING: General surgery, orthopedic surgery, and gynecology services at Brigham and Women's Hospital, Boston, Mass. PATIENTS: Cases (n = 91) were patients enrolled in a prospective cohort study who developed delirium during postoperative days 2 through 5. One or two controls (n = 154) were matched to each case by the calculated preoperative risk for delirium using a predictive model developed and validated in the prospective cohort study. MAIN OUTCOME MEASURES: Medication exposures were ascertained from the medical record by a reviewer blinded to the study hypothesis. Exposures to narcotics, benzodiazepines, and anticholinergics were recorded for the 24-hour period before delirium developed in the 91 cases and for the same 24-hour postoperative period for the 154 matched controls. RESULTS: Delirium was significantly associated with postoperative exposure to meperidine (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3 to 5.5) and to benzodiazepines (OR, 3.0; 95% CI, 1.3 to 6.8). Meperidine had similar associations with delirium whether administered via epidural or patient-controlled routes, although only the epidural route reached significance (OR, 2.4; 95% CI, 1.3 to 4.4; OR, 2.1; 95% CI, 0.4 to 10.7, respectively). For benzodiazepines, long-acting agents had a trend toward stronger association with delirium than did short-acting agents (OR, 5.4; 95% CI, 1.0 to 29.2; vs 2.6; 1.1 to 6.5), and high-dose exposures had a trend toward slightly stronger association than low-dose exposures (OR, 3.3; 95% CI, 1.0 to 11.0; vs 2.6; 0.8 to 9.1). Neither narcotics (OR, 1.4; 95% CI, 0.5 to 4.3) nor anticholinergic drugs (OR, 1.5; 95% CI, 0.6 to 3.4) were significantly associated with delirium as a class, although statistical power was limited because of the high use of narcotics and the low use of anticholinergics in the study population. CONCLUSIONS: Clinicians caring for patients at risk for delirium should carefully evaluate the need for meperidine and benzodiazepines in the postoperative period and consider alternative therapies whenever possible.

Reduced severity of eosinophilia-myalgia syndrome associated with the consumption of vitamin-containing supplements before illness.

OBJECTIVE: To determine if the severity of subacute symptoms in eosinophilia-myalgia syndrome (EMS) was affected by medical history or use of nutritional supplements other than tryptophan before illness. DESIGN AND STUDY POPULATION: A case-control study was conducted of EMS cases systematically sampled from all those reported to a statewide surveillance system in California in 1989. Excluding two previous EMS-related deaths, interviews were completed in 73% (57/78) of the eligible case patients sampled. MAIN OUTCOME MEASURES: The severity of any myalgia(s), dyspnea, or walking impairment during each of the first 3 months of EMS was quantified by means of self-reported integer scores ranging from 0 (asymptomatic) to 10 (severe symptoms). Case patients in the top tercile of combined, unweighted monthly scores were defined as having severe symptoms. RESULTS: All interviewees (57 of 57) had consumed supplemental tryptophan before illness; 89% (51/57) were female. The odds of severe symptoms were not significantly associated with gender, age, previous antidepressant use, or cumulative amounts of supplemental tryptophan consumed before or after EMS onset (P > .1). Previous consumption of any multivitamin(s), however, was associated with significantly lower odds of severe symptoms (adjusted odds ratio, 0.05; 95% confidence limits, 0.007, 0.4; P = .006). CONCLUSIONS: The consumption of multivitamin-containing supplements before EMS appears to have modified the severity of subacute symptoms in this sample of cases from California.

Acute iron intoxication in pregnancy: case report and review of the literature.

Limited reports exist regarding acute iron intoxication during pregnancy. The maternal and fetal effects of accidental or deliberate ingestion of large amounts of iron may be catastrophic. A case report of acute iron intoxication, management strategies, and a review of the literature are presented. The cornerstones of effective therapy are aggressive management with emesis induction or gastric lavage, bicarbonate instillation, vigorous intravenous hydration, and chelation therapy with deferoxamine.

Micronucleated erythrocytes as an index of cytogenetic damage in humans: demographic and dietary factors associated with micronucleated erythrocytes in splenectomized subjects.

Erythrocytes containing micronuclei serve as an indicator of genotoxic exposure in splenectomized individuals. Micronucleated erythrocytes, derived from cytogenetically damaged RBC precursors, are not selectively removed from peripheral blood in individuals who lack splenic function. The relationship between micronucleated cell frequencies and demographic, environmental, and dietary factors was examined in 44 subjects with previous splenectomy due to trauma. Their micronucleated cell counts fit a log-normal distribution, with geometric means of 3.3 micronucleus-containing cells/1000 reticulocytes and 2.7/1000 normochromatic erythrocytes. A multiple regression analysis showed that drinking five cups of coffee or tea/day (relative to none) was associated with an approximately 2-fold higher frequency of micronucleated cells. Weaker statistical associations were also noted with micronucleus frequency and the consumption of calcium supplements (associated with a higher frequency) and vitamins A, C, or E (lower frequency). An apparent trend of higher micronucleus counts with age was attenuated when other factors were considered in the regression. Cigarette smoking and decaffeinated coffee consumption were among the factors not associated with elevated micronucleated cell frequencies. Because the occurrence of micronuclei in reticulocytes reflects cytotoxic exposures within the past 3-8 days, it may be possible to test directly the relationship of these factors to micronucleus formation through intervention studies.

The mathematics of hypnosis and pain.

Hypnosis is used as part of a psychological approach in dealing with phobic patients. The patient focuses on the stimuli of images offered by the therapist's voice. The critical faculty is bypassed, and selective thinking is established. The induction is the choice of the therapist, and imagery is introduced using numerical concepts associated with left-brain-related logic rather than right-brain-related nonverbal emotionality.(1,2) There is an emotional component in the perception of pain, and this is a large factor in the development of dental phobia.(3) Clinical skill and a sympathetic manner are not sufficient to ensure absence of pain perception in the patient: there must be a lack of awareness of any of the stimuli of dentistry. The hypnotic diversion of attention from dental treatment, aiming at the elimination of the emotional perception of pain, is described in this article.

Narrowing resection margins for patients with low-risk melanoma.

Surgeons hesitate to accept lesser cancer operations for several reasons. Paramount, however, is the fear that they might jeopardize cure rates by inadvertently leaving residual tumor behind. In cutaneous melanoma, for example, wide excision of the primary tumor site, usually in combination with skin grafting, has been the standard for years. Recently, as the biologic characteristics of this neoplastic system have become better understood, a subset of patients has been identified who can be cured readily by surgical excision alone. It is in this low-risk group of patients that lesser margins of excisions have been advocated. To date, a majority of surgeons have not accepted this thesis. In an effort to study this further, one of us prospectively treated 45 patients with thin, low-risk melanomas by conservative excision of their primary tumor sites. The margins invariably were 2 cm or less, and two thirds of the patients were operated on as out-patients utilizing local anesthesia. After a mean follow-up period of 36 months, no recurrences of melanoma developed. Acceptance of this treatment appears appropriate in this subset of patients.

Screening for occult blood in selected patients. The potential for false-negatives.

Seventy-one patients presenting for elective hernia repair without gastrointestinal symptoms were screened for occult blood in their stools. All patients had stools negative for occult blood and were studied with proctosigmoidoscopy and barium enema. Polyps were found in 10% of the study population. The potential for missing polyps definitely exists if patients are selected for further studies only on the basis of tests for occult stool blood.

Surgery with the argon laser: recent advances in instrumentation and techniques.

There have been several recent advances in the instrumentation and techniques of use of the argon laser in dermatologic surgery. Dispersion lenses that enlarge the areas of impact, operation through a microscope that permits precise microsurgery, templates that delimit areas of treatment, special eyeshields, nerve block anesthesia, and intermittent, light general anesthesia feasible in an out-patient setting are discussed.

The efficacy of several irrigating solutions for endodontics: a scanning electron microscopic study.

The perforated irrigation needle was used to test a high-volume (20 c.c.) final flush of prepared root canals. Three solutions: TEGO 1 percent, NaOCl 5.25 percent, and REDTA were tested. The roots were split longitudinally and were prepared for examination under the scanning electron microscope immediately after preparation and final flushing. In addition, groups were prepared and flushed in the same manner, but after splitting they were soaked in the respective solutions for 3 hours and then examined. The results indicated that the smeared layer is caused by instrumentation, that it is not removed by TEGO or NaOCl, and that it is removed by REDTA. It may be that the smeared layer is a slurry of dentin filings, since REDTA does not remove soft tissue. All solutions produced a canal quite free of debris; however, none of the tested irrigants was completely satisfactory by itself.

Evaluation of nonhormonal cytotoxic chemotherapy in the Nb rat prostate adenocarcinoma: autonomous tumor (18-Pr and 13-Pr).

The Nb rat prostatic adenocarcinomas is an appropriate animal model for the study of cytotoxic chemotherapeutic agents. The autonomous tumor, 18-Pr, was evaluated with single-agent cytotoxic chemotherapy consisting of actinomycin-D, BCNU, cyclophosphamide, and two doses of 5-fluorouracil (5-FU). The effect of these agents was significant (P less than 0.05) when cyclophosphamide, BCNU, and the higher dose of 5-FU were used. The autonomous tumor, 13-Pr, was treated with 5-FU, methotrexate, adriamycin, and cyclophosphamide. A significant effect was observed with methotrexate and cyclophosphamide (P less than 0.05). These chemotherapeutic agents were evaluated in this animal model in order to test its suitability for evaluating BCNU and actinomycin-D, agents not currently being administered for the treatment of prostatic adenocarcinoma, and in order to evaluate agents that have yielded objective responses in the treatment of metastatic prostate cancer. These tumors have been effectively treated with cyclophosphamide, 5-FU, and methotrexate, as well as BCNU, and agent not currently in vogue for treatment of metastatic prostate cancer.

Evaluation of chemotherapeutic responsiveness in Nb rat prostate cancer model. 5-fluorouracil, methotrexate, cyclophosphamide, and adriamycin.

We elevated four chemotherapeutic agents in 105 male Nb rats with transplanted Nb rat prostatic tumors. Tumor volume and the presence or absence of metastasis were determined at the completion of the experiment and served as indicators of agent effectiveness. 5-Fluorouracil and cyclophosphamide were the most effective agents (P < 0.01). Seven of ten animals treated with cyclophosphamide had complete tumor regression; only one had pulmonary visceral or mediastinal metastasis. In other chemotherapeutic and control groups, no animal had complete tumor regression and approximately 50% of the experimental animals developed metastases despite chemotherapy. Final tumor volume was significantly reduced when compared to controls in the high-dose methotrexate doxorubicin hydrochloride (Adriamycin), cyclophosphamide, and both 5-fluorouracil groups (P < 0.01).