Worth the wait: The impact of government funding on hospital emergency waiting times.

In the absence of a price mechanism, emergency department waiting times act as a rationing device to equate demand for treatment with available supply. Sustained increases to demand stemming from population growth, aging populations, and rising comorbidities has caused waiting times internationally to rise. This has resulted in increased calls for higher funding from governments and commitments from both state and national governments to address excessive waiting times. This paper aims to determine the effectiveness of government funding for improving the median waiting times for treatment and the proportion of patients seen within clinically recommended waiting times. For this purpose, an econometric analysis was conducted on a panel of data on Victorian local health networks over the period 2015-2018. This is supplemented with a discussion of the alternative measures which governments might take to both address demand for emergency treatment, and also ensure that waiting time reductions can be maintained over the long-term.

Twenty-six-week oral toxicity of diheptyl phthalate with special emphasis on its induction of liver proliferative lesions in male F344 rats.

The 26-week oral toxicity of diheptyl phthalate (DHP), a peroxisome proliferator-activated receptor α (PPARα) agonist, with special emphasis on the potential induction of hepatocellular proliferative lesions was investigated in this study. DHP was administered to male F344 rats via gavage at 0 (control), 1,000 or 2,000 mg/kg/day for 26 weeks. Body weight gain was significantly lower, whereas food and water consumption was significantly higher in DHP-treated rats compared with controls. DHP-treated rats exhibited decreases in blood triglyceride, total cholesterol, phospholipid and glucose levels, which were likely related to biological effects of the PPARα agonist. Absolute and relative organ weights of the livers with pale brown discoloration and dark brown spots significantly increased in DHP-treated rats. Histopathological examinations revealed remarkable diffuse hypertrophy of hepatocytes with ground-glass appearance, intracytoplasmic inclusion bodies and/or vacuolation in the DHP-treated groups. These findings were associated with increases in serum aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and γ-glutamyltranspeptidase. The number and area of glutathione S-transferase placental form positive foci, a marker of hepatocellular preneoplastic lesions in rats, significantly increased in DHP-treated groups. Additionally, proliferating cell nuclear antigen positive liver cell counts in DHP-treated groups were significantly higher than those of the controls. Testicular alterations were not detected histopathologically, whereas absolute and relative prostate weights significantly decreased at both doses. These results indicate that DHP induces liver pre-neoplastic foci, and suggest the possibility that DHP is a possible genotoxic carcinogen in the liver of rats.

[Sterility and STD].

About one million Chlamydia trachomatis urogenital infections occur in Japan. Infections of Chlamydia trachomatis or gonococci are associated many clinical syndromes, ranging from urethritis and epididymitis in men to cervicitis, salpingitis, acute urethra syndrome, endometritis, ectopic pregnancy, infertility and pervic inflammatory disease in women. Unfortunately early infected symptoms are often very mild or absent among women. So early diagnosis and treatment are both important in Chlamydia trachomatis and gonococci infection in women. Chlamydial and gonococcal infection are highly prevalent in young sexually active adolescent. With sexually active teens practicing high-risk behavior, frequent testing is ideal and offers multiple opportunities for education and counseling by the care workers.

[Evaluation of the new nucleic acid amplification system for direct detection of Chlamydia trachomatis and Neisseria gonorrhoeae in women].

The performance of a real-time DNA amplification assay, BD ProbeTec ET System (BDPT, BD Diagnostic Systems), to detect Chlamydia trachomatis and Neisseria gonorrhoeae on endocervical and oropharyngeal samples was evaluated. After obtaining informed consent, 364 endocervical, 363 urine and 247 oropharyngeal specimens were collected from 307 cases. The overall agreement rate of the BDPT and Amplicor (AMP, Roche) assays for the detection of C. trachomatis and N. gonorrhoeae in endocervical samples was 99.2% (361/364) for C. trachomatis and 99.5% (362/364) for N. gonorrhoeae. Assay of oropharyngeal swabs by the BDPT yielded 21 C. trachomatis positives, and 19 of them were C. trachomatis negative by the DNA probe assay (Gen-Probe PACE). The AMP assay showed that 16/19 (84.2%) of the BDPT +/DNA probe - samples were positive. The BDPT also yielded 21 N. gonorrhoeae positives, 15 of which were negative with the DNA probe. Additional testing showed that all 15 BDPT +/DNA probe - samples were positive by the established nested PCR method. Our data suggest that the performance of the BDPT is comparable to that of AMP for detection of C. trachomatis and N. gonorrhoeae in endocervical swab samples and that it may be a useful method for detecting of C. trachomatis and N. gonorrhoeae in oropharyngeal samples clinically.

Role of hyaluronan and hyaluronan synthase in endometrial cancer.

The aim of this study was to determine if the immunohistochemical expression of hyaluronan synthase (HAS) and serum levels of hyaluronan correlate with the clinicopathological manifestations of endometrial carcinoma. Sera were obtained from 59 endometrial cancer patients and 22 post-menopausal healthy women. Concentration of hyaluronan in sera was measured by an inhibitory ELISA using a hyaluronan-binding protein. Tissues obtained from 59 endometrial cancer patients were immunostained by the avidin-biotin-peroxidase complex method using anti-HAS1, anti-HAS2, anti-HAS3 and anti-CD44 antibody. A section was defined as having positive expression when >50% of the tumor cells were intensely stained. The expression of HAS1 was related to the depth of myometrial invasion, histological grade and lymph-vascular space involvement, but the expression of HAS2 and HAS3 was unrelated to these parameters. CD44 expression occurred more frequently in the HAS2- or HAS3-positive groups than in the HAS2- or HAS3-negative groups, and the expression of HAS1 was unrelated to CD44 expression. Serum levels of hyaluronan were higher in the endometrial cancer group than in the healthy control group, and increased with depth of myometrial invasion, histological grade and lymph-vascular space involvement. Serum hyaluronan levels were higher in the HAS1-positive group than in the HAS1-negative group, but the expression of HAS2 and HAS3 was unrelated to serum hyaluronan levels. HAS1 expression and an increase in serum hyaluronan in endometrial cancer may be associated with disease progression through myometrial invasion and lymph-vascular space involvement.

Hyaluronan synthase expression in ovarian cancer.

To determine if the immunohistochemical expression of hyaluronan synthase (HAS) correlates with the clinicopathological manifestations or clinical outcomes of ovarian carcinoma, sections of tumor tissue from 33 ovarian cancer patients were immunostained by the avidin-biotin-peroxidase complex method using anti-HAS1, anti-HAS2, anti-HAS3 and anti-CD44 antibody. A section was defined as having positive expression when >50% of the tumor cells were intensely stained. The microvessel density, which was defined as the mean number of new vessels, was determined under light microscopy. In the 33 ovarian cancer cases, 12 cases had positive expression of HAS1, 21 cases had positive expression of HAS2 and 11 cases had positive expression of HAS3. The expression of HAS1, HAS2 and HAS3 was unrelated to the stage of disease. CD44 expression occurred more frequently in the HAS1-positive group than in the HAS1-negative group, but the expression of HAS2 and HAS3 was unrelated to CD44 expression. The microvessel density was higher in the HAS1-positive group than in the HAS1-negative group. But the microvessel density did not differ in relation to the expression of HAS2 and HAS3. In the 23 patients that received chemotherapy, the expression of HAS1, HAS2 and HAS3 was unrelated to the chemotherapy response. The overall survival time was longer in the HAS1-negative group than in the HAS1-positive group. However, the expression of HAS2 and HAS3 was unrelated to the overall survival time. These results suggest that HAS1 expression in ovarian cancer may be associated with disease progression through angiogenesis and is an independent predictor of patient survival.

Usefulness of collagen gel droplet embedded culture drug sensitivity testing in ovarian cancer.

Due to the emergence of new anticancer agents for the treatment of ovarian cancer, methods to determine which agents will be most effective in individual patients are required. In order to investigate the potential for tailor-made chemotherapy, the drug sensitivities of various ovarian cancers were examined using collagen gel droplet embedded culture drug sensitivity testing (CD-DST), and the results were correlated with clinical outcomes. Sensitivities to paclitaxel, cisplatin, doxorubicin, etoposide, and SN-38, which is an active metabolite of irinotecan, were examined. Eight out of 22 samples failed to grow colonies and thus, their cell sensitivities could not be determined. Out of the 14 cases from which CD-DST results were obtained, seven patients then received chemotherapy aimed at inducing remission, while four received adjuvant, and three did not receive any chemotherapy. Three of the four tumors subsequently treated with adjuvant chemotherapy showed sensitivity to TXL and CDDP on CD-DST analysis, while one did not. None of these patients experienced recurrent disease from 24 to 36 months. Five of the seven tumors subsequently treated with chemotherapy aimed at inducing remission showed sensitivity to the relevant anticancer agents upon CD-DST analysis, while two did not. Among the five cases that showed tumor cell sensitivity, three experienced complete responses, one achieved a partial response and one had progressive disease. For the remaining two cases that demonstrated tumor cell resistance, one had stable disease and one had progressive disease following chemotherapy. Thus, six out of the seven cases (85.7%) that received chemotherapy aimed at inducing remission had clinical outcomes in keeping with the results of CD-DST. In conclusion, CD-DST results reflect clinical outcomes and may be a useful means by which to select drugs to which ovarian cancer cells are chemosensitive.

Angiostatin expression in ovarian cancer.

Angiostatin is a potent inhibitor of neovascularization, tumor growth and metastasis. We examined the expression of angiostatin and vascular endothelial growth factor (VEGF) through immunohistochemical analysis, along with microvessel density, in primary tumors obtained from 55 ovarian carcinoma patients. Angiostatin expression was not related to either stage of disease or histology. However, VEGF expression and microvessel density were related to stage of disease. Angiostatin expression did not correlate with VEGF expression. Microvessel density correlated with VEGF, but not angiostatin expression. Univariate analysis revealed that lack of angiostatin expression, VEGF expression, microvessel density and advanced stage of disease were significant risk factors for reduced survival. Multivariate analysis revealed that lack of angiostatin expression and advanced stage of disease were significant risk factors for reduced survival. Survival time was longer in patients with angiostatin-positive and VEGF-negative tumors than in patients with angiostatin-negative and VEGF-positive tumors. The presence of angiostatin expression and absence of VEGF expression are favorable prognostic factors with regard to survival in ovarian carcinoma patients.

Bullous lesion in the prostatic urethra: morphological change caused by putative chlamydial infection.

PURPOSE: The cause of benign bullous lesions in the prostatic urethra, which we encountered in 10 patients during the last 18 years and which has not been described in literature, was studied. MATERIALS AND METHODS: Among 1,236 patients who underwent cystourethroscopy for a urological complaint 10 had bullous lesions in the prostatic urethra which were empirically thought to be inflammatory rather than tumorous lesions at initial cystourethroscopy. We retrospectively searched for common clinical characteristics for these 10 patients who had a median age of 33.5 years (range 20 to 47). The reasons for cystourethroscopy were terminal gross hematuria in 3 patients, initial gross hematuria in 1, total gross hematuria in 2, blood stain on underpants without scrotal keratoangioma in 1, hemospermia in 1 and voiding difficulty in 2. RESULTS: Based on the results of urinalysis, expressed prostatic secretion, transrectal examination of the prostate, cystourethroscopy, urethral swab test for Chlamydia trachomatis and punch biopsy of urethral mucosa with or without immunofluorescence staining with fluorescein isothiocyanate labeled monoclonal antibody for C. trachomatis, inflammation of the prostatic urethra was considered the cause of these bullous lesions. CONCLUSIONS: Bullous lesions in the prostatic urethra appear to be due to an inflammatory change. We should consider these lesions when we encounter young patients with asymptomatic gross hematuria. We should also note microscopic pyuria in such patients and subsequently perform C. trachomatis polymerase chain reaction test using urine initially as a noninvasive examination before cystourethroscopy.

Vascular endothelial growth factor activating matrix metalloproteinase in ascitic fluid during peritoneal dissemination of ovarian cancer.

The role of vascular endothelial growth factor (VEGF) during peritoneal dissemination of ovarian carcinoma and the association with tumor microvessel density (MVD) and matrix metalloproteinase (MMP) activity was investigated. To this end, MVD, tumor tissue and ascitic fluid levels of VEGF, and MMP activity of ascitic fluid were examined in patients with ovarian cancer and benign ovarian tumor. The effect of ascites on cell growth, cell invasion activity and angiogenesis was investigated in vitro. Ascitic fluid and tumor tissue samples were obtained from 15 patients with benign ovarian tumor and 24 patients with ovarian carcinoma. Tissue extract and ascitic fluid levels of VEGF were measured using enzyme immunoassay. Tumor microvessels were detected immunohistochemically. MMP activity was measured by gelatin zymography. For the in vitro experiment, the SKOV-3 human ovarian carcinoma cell line was utilized. Cell growth was examined using MTT-assay, cell invasion activity was measured by Matrigel in vitro invasion assay, and neovascularization was assessed using an angiogenesis kit. VEGF levels in tissue extract and ascitic fluid, MVD, expression of active form MMP-2 in ascitic fluid and ascites volume were higher in ovarian cancer patients than in benign ovarian tumor patients. In addition, these were elevated in stage III and IV diseases compared to stage I and II diseases in ovarian cancer patients. MVD and expression of active form MMP-2 in ascitic fluid were closely correlated with VEGF level in tissue extracts, and MVD and ascites volume were closely correlated with VEGF level in ascitic fluid. Cell invasive activity and angiogenesis activity increased when cells were exposed to ascites. These increases were apparent when exposed to ascites obtained from ovarian cancer patients and were related to VEGF concentrations of ascitic fluid and expression of active form MMP-2 in ascitic fluid. The increased VEGF secreted from tumor cells is suggested to enhance tumor growth through angiogenesis, to produce ascites and to elevate ascitic VEGF concentrations and expression of active form MMP-2. The progression of peritoneal involvement may be induced by elevated VEGF and expression of active form MMP-2, followed by increased VEGF in the primary tumor. Control of VEGF in the primary tumor may become an effective strategy against peritoneal dissemination of ovarian carcinoma.

Angiostatin expression in endometrial cancer.

Angiostatin is a potent inhibitor of neovascularization, tumor growth and metastasis. The expressions of angiostatin and vascular endothelial growth factor (VEGF) were immunohistochemically examined, along with microvessel density, in primary tumors obtained from 57 endometrial carcinoma patients with stage I disease. Angiostatin expression was not related to depth of myometrial invasion, histological grade or lymph-vascular space involvement. VEGF expression also had no relation to depth of myometrial invasion or histological grade, however, it was enhanced in tumors with lymph-vascular space involvement. Angiostatin expression did not correlate with VEGF expression. Microvessel density correlated with VEGF, but not angiostatin expression. Disease-free survival was longer in patients with angiostatin-positive tumors than in patients with angiostatin-negative tumors, but did not differ among patients with VEGF-negative and VEGF-positive tumors. No patients with angiostatin-positive and VEGF-negative tumors had recurrent disease. We concluded that negative-expression of VEGF and positive-expression of angiostatin are significant prognostic factors in endometrial carcinoma patients.

Detection of Chlamydia trachomatis infection with DNA extracted from formalin-fixed paraffin-embedded tissues.

It is a well-known fact that tubal stenosis and/or peritubal adhesion are often associated with Chlamydia trachomatis infection. Although tubal pregnancy may be attributed to this infection, there are only extremely rare cases in which the presence of C. trachomatis has been confirmed by immumo-histochemical examination on tissues isolated from patients with tubal pregnancy. We thus tried to confirm the presence of C. trachomatis infection by detecting DNA of the organism in tissues surgically isolated from patients with tubal pregnancy. Two detection methods, a ligase chain reaction (LCR) method and an immuno-histochemical staining which detects an antigen of C. trachomatis, were compared using paraffin-embedded tissue samples which were surgically isolated from patients with tubal pregnancy or hydrosalpinx. The LCR method was capable of detecting DNA of C. trachomatis in tissue samples in which the C. trachomatis-specific antigen could not be detected using immuno-histochemical staining. This was due to the fact that immuno-histochemical staining methods are applicable to the analysis of sequences the length of which range from 200 to 400 bp (base pairs), while the LCR method used here allows the analysis of sequences as small as 48 bp. This fact makes the LCR method a very convenient tool, as compared with immuno-histochemical methods, for analysis of the paraffin embedded tissue samples where by effects of formalin--used for fixation for pathologic diagnosis--the risk of fragmenting the DNA samples is relatively high. Presence of C. trachomatis DNA as detected by LCR method in surgically isolated samples from patients with tubal pregnancy supports the involvement of Chlamydia trachomatis infection in the occurrence of tubal pregnancy. Accordingly the LCR method is capable of detecting DNA of C. trachomatis in paraffin-embedded samples of tubal tissue in which presence of C. trachomatis could not be confirmed by an immuno-histochemical staining method.

Effects of chemically modified heparin on Chlamydia trachomatis serovar L2 infection of eukaryotic cells in culture.

The mechanism and inhibitors of Chlamydia trachomatis serovar L2 infection of eukaryotic host cells were studied using a tissue culture model infection system. Potent inhibition of infectivity was observed when elementary bodies (EBs) were exposed to heparin or when HeLa 229 cells were treated with heparinase. No significant inhibition was seen the other way around. The same potent inhibition was observed when EBs were exposed to chemically 2-O-desulfated heparin (2-ODS heparin), which is composed of repeating disaccharide units of IdoA-GlcNS(6S), but not when exposed to chemically 6-ODS heparin or completely desulfated and N-resulfated heparin, which is composed of repeating disaccharide units of IdoA(2S)-GlcNS or IdoA-GlcNS, respectively. The inhibitory effects of 2-ODS heparin could be seen only with oligosaccharides longer than dodecasaccharides. The mutant Chinese hamster ovary (CHO) cell line 677, which is deficient in the biosynthesis of heparan sulfate, was less sensitive to C. trachomatis infection than were wild-type CHO cells. F-17 cells, deficient in 2-O-sulfation of heparan sulfate, had the same sensitivity to infection as wild-type CHO cells did. These data suggest that infection of host cells by EBS results from the specific binding of ligand molecules with affinity for heparin on the EB surface to heparan sulfate proteoglycans on the host cell surface. This binding may depend on host cell heparan sulfate chains that are 6-O-sulfated and longer than dodecasaccharides. The 2-ODS heparin oligosaccharides may be a potential agent for the prevention of C. trachomatis infection.