Indications for Red Cell Transfusion in the Intensive Care Unit at the University Hospital of the West Indies.

OBJECTIVE: To determine current red cell transfusion practices, transfusion indications and their relationship to patient outcome in intensive care unit (ICU) patients at the University Hospital of the West Indies (UHWI). METHOD: An observational study was conducted over seven months in the two ICUs at the UHWI, on all patients over 16 years who had been admitted for more than 24 hours. Patient demographics, indication(s) for transfusion, haemoglobin level at the time of transfusion, details of ICU admission and patient outcome were recorded. Data analysis was done using Stata v12. RESULTS: Of the 203 patients included in the study, 79 were transfused (39%). A low haemoglobin level was the most common indication for transfusion, with a mean of 7.3 ± 1.5 g/dL. Patients who were transfused had higher phlebotomy volumes [61.9 versus 126.1 mL, p < 0.001], were more likely to require mechanical ventilation (p = 0.002) and inotropic support (p = 0.007). Most were surgical patients (p = 0.01) and were post-open heart/thoracic surgery (66% transfusion rate). Patient outcome was correlated with transfusion, as transfused patients had longer ICU stays (13.0 versus 6.7 days, p < 0.001) and increased mortality rates (32.9% compared to 20.2%, p = 0.04). Most transfusions occurred within the first week of admission (83.5%). CONCLUSION: The mean haemoglobin for transfusion at the ICU, UHWI, is 7.3 g/dL, just above the recommended trigger of 7.0 g/dL in a restrictive transfusion practice. Transfusion policies are needed to better allocate a scarce commodity and minimize complications associated with blood transfusion.

Vitamin D levels in Jamaican patients with systemic lupus erythematosus.

Vitamin D has important effects on the immune system as it has been shown to exert antiproliferative and relative immunosuppressant effects. Low levels of this hormone may contribute to the immune activation in systemic lupus erythematosus (SLE) and other autoimmune diseases. Serum levels of 25-OH vitamin D were measured in 75 patients with SLE in Jamaica, using an enzyme-linked immunoassay. Correlations with clinical data and disease activity as determined by the BILAG index were determined. Of a total of 75 patients, 33 (44%) had vitamin D sufficiency with mean vitamin D level of 39.45 ng/ml (range, 30.35-58.16). Forty-two (56%) patients had either vitamin D deficiency or insufficiency, 30 (40%) had vitamin D insufficiency, mean 26.36 ng/ml (range, 20.26-29.88), and 12 (16%) had vitamin D deficiency, mean 16.07 ng/ml (range, 7.78-19.90). There was an overall negative relationship between the total disease activity score using the BILAG index and vitamin D levels, and this was influenced primarily by the relationship seen among the vitamin D-deficient subgroup. This was also impacted on by a patient population that was significantly skewed toward low disease activity. The negative association trended toward statistical significance. Vitamin D deficiency is prevalent among patients with SLE in Jamaica. A relationship between low serum levels of vitamin D and SLE activity may occur.

Improvement in HDL cholesterol in postmenopausal women supplemented with pumpkin seed oil: pilot study.

OBJECTIVE: Pumpkin seed oil is rich in phytoestrogens and animal studies suggest that there is some benefit to supplementation in low estrogen conditions. This study is the first to evaluate the benefit of pumpkin seed oil in postmenopausal women. METHODS: This pilot study was randomized, double-blinded and placebo-controlled. Study participants included 35 women who had undergone natural menopause or had iatrogenically entered the climacteric due to surgery for benign pathology. Wheat germ oil (placebo; n = 14) and pumpkin seed oil (n = 21) were administered to eligible participants over a 12-week period at a dose of 2 g per day. Serum lipids, fasting plasma glucose and blood pressure were measured and an 18-point questionnaire regarding menopausal symptoms was administered; the atherogenic index was also calculated. Differences between groups, as well as before and after the period of supplementation, were evaluated with Student's t-test, Wilcoxon matched-pair signed-ranked test and Mann-Whitney test, as appropriate (Stata version 10.1). RESULTS: Women receiving pumpkin seed oil showed a significant increase in high density lipoprotein cholesterol concentrations (0.92 ± 0.23 mmol/l vs. 1.07 ± 0.27 mmol/l; p = 0.029) and decrease in diastolic blood pressure (81.1 ± 7.94 mmHg vs. 75.67 ± 11.93 mmHg; p < 0.046). There was also a significant improvement in the menopausal symptom scores (18.1 ± 9.0 vs. 13.2 ± 6.7; p < 0.030), with a decrease in severity of hot flushes, less headaches and less joint pains being the main contributors. Women in the group receiving wheat germ oil reported being more depressed and having more unloved feeling. CONCLUSION: This pilot study showed pumpkin seed oil had some benefits for postmenopausal women and provided strong evidence to support further studies.

Propofol sedation in patients undergoing colonoscopy in Jamaica.

BACKGROUND: Propofol sedation is increasingly used for colonoscopy and may be associated with increased satisfaction and efficiency in diagnostic and therapeutic endoscopy. However propofol has a relatively narrow therapeutic window as it frequently produces deep sedation, and can precipitate respiratory depression. AIM: To determine the efficacy, safety and patient satisfaction with propofol sedation in patients undergoing colonoscopy at the University Hospital of the West Indies (UHWI). METHODS: Patients undergoing outpatient colonoscopy at the UHWI who were sedated with propofol were studied. Boluses of 10 - 20 mg of propofol at intervals of 2 - 5 minutes, as needed for adequate sedation, were administered after initial induction. Continuous monitoring of the pulse rate, and oxygen saturation were performed and the blood pressure checked every 2 - 5 minutes. All patients received supplemental oxygen (4 L/min). The following observations were recorded: the endoscopist recorded the ease of the procedure, the anaesthetist recorded the comfort of the patient throughout the procedure and at the time of discharge, and the patient stated the degree of satisfaction with the procedure. Any unusual events were recorded. RESULTS: Sixty consecutive patients sedated with propofol were studied. There were 28 (46.7%) males, with a mean age of 58.3 years and 32 (53.3%) females, with mean age of 59.5 years. Most were normal healthy patients (56.6%). Comorbid illnesses were present in 43.4%, with hypertension being most common (23.3%). All patients were classified as ASA class 1 and 2. The average dose of propofol used was 180 mg (range 50 - 355 mg). The mean duration of colonoscopy was 19.5 minutes. The mean recovery period (able to stand) was 29.6 minutes. There were no documented cases of significant hypotension, bradycardia, or hypoxaemia during the procedure. Transient apnoeic episodes during the initial stages of sedation occurred in 12 (20%) patients. The majority of patients (91.7%) rated the experience as being extremely good or excellent. The majority could not recall the actual colonoscopy and there were minimal subjective reports of nausea or discomfort during the procedure. CONCLUSIONS: Propofol sedation was associated with quick recovery and excellent satisfaction by patients and is a suitable alternative for sedation for colonoscopy in Jamaica.

Error patterns of 3rd-year medical students on the cardiovascular physical examination.

BACKGROUND: Recent research documents widespread deficits in the physical examination skills of practicing physicians. PURPOSE: This study explored physical examination skills of 3rd-year medical students after completion of a course in physical diagnosis. METHODS: Standardized patient physical examination checklist data were analyzed for a cohort of 2,038 medical students for a patient presenting with classic signs and symptoms of an acute myocardial infarction. A follow-up paper case and survey explored reasons underlying omissions. RESULTS: Students systematically omitted 3 of 10 component maneuvers critical to the evaluation of a patient with shortness of breath and chest pain. The same pattern of omissions was observed across 8 medical schools and over 2 successive years. The paper case follow-up study ruled out time constraints and performance anxiety as the cause. Survey data revealed that students may omit a maneuver due to inability to recall pertinence (blood pressure in both arms) or difficulty discriminating findings (heart sounds at different locations), or because of inadequate technical mastery (percussion of the lungs). CONCLUSIONS: These data suggest fundamental inadequacies in the current paradigm for teaching physical examination skills. Standardized patient checklist data can provide an informative window into the efficacy of teaching practices.

A comparison of time, temperature, and refreezing variables on frozen sperm motility recovery.

OBJECTIVE: To compare motility recovery among methods of thawing semen in serial freeze-thaw processes. DESIGN: A comparison of treatments. SETTING: Semen cryobank laboratory. PARTICIPANTS: Semen samples from an existing cryobank. INTERVENTIONS: Portions of each of 35 ejaculates were thawed serially in either a 37 degrees C water bath for 10 minutes or at room temperature for 30 minutes. Motility was estimated, and the samples were immediately refrozen. Thaws were performed initially (T1), at 24 hours (T2), and at 1 week (T3). MAIN OUTCOME MEASURE: Percent motility. RESULTS: The initial motility of all samples averaged 73.2%. Serial thaws at 37 degrees C yielded mean motility recoveries of 34.0%, 21.8%, and 8.3% for T1, T2, and T3, respectively. Those at room temperature were 22.4%, 7.9%, and 1.3%. Motilities progressively decreased from initial to final thaw regardless of temperature. Semen thawed at 37 degrees C had a higher motility recovery at all thaw times compared with samples thawed at room temperature. CONCLUSIONS: For sperm frozen rapidly in liquid nitrogen and for sperm subjected to multiple freeze-thaw processes, motility recovery is improved if thaw is carried out at 37 degrees C versus room temperature.

Luteal phase defect and premenstrual syndrome in an infertile population.

To test the hypothesis that an abnormal luteal phase is associated with significant symptoms of premenstrual syndrome, psychologic and somatic premenstrual syndrome symptoms were evaluated in a group of 83 infertile patients undergoing timed endometrial biopsy for the assessment of luteal phase adequacy. The severity of psychologic and somatic symptoms was evaluated separately. It was found that luteal phase defect, defined by endometrial biopsy, was associated with less severe psychologic and no more severe somatic symptoms of premenstrual syndrome in comparison with normal luteal phase controls. The data suggest that the hormonal milieu associated with luteal phase defects does not correlate with premenstrual syndrome symptoms and do not support the hypothesis that suboptimal ovarian function causes premenstrual syndrome.

Prolactin production by explants of normal, luteal phase defective, and corrected luteal phase defective late secretory endometrium.

The production of prolactin by explants of late secretory endometrium has been correlated with the extent of decidual differentiation. This correlation is strengthened by the observation that luteal phase defective endometrium produces less prolactin than normal control endometrium in a 24-hour in vitro culture system. In the present study the prolactin production by explants of normal, luteal phase defective, progesterone-corrected luteal phase defective, and clomiphene- or follicle-stimulating hormone/luteinizing hormone-corrected luteal phase defective late secretory endometrium was measured over 96 hours at 24-hour intervals. Progesterone in physiologic concentrations was added to the culture medium to maintain tissue integrity and prolactin synthesis. The prolactin production of normal late secretory endometrium rose over 96 hours under progesterone stimulation. The luteal phase defective endometrium produced significantly less prolactin under the same conditions. Histologically proven corrected luteal phase defective endometrium, regardless of treatment method, produced prolactin not different from the normal controls of the same dates. From these results it is concluded that histologic correction of luteal phase defective endometrium is associated with a corresponding biochemical correction with use of prolactin as a metabolic marker. The findings also strongly support timed endometrial biopsy as the method of diagnosis and evaluation of treatment of luteal phase defect.

Titrating the dose of bromocriptine when treating hyperprolactinemic infertile women.

We have shown that a smaller dose of bromocriptine is effective in lowering the PRL level to the normal range in some hyperprolactinemic women. Based on these findings, we recommend that when treating hyperprolactinemic women who desire conception, the dose of bromocriptine should be titrated according to the response of circulating PRL levels. This will minimize the dose, reduce cost, probably reduce side effects, and possibly avoid undesirable functional effects such as corpus luteum dysfunction.

A randomized study of dexamethasone in ovulation induction with clomiphene citrate.

Improved understanding of follicular dynamics has led to a reevaluation of suppression of adrenal androgens in ovulation induction. To test whether adrenal suppression during clomiphene citrate (CC) therapy would improve ovulation/pregnancy rates, 64 anovulatory patients who had not previously received CC were randomly assigned to receive either 50 mg CC on days 5 to 9 alone or with 0.5 mg dexamethasone (CC + DEX). Patients were then screened for dehydroepiandrosterone sulfate (DHEA-S) (normal range, 80 to 320 micrograms/dl), prolactin, testosterone, and semen analysis of the partner. Nine patients discontinued participation prior to completing the first treatment cycle, and ten patients were found to have either elevated prolactin (4), severe male factors (3), or tubal disease (3) and were discontinued. CC was increased 50 mg/day per cycle through 150 mg/day until ovulation occurred. Once the patient was ovulatory on therapy, a properly timed postcoital test and endometrial biopsy for luteal phase defect were performed. If anovulatory at 150 mg/day of CC or demonstrating abnormal postcoital test or endometrial biopsy at 150 mg/day of CC, patients were crossed to the other arm of the treatment protocol. The results revealed a significantly higher rate of ovulation (P less than 0.01) and conception (P less than 0.05) in the CC + DEX-treated group. When correlated with DHEA-S levels, this improvement occurred in patients with DHEA-S greater than 200 micrograms/dl (P less than 0.05).

Prolactin production from proliferative phase leiomyoma.

In vivo and in vitro endometrial stromal synthesis of prolactin occurs after progesterone-induced decidualization. Synthesis of prolactin by myometrium in vitro suggests that cells whose embryologic origin is the loose mesenchyme surrounding the paramesonephric ducts may retain the capacity to synthesize prolactin. Since physiologic myometrial synthesis of prolactin has not been demonstrated in vivo, prolactin genome expression in pathologic conditions was considered. Follicular phase leiomyomas were diced to 8 mm3 and cultured in Dulbecco's modified Eagle's medium (DMEM) with either no hormones, estradiol 200 pg/ml, progesterone 20 ng/ml, or estradiol and progesterone. Media were sampled and changed every other day for 8 days, followed by culture in tritium-labeled leucine DMEM for 2 days. Portions of leiomyomas were homogenized for initial prolactin content, and all samples were assayed for prolactin by radioimmunoassay. Follicular phase leiomyomas contained prolactin (47 +/- 15 ng/gm) in excess of normal serum values. Synthesis was demonstrated during all time periods from leiomyomas not exposed to progesterone. Progesterone variably suppressed the synthesis of prolactin until after 144 hours of culture. Determination of molecular weight on a 60 by 1.5 cm Sephadex G-100 column revealed identical estimates for pituitary, decidual, and leiomyoma prolactin. Tritium-labeled leucine incorporation into prolactin was confirmed by immunoprecipitation of Sephadex G-100 column fractions. Similar antigenicity was confirmed by parallel dilution curves for pituitary, decidual, and leiomyoma prolactin. Preliminary bioactivity in lymphoma proliferation assays confirmed prolactin activity. The conclusion reached was that proliferative phase leiomyomas contained elevated prolactin presumably secondary to in vivo synthesis. This synthesis was confirmed in vitro.

Human myometrium: a new potential source of prolactin.

Human myometrium is shown for the first time to produce prolactin in vitro. This prolactin is similar to pituitary prolactin by criteria of immunologic identity, gel chromatography and bioassay. The de novo synthesis of myometrical prolactin is supported by no detectable prolactin in initial tissue homogenate, nondetectable prolactin production during the first 24 hours of culture, cycloheximide inhibition of prolactin production with recovery of production in control medium, and tritiated leucine incorporation into prolactin. Although human myometrium is capable of producing prolactin without the addition of exogenous hormones, the addition of estrogen and progesterone, respectively, enhances and suppresses prolactin production in contrast to decidualized human endometrium where opposite effects on prolactin production are found.

The uterus as an endocrine compartment.

Evidence has begun to accumulate over the past several years that the uterus is a much more complex organ than was previously thought. Data would suggest that the uterus is a tissue that actively secretes a variety of substances that act locally and at distant sites from the uterus in the control of normal nonconceptual physiologic events, in gestation, and in influencing pathophysiologic symptoms. This article discusses the data underlying the concept of the uterus as an endocrine compartment with particular emphasis on the physiology of the decidualized endometrial stroma.

Endometrial biopsy during treatment of luteal phase defects is predictive of therapeutic outcome.

Luteal phase deficiency (LPD), as diagnosed by endometrial biopsy, is not a single disorder but rather a spectrum of dysfunction that reflects both endometrial cycle and ovarian cycle abnormalities. Forty-three patients were diagnosed as having LPD by two consecutive abnormal cycles. Seven patients (16%) with hyperprolactinemia received bromocriptine, and one hypothyroid patient received thyroid replacement. The remaining patients were treated sequentially with progesterone suppositories, clomiphene, the combination, and follicle-stimulating hormone and luteinizing hormone. If no conception occurred in 6 months on a given type of therapy, treatment was advanced. Patients were rebiopsied on each medication. In all, 33 of 41 (81%) compliant patients conceived. No viable pregnancies occurred without normal endometrial maturation, regardless of the treatment modality employed. When compared with time-life table projections, pregnancies occurred at rates comparable to those of a normal population once normal endometrial maturation was obtained with therapy. The endometrial biopsy accurately reflects the functional state of both the ovarian cycle and the endometrial cycle and can be used to determine adequacy of therapy, thereby improving conception rates in patients with LPD and eliminating the need for therapeutic trials.

The neglected laboratory test. The semen analysis.

Sixty-four laboratories from Connecticut, Massachusetts, and California were involved in a comparison of the types of semen analyses offered. The collected data indicate that there is a wide range of normal values for each parameter considered in a semen analysis. Very few laboratories gave simple and precise instructions for collection of the specimen. In many instances there was no record of the collection time or of the arrival time of the specimen at the laboratory. Most laboratories did not report motility or forward progression at time intervals, and abnormal morphology was not broken down according to the types of abnormalities involved. These data indicate the absolute need for adequate standardization of this important test, which is the basis upon which the clinician makes the important decision of implicating the male partner in the couple's infertility problem.