[Criteria for medical prioritisation: results from a regional survey and methodological reflections]. / Kriterien für die Priorisierung medizinischer Leistungen im Licht eines regionalen Surveys--Ergebnisse und methodologische Fragen.

AIMS: In Germany, in contrast to many foreign countries, scientists and medical professionals have been discussing prioritisation in medicine almost without consulting German citizens. We address the question of what questionnaire surveys can contribute to the understanding of citizens' attitudes towards prioritisation - with a focus on some difficulties and challenges of the method. METHOD: We conducted a postal survey with a random sample of 3 000 residents of the City of Lübeck (age ≥18). Respondents were asked to appraise different substantial and procedural criteria for prioritisation in medicine. In addition to descriptive statistical analyses, logistical regression models were performed to identify potential explanatory variables for the appraisal of prioritisation criteria. RESULTS: The response rate was 45.6% (N=1 363). Some prioritisation criteria are accepted by the majority: severity of disease, effectiveness of an intervention and a firm evidence base. Other criteria were appraised controversially: personal life-style, responsibility for family members and general prioritisation of children. A patient's responsibility in society and age as well as an intervention's cost-benefit ratio were generally rejected. The results of logistic regression analyses showed some significant but minor effects of demographic and health-related variables. The citizens in our study want decision-making procedures in health care to be transparent and equally applied to all patients. According to the survey respondents decisions about the catalogue of services of Germany's statutory health insurance should mainly be made by doctors. The statutory health insurance as well as patients and scientists also should take part in the decision-making procedure. DISCUSSION: Comparing our results to those of a national interview survey reveals some relevant differences: The respondents' assessment of some substantial criteria seems to vary according to the contextualisation and wording of the items. We found less difference - but still some inconsistent results - in the participants' appraisal of potential decision-makers in health care. To our surprise, the logistic regression models including standard demographic and health-related variables account for only a small proportion of the variance of all dependent variables. CONCLUSION: Our discussion emphasises some difficulties and challenges of questionnaire surveys on prioritisation criteria - reflecting on the state of the German debate on prioritisation. There has been hardly any public discussion on this issue prior to our survey in autumn 2009. It is thus unlikely that people have been able to state well-informed preferences. Instead they seem to have followed some kind of "social reflexes" depending on the context and wording of each item. Subsequent studies on preferences and priorities should (i) more closely assess the understanding of each item in advance and (ii) adapt the aims of their study and its methodology to the actual stage of the public discourse on the topic in question.

Establishment of an optimized ex vivo system for artificial root canal infection evaluated by use of sodium hypochlorite and the photodynamic therapy.

AIM: To establish a refined model of artificially infected root canals and confirm its suitability as a sensitive ex vivo method to assess the efficacy of disinfecting agents. Disinfection was evaluated using sodium hypochlorite (NaOCl), either blocked or unblocked by sodium thiosulphate, and a recently promoted method of disinfection, the antibacterial photodynamic therapy (PDT). METHODOLOGY: The roots of bovine incisors were sectioned into three parts, the canals of coronal and middle regions were filled with a suspension of Enterococcus faecalis and the apical region with culture medium. After 7 days, coronal sections were disinfected using NaOCl (0.5%, 1.0% and 3.0% for 30, 60 and 600 s) or a system for photoactivated chemotherapy (PACT; Cumdente, Tübingen, Germany) for antibacterial PDT. Apical sections served as sterile controls and middle sections as bacterial growth controls. In half of the NaOCl-treated specimens, disinfection was arrested. Dentine chips from biopsies at different depths from the central canal towards the periphery were plated and assessed for colony-forming units (CFU). Disinfection was considered biologically relevant if the reduction of CFU was at least three log10 orders of magnitude. RESULTS: Colony-forming units of 10³ - 104 in growth controls indicated effective artificial infection. A biologically relevant reduction of CFU was accomplished with unblocked NaOCl, but not after blocking with NaOCl nor with PDT. CONCLUSIONS: The system reliably detected disinfection of the root canal and dentinal tubules and proved suitable for ex vivo testing of root canal disinfection. The effect of NaOCl depended on the duration of impact. Under the present experimental conditions, the antibacterial PDT system did not achieve sufficient disinfection.

CD95 (APO-1/FAS)-mediated apoptosis in cytokine-activated hematopoietic cells.

Elimination of peripheral T cells is crucially regulated via apoptosis through CD95 (APO-1/Fas) receptor ligand interaction. Because homeostasis in hematopoietic cells may also involve the CD95 system, we analyzed CD95 expression and sensitivity to CD95-induced apoptosis in human bone marrow cells. During hematopoiesis CD95 is differentially expressed on distinct cell types and at different maturational stages with an increase in receptor density from early CD34+ stem cells to maturing progenitor cells. Incubation of bone marrow cells with anti-APO-1 (anti-CD95) induces apoptosis in maturing erythroblasts and neutrophil progenitors (10-19%) and to a lesser extent in stem cells and myeloblast/proerythroblasts (4-9%). On in vitro culture, CD95 expression is particularly upregulated on activated CD71+ myeloid progenitors. Hematopoietic cytokines (stem cell factor, interleukin-3, granulocyte macrophage colony-stimulating factor [GM-CSF], and granulocyte-colony-stimulating factor [G-CSF] contribute to upregulation of CD95 on bone marrow cells. CD95-induced apoptosis in activated progenitors was markedly enhanced by activating cytokines. Thus cytokines known to mediate proliferation, survival, and maturation, in hematopoiesis do not prevent, but rather facilitate negative growth regulation via the CD95 pathway in activated cells. Deregulation of the CD95 system may provide a molecular basis for the development of bone marrow failure or immune-mediated cytopenia. Defects in the CD95 pathway may contribute to the development of hematopoietic malignancy by abrogating CD95-mediated growth control of activated cells.

Total synthesis and biological evaluation of structural analogues of compactin and dihydromevinolin.

The full experimental details for the total synthesis of (+)-compactin and 19 structural analogues are reported. We have evaluated three classes of analogues as inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase: (1) functional and stereoisomeric analogues that possess the full carbon skeleton of compactin or dihydromevinolin, (2) functional analogues in which one carbon of the skeleton has been replaced by oxygen, and (3) analogues in which all of the 3,5-dihydroxyvaleric acid moiety has been omitted. Our most potent inhibitors belong to the first class of analogues. Compounds 42 (5-ketocompactin) and 69 (5-ketodihydromevinolin) are as active as the natural products compactin and dihydromevinolin, respectively (I50 = 1-20 nM). The corresponding enones 37 and 68 are less active, having I50 values 20-30 times larger. Inverting the stereochemistry at C-3 or C-5 or about the hexahydronaphthalene ring of compactin results in the elevation of the I50 to values in the micromolar range, comparable to the KM of the natural substrate 3-hydroxy-3-methylglutaryl coenzyme A. Class 2 analogues are active in this concentration range also. The synthetic sequence developed for compactin and its analogues includes a new method that permits the selective preparation of either the R or the S epimer at C-3 of the 3,5-dihydroxyvaleric acid moiety. This entails the reaction of anhydride 9 with either (R)- or (S)-1-phenylethanol in the presence of 4-(N,N-dimethylamino)pyridine and triethylamine. The prochiral recognition is surprisingly high; under optimum conditions, the reaction of 9 with (R)-1-phenylethanol leads to a 15:1 ratio of diesters 17 and 18.

Repromicin derivatives with potent antibacterial activity against Pasteurella multocida.

Reductive amination of repromicin with polyfunctional amines has led to new macrolide antibacterial agents, some of which are highly potent against the Gram-negative pathogen Pasteurella multocida both in vitro and in a mouse infection model. A key element in this discovery was the recognition that among certain known macrolides increasing lipophilicity results in diminished in vivo activity. One repromicin derivative, 20-[N-[3-(dimethylamino)-propyl]-N-L-alanylamino]-20-deoxorepro micin (35), was selected for advanced evaluation. At 5 mg/kg, a single subcutaneous dose was found to control induced pasteurellosis in swine and induced respiratory disease in cattle.

Quantitative structure-activity relationships among macrolide antibacterial agents: in vitro and in vivo potency against Pasteurella multocida.

Quantitative structure-activity relationships have been found among macrolide antibacterial agents in their potencies against the bacterial pathogen Pasteurella multocida both in vitro and in mouse infections. To obtain these relationships we measured, among other things, the pK(a)'s and log P's of 15 known macrolides of diverse structures. Among these compounds, in vitro potency [log(1/MIC)] is a function of log P, log D, and CMR (R = 0.86). In vivo potency is a function of the higher pK(a), the HPLC chromatographic capacity factor log k', log(1/MIC) and pNF (R = 0.93). pNF is defined as the negative logarithm of the fraction of neutral drug molecules present in aqueous solution at pH 7.4. The same physical properties were determined for 14 macrolides not used in developing the original QSAR models. Using the in vivo model, we calculated the mouse protection potency ranges for these new compounds. Ten estimates agreed with those observed, three were lower by a half-order of magnitude, and one was calculated to be active in the range of 15-50 mg/kg, but in fact was not active at 50 mg/kg, the highest level tested. When these new compounds were combined with the original 15, and the QSAR's updated, the new equations for the in vitro and in vivo potencies were essentially the same as those originally found. Hence, the physical properties indicated above are major determinants of macrolide antibacterial potencies.

Two types of cholinergic projections to the rat amygdala.

The cholinergic innervation of the rat amygdala was studied immunohistochemically with antibodies against choline acetyltransferase and the low affinity p75 nerve growth factor receptor in normal rats and in rats lesioned with an immunotoxin, 192 IgG-saporin, directed against the p75 nerve growth factor receptor. The density of choline acetyltransferase-positive fibers was high in the nucleus of the lateral olfactory tract, the basolateral nucleus, and the amygdalohippocampal area; medium in the lateral nucleus, the cortical nucleus, the accessory basal nucleus, the periamygdaloid cortex, and the anterior amygdaloid area; and low in the medial and central nuclei. Nerve growth factor receptor-positive fibers were of medium density in the lateral nucleus, the accessory basal nucleus, the cortical nucleus, the anterior amygdaloid area, the periamygdaloid cortex, and the amygdalohippocampal area. The medial nucleus and the central nucleus displayed a low density of nerve growth factor receptor-positive fibers. The basolateral nucleus and the nucleus of the lateral olfactory tract also contained a low density of nerve growth factor receptor-positive fibers even though the two nuclei displayed the highest density of choline acetyltransferase-positive fibers in the amygdala. Injections of 192 IgG-saporin induced a complete loss of cholinergic nerve growth factor receptor-positive neurons in the basal forebrain but spared a subpopulation of nerve growth factor receptor-negative cholinergic neurons in the nucleus basalis-substantia innominata complex. Following 192 IgG-saporin injections, choline acetyltransferase-positive and acetylcholinesterase-positive fibers were essentially unchanged in the nucleus of the lateral olfactory tract and the basolateral nucleus and showed a partial reduction in the remaining nuclei of the amygdaloid complex. Cholinergic fibers emanating from cholinergic cell group 4 neurons reached the amygdala via the stria terminalis and the ventral amygdalofugal pathway. These observations indicate that two amygdaloid nuclei, the nucleus of the lateral olfactory tract and the basolateral nucleus, receive their cholinergic projections predominantly, if not exclusively, from nerve growth factor receptor-negative cholinergic neurons whereas all remaining amygdaloid regions receive fibers from nerve growth factor receptor-negative as well as nerve growth factor receptor-positive cholinergic neurons.

Comparison of exercise and dobutamine stress echocardiography in assessing mitral stenosis.

Dobutamine elicited similar hemodynamic response to exercise in 20 consecutive patients with mitral stenosis, and significantly altered management in 6 of them (30%). Dobutamine stress echocardiography is a safe and feasible alternative to exercise in patients with mitral stenosis of mild-to-moderate severity and ambiguous symptoms.

Investigation of the mechanism of action of oxotremorine on the guinea-pig isolated ileum preparation.

1. The effects of oxotremorine on the guinea-pig ileum have been investigated to determine whether any component of its action is due to acetylcholine release.2. Log dose-response curves to oxotremorine and acetylcholine were similar and both drugs were competitively antagonized by atropine.3. Mipafox potentiated acetylcholine but not oxotremorine.4. No evidence of an indirect component of the action of oxotremorine was obtained using various pharmacological procedures (tetrodotoxin, morphine, cooling, procaine and hemicholinium-3).5. Oxotremorine had no effect on acetylcholine release from mipafox treated ileum but decreased the release from physostigmine treated ileum.6. It is concluded that oxotremorine acts directly on muscarinic receptors and not by releasing acetylcholine.

Association of p53 expression with proliferative activity and poor-prognosis in patients with squamous-cell lung carcinomas.

Tumor tissue of 65 patients with squamous cell lung carcinoma was analyzed for p53 expression using immunohistochemistry (DO-1) and for proliferative activity using flow cytometry. Of the 65 cases, 17 cases (26%) showed positive staining for p53, whereas 48 cases (74%) showed no expression. The median survival time for patients with p53-negative tumors was 100 weeks and for patients with p53-positive tumors 30 weeks (rank-sum test, p=0.03; log-rank test, p=0.14). The median survival time for patients with high proliferative activity (proportion of SG(2)M-phase cells >22%) was one year and for patients with low proliferative activity (proportion of SG(2)M-phase cells less than or equal to 22%) over 6 years (rank-sum test, p=0.04; log-rank test, p=0.01). There exists a trend that p53-positive squamous cell lung carcinoma had a higher proportion of SG(2)M-phase cells than p53-negative tumors. Multivariate analysis found independent prognostic significance for proliferative activity and stage but not for p53.

p53 expression and poor prognosis in childhood acute lymphoblastic leukemia.

Ninety-one children with untreated acute lymphoblastic leukemia (ALL) were analysed for expression of p53 using immunocytochemistry. p53 expression was found in 80% of the cases by Mab 421. Kaplan-Meier estimates show that patients with p53-positive leukemic cells had significantly shorter survival times under chemotherapy than those with p53-negative leukemic cells (p = 0.05, log-rank test). Statistical analysis revealed no correlation between p53 expression and patient's age, sex, immunotyping and initial peripheral blast cell count.

Discovery of RWJ-54428 (MC-02,479), a new cephalosporin active against resistant gram-positive bacteria.

The discovery of RWJ-54428 (MC-02,479), a new cephalosporin displaying promising activity against sensitive and resistant Gram-positive bacteria, is described. Progressive structural modification from the previously reported 3-phenylthiocephem MC-02,331 afforded an overall increase in potency against MRSA while retaining other key properties such as acceptable solubility and serum binding. Evaluation of the in vitro potency and in vivo efficacy of a series of closely related compounds resulted in selection of RWJ-54428 (MC-02,479) for further studies.

SAR studies of anti-MRSA non-zwitterionic 3-heteroarylthiocephems.

SAR studies in a series of 3-heteroarylthio substituted cephalosporins established that high activity against methicillin-resistant Staphylococcus aureus (MRSA) can be achieved with various heteroaryl substituents. Early results showed that highly lipophilic 3-heteroarylthio substituents, which were necessary for anti-MRSA activity, caused high affinity of such cephems toward serum proteins. Our earlier published efforts described discovery of zwitterionic cephems MC-02,331 and RWJ-54428 (MC-02,479), where serum binding was reduced by employing basic, positively charged functionalities attached to the 3-heteroarylthio substituent. In order to avoid low solubility problems associated with most such zwitterionic cephalosporins a wide variety of non-basic heteroaryl substituents was tested (non-zwitterionic cephems are more easily formulated as water soluble sodium salts for intravenous administration). Considerable reduction in serum binding was obtained in some analogs while maintaining high anti-MRSA potency.

In vitro microbiological characterization of novel macrolide CP-163,505 for animal health specific use.

A novel 16-membered-ring macrolide agent (CP-163,505, a reductive amination derivative of repromicin) was identified as an antibacterial against Pasteurella haemolytica, P. multocida and Actinobacillus pleuropneumoniae, important etiological agents of livestock respiratory disease. In vitro MIC50/90 analysis revealed that CP-163,505 was more potent (4x) than tilmicosin against P. multocida, and equivalent to tilmicosin against P. haemolytica and A. pleuropneumoniae. In time kill kinetic studies, CP-163,505 showed bactericidal activity against P. haemolytica, P. multocida and A. pleuropneumoniae and bacteriostatic activity against E. coli at 8 times its MIC. In vitro, CP-163,505 was more potent in alkaline pH (16 approximately 32 x ) and less potent in the presence of excess cations (Mg+2 and Ca+2, 4x). EDTA and PMBN increased CP-163,505 potency against E. coli (4x) but not against the other species. Similar results were obtained with erythromycin A and tilmicosin, which were used as controls. From our data, we hypothesize that Pasteurella and Actinobacillus have an outer membrane significantly different from that of the typical enteric Gram-negative bacterium E. coli.

Discovery of MC-02,331, a new cephalosporin exhibiting potent activity against methicillin-resistant Staphylococcus aureus.

A systematic approach toward building activity against methicillin-resistant staphylococci into the cephalosporin class of beta-lactam antibiotics is described. Initial work focused on finding the optimal linkage between the cephem nucleus and a biphenyl pharmacophore, which established that a thio linkage afforded potent activity in vitro. Efforts to optimize this activity by altering substitution on the pharmacophore afforded iodophenylthio analog MC-02,002, which although highly potent against MRSA, was also highly bound to serum proteins. Further work to decrease serum protein binding showed that replacement of the iodo substituent by the positively-charged isothiouronium group afforded potent activity and reduced serum binding, but insufficient aqueous solubility. Solubility was enhanced by incorporation of a second positively-charged group into the 7-acyl substituent. Such derivatives (MC-02,171 and MC-02,306) lacked sufficient stability to staphylococcal beta-lactamase enzymes. The second positive charge was incorporated into the cephem 3-substituent in order to utilize the beta-lactamase-stable aminothiazolyl(oximino)acetyl class of 7-substituents. These efforts culminated with the discovery of bis(isothiouroniummethyl)phenylthio analog MC-02,331, whose profile is acceptable with respect to potency against MRSA, serum binding, aqueous solubility, and beta-lactamase stability.

The effect of cholinesterase inhibitors on the antimuscarinic effect of hemicholinium-3 (HC-3) in the rat.

The effect of hemicholinium-3 (HC-3) on responses of the rat isolated bladder and ileum to acetylcholine and carbachol was investigated in the absence and presence of a number of anticholinesterases. Responses of the bladder to acetylcholine were potentiated by DFP, edrophonium, BW284C51 and physostigmine but were unaffected by the specific butyrylcholinesterase inhibitor iso-OMPA. Responses to carbachol were not potentiated by the anticholinesterases. HC-3 (1.7 X 10(-4) M) inhibited responses to carbachol without affecting those to acetylcholine. In the presence of physostigmine or DFP responses to acetylcholine were inhibited by HC-3 but no such inhibition was observed in the presence of BW284C51, edrophonium or iso-OMPA or a combination of the latter two anticholinesterases. Responses to carbachol were also inhibited to a greater extent in the presence of DFP. In the ileum, responses to acetylcholine were increased in the presence of DFP, edrophonium and physostigmine but were unaffected by iso-Ompa. responses to carbachol were not increased by any of the anticholinesterases. HC-3 (2.8 X 10(-4) M) inhibited responses to both acetylcholine and carbachol in the ileum and the degree of inhibition was not significantly altered by the presence of any of the anticholinesterases used. Although a weak anticholinesterase, HC-3 was also found to decrease the inhibitory action of physostigmine on the hydrolysis of acetylcholine by homogenates of rat ileum. A similar effect was noted with DFP but not with edrophonium. The results obtained do not support a prejunctional action for HC-3 in antagonizing responses to carbachol. It is concluded that in addition to an inhibitory action on the post-junctional muscarinic receptor HC-3 may interfere with the anticholinesterase activity of some cholinesterase inhibitors such as physostigmine and DFP but not edrophonium.

Workplace drug testing as social control.

In this article, the emergence of employee drug screening is examined in the context of the historical development of the principle and practice of workplace surveillance. The authors trace the evolution of disciplinary and control systems from the early Industrial Revolution through the Scientific Management movement and its recent offshoots. Industrial medicine and industrial psychology are presented as elements of the "scientification" of surveillance. Drug testing and other contemporary surveillance technologies are placed in this context, and their cultural, political-economic, and moral underpinnings are examined. The dilemma posed by the need to address the real problem of drug abuse in the context of a social control paradigm is explored.