Compared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator.
Methods and Study Design
In this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education.
At the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients, over several months directly in their homes, can help more individuals learn about the options of DDKT and LDKT. We also will be able to examine the efficacy of different educational delivery approaches to further understand whether the addition of a telephone educator is necessary for increasing transplant knowledge.
Kidney transplantation; Living donor; Racial disparities; African-Americans; Patient education; Health knowledge/attitudes; Transtheoretical model of behavioral change; Stages of Change
The purpose of this study was to review institutional statistics provided in dean's letters and determine the percentage of honors awarded by institution and clerkship specialty.
Institutional and clerkship aggregate data were compiled from a review of dean's letters from 80 United States medical schools. The percentage of honors awarded during 3rd year clerkships during 2005 were collected for analysis. Across clerkship specialties, there were no statistically significant differences between the mean percentage of honors given by the medical schools examined with Internal Medicine (27.6%) the low and Psychiatry (33.5%) the high. However, inter-institutional variability observed within each clerkship was high, with surgery clerkship percentage of honors ranging from 2% to 75% of the students. This suggests some schools may be more lenient and other more stringent in awarding honors to their students. This inter-institutional variability makes it difficult to compare honors received by students from different medical schools and weakens the receipt of honors as a primary tool for evaluating potential incoming residents.
Shame and honor are mechanisms that expose behavior that falls outside the social norm. With recent six-player public goods experiments, we demonstrated that the threat of shame or the promise of honor led to increased cooperation. Participants were told in advance that after ten rounds two participants would be asked to come forward and write their names on the board in front of the fellow group members. In the shame treatment, the least cooperative players were exposed and wrote their names under the sentence “I donated least” while the honored participants wrote their name under “I donated most.” In both the shame and honor treatments, participants contributed approximately 50% more to the public good, as compared with the control treatment in which all players retained their anonymity. Here, we also discuss how shame and honor differ from full transparency, and some of the challenges to understanding how anonymity and exposure modify behavior.
cooperation; honor; public goods game; shame; tragedy of the commons
To examine the language of “turfing,” a ubiquitous term applied to some transfers of patients between physicians, in order to reveal aspects of the ideology of internal medicine residency.
Academic internal medicine training program.
Using direct observation and a focus group, we collected audiotapes of medical residents’ discussions of turfing. These data were analyzed using interpretive and conversation analytic methods. The focus group was used both to validate and to further elaborate a schematic conceptual framework for turfing.
The decision to call a patient “turfed” depends on the balance of the values of effectiveness of therapy, continuity of care, and power. For example, if the receiving physician cannot provide a more effective therapy than can the transferring physician, medical residents consider the transfer inappropriate, and call the patient a turf. With appropriate transfers, these residents see their service as honorable, but with turfs, residents talk about the irresponsibility of transferring physicians, burdens of service, abuse, and powerlessness.
Internal medicine residents can feel angry and frustrated about receiving patients perceived to be rejected by other doctors, and powerless to prevent the transfer of those patients for whom they may have no effective treatment or continuous relationship. This study has implications for further exploration of how the relationships between physicians may uphold or conflict with the underlying moral tenets of the medical profession.
residency; patient transfers; turfing; professional relationships; professional values
A majority of end-of-life medical decisions are made by surrogate decision-makers who have varying degrees of preparation and comfort with their role. Having a seriously ill family member is stressful for surrogates. Moreover, most clinicians have had little training in working effectively with surrogates.
To better understand the challenges of decision-making from the surrogate’s perspective.
Semistructured telephone interview study of the experience of surrogate decision-making.
Fifty designated surrogates with previous decision-making experience.
We asked surrogates to describe and reflect on their experience of making medical decisions for others. After coding transcripts, we conducted a content analysis to identify and categorize factors that made decision-making more or less difficult for surrogates.
Surrogates identified four types of factors: (1) surrogate characteristics and life circumstances (such as coping strategies and competing responsibilities), (2) surrogates’ social networks (such as intrafamily discord about the “right” decision), (3) surrogate–patient relationships and communication (such as difficulties with honoring known preferences), and (4) surrogate–clinician communication and relationship (such as interacting with a single physician whom the surrogate recognizes as the clinical spokesperson vs. many clinicians).
These data provide insights into the challenges that surrogates encounter when making decisions for loved ones and indicate areas where clinicians could intervene to facilitate the process of surrogate decision-making. Clinicians may want to include surrogates in advance care planning prior to decision-making, identify and address surrogate stressors during decision-making, and designate one person to communicate information about the patient’s condition, prognosis, and treatment options.
surrogate decision-making; advance care planning; substituted judgment; qualitative research
Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences.
This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians.
Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences.
Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.
No consensus exists about when researchers need additional participant consent (re-consent) to submit existing data to the federal database of Genotypes and Phenotypes (dbGaP). Reconsent for submission of their data to dbGaP was sought from 1,340 study participants, 1,159 (86%) of whom agreed. We invited the first 400 of those who agreed to complete a telephone survey about their reasoning for their consent decision and their satisfaction with the re-consent process; 365 participants completed the survey. Respondents reported that it was very (69%) or somewhat (21%) important that they were asked for their permission. Many respondents considered alternatives to consent, such as notification-only or opt-out, to be unacceptable (67% and 40%, respectively). These results suggest that re-consent for dbGaP deposition may be advisable in certain cases to anticipate and honor participant preferences.
informed consent; data sharing; dbGaP
Genetic testing is increasingly used as a tool throughout the health care system. In 2011 the number of clinically available genetic tests is approaching 2,000, and wide variation exists between these tests in their sensitivity, specificity, and clinical implications, as well as the potential for discrimination based on the results.
As health care systems increasingly implement electronic medical record systems (EMRs) they must carefully consider how to use information from this wide spectrum of genetic tests, with whom to share information, and how to provide decision support for clinicians to properly interpret the information. Although some characteristics of genetic tests overlap with other medical test results, there are reasons to make genetic test results widely available to health care providers and counterbalancing reasons to restrict access to these test results to honor patient preferences, and avoid distracting or confusing clinicians with irrelevant but complex information. Electronic medical records can facilitate and provide reasonable restrictions on access to genetic test results and deliver education and decision support tools to guide appropriate interpretation and use.
This paper will serve to review some of the key characteristics of genetic tests as they relate to design of access control and decision support of genetic test information in the EMR, emphasizing the clear need for health information technology (HIT) to be part of optimal implementation of genetic medicine, and the importance of understanding key characteristics of genetic tests when designing HIT applications.
genetic tests; electronic medical records; privacy; storage of genetic information; access to genetic information; types of genetic information
One of the most commonly used eponymous terms in neuroscience and gross anatomy is Sylvius. The 2 most recognized uses of this term today are the sylvian fissure for the lateral cerebral sulcus and the sylvian aqueduct for the cerebral aqueduct. There is some controversy surrounding these terms because there were 2 famous anatomists named Sylvius after whom these structures could easily have been named. The purpose of this article is to provide a brief historical review of these 2 scientists and offer an observation on the historical use of the name Sylvius as an anatomical term.
Franciscus Sylvius was a popular teacher at the University of Leiden. One of his most famous students, Thomas Bartholinus, published F Sylvius' neuroanatomical work on the lateral cerebral sulcus. Although this structure had been known from antiquity, Bartholinus' description linked F Sylvius' name to the structure. As well, the description of the cerebral aqueduct was also published in other influential anatomy texts as an attempt by students to honor F Sylvius' name, despite the fact that this structure had been described more than a century before. Jacobus Sylvius was a successful but reportedly disliked anatomist at the University of Paris. Although he urged his students to learn from dissection rather than lectures or books, he had an unyielding devotion to Galen's teachings. His most famous student, Vesalius, went on to refute many of Galen's ideas as documented in his later publications. The rift between teacher (J Sylvius) and student (Vesalius) may have resulted in the marginalization of J Sylvius as a figure immortalized in anatomical texts. This may be the probable reason that J Sylvius' name is not associated with anatomical terms.
The lesson from this brief review of the 2 Dr Sylviuses may be that a teacher's historical legacy being preserved as an eponym may have more to do with his or her likability than productivity during his or her lifetime.
History; Anatomy; Neuroanatomy
The risks and benefits of research using large databases of personal information are evolving in an era of ubiquitous, internet-based data exchange. In addition, information technology has facilitated a shift in the relationship between individuals and their personal data, enabling increased individual control over how (and how much) personal data are used in research, and by whom. This shift in control has created new opportunities to engage members of the public as partners in the research enterprise on more equal and transparent terms. Here, we consider how some of the technological advances driving and paralleling developments in genomics can also be used to supplement the practice of informed consent with other strategies to ensure that the research process as a whole honors the notion of respect for persons upon which human research subjects protections are premised. Further, we suggest that technological advances can help the research enterprise achieve a more thoroughgoing respect for persons than was possible when current policies governing human subject research were developed. Questions remain about the best way to revise policy to accommodate these changes.
respect for persons; genomics; genetics; informed consent
To examine healthcare coverage and access disparities for American Indian/Alaska Native (AIAN) veterans compared with non-Hispanic white veterans.
We examined national survey data for honorably discharged veterans in the United States using National Health Interview Survey (NHIS) data between 1997 and 2006. NHIS data were obtained from the Integrated Health Interview Series, a web-based data resource containing harmonized NHIS data from 1969 to the present. Our sample included AIAN and White veterans aged 18 to 64 years (n = 34,504). We used multivariate logistic regression models to estimate the odds of being uninsured, reasons for delayed care, and types of foregone care.
In multivariate analysis, AIAN veterans have 1.9 times higher odds of being uninsured compared with non-Hispanic white veterans (95% CI: 1.6–2.7). Compared with white veterans, AIAN veterans are significantly more likely to delay care due to not getting timely appointments (OR = 2.0, 95% CI: 1.1–2.6), not getting through on the phone (OR = 3.0, 95% CI: 1.6–5.8), and transportation problems (OR = 2.9, 95% CI: 1.1–7.3). In unadjusted models, AIAN veterans have significantly higher odds of having foregone 4 of 5 types of care compared with non-Hispanic white veterans. Adjusting for sociodemographic characteristics and insurance eliminated all significant relations.
AIAN veterans have considerable disparities in healthcare coverage and access compared with non-Hispanic whites. Although barriers to care due to cost are nominal for AIAN veterans, barriers to care due to navigating the healthcare system and due to lack of transportation remain substantial.
access to healthcare; American Indians/Alaska Natives; disparities; veterans
Assessing the magnitude of an antibody response is important to many research and clinical endeavors; however, there are considerable differences in the experimental approaches used to achieve this end. Although the time-honored approach of end point titration has merit, the titer can often be misleading due to differences in how it is calculated or when samples contain high concentrations of low-avidity antibodies. One frequently employed alternative is to adapt commercially available enzyme-linked immunosorbent assay kits, designed to measure total antibody concentrations, to estimate antigen-specific antibody concentrations. This is accomplished by coating the specific antigen of interest in place of the capture antibody provided with the kit and then using the kit's standard curve to quantify the specific antibody concentration. This approach introduces considerable imprecision, due primarily to its reliance on a single sample dilution. This “single-point” approach fails to address differences in the slope of the sample titration curve compared to that of the standard curve. Here, we describe a general approach for estimating the effective concentration of specific antibodies, using antisera against foot-and-mouth disease virus VP1 peptide. This was accomplished by initially calculating the slope of the sample titration curve and then mathematically correcting the slope to that of a corresponding standard curve. A significantly higher degree of precision was attained using this approach rather than the single-point method.
The northern part of India harbours a great diversity of medicinal plants due to its distinct geography and ecological marginal conditions. The traditional medical systems of northern India are part of a time tested culture and honored still by people today. These traditional systems have been curing complex disease for more than 3,000 years. With rapidly growing demand for these medicinal plants, most of the plant populations have been depleted, indicating a lack of ecological knowledge among communities using the plants. Thus, an attempt was made in this study to focus on the ecological status of ethnomedicinal plants, to determine their availability in the growing sites, and to inform the communities about the sustainable exploitation of medicinal plants in the wild.
The ecological information regarding ethnomedicinal plants was collected in three different climatic regions (tropical, sub-tropical and temperate) for species composition in different forest layers. The ecological information was assessed using the quadrate sampling method. A total of 25 quadrats, 10 × 10 m were laid out at random in order to sample trees and shrubs, and 40 quadrats of 1 × 1 m for herbaceous plants. In each climatic region, three vegetation sites were selected for ecological information; the mean values of density, basal cover, and the importance value index from all sites of each region were used to interpret the final data. Ethnomedicinal uses were collected from informants of adjacent villages. About 10% of inhabitants (older, experienced men and women) were interviewed about their use of medicinal plants. A consensus analysis of medicinal plant use between the different populations was conducted.
Across the different climatic regions a total of 57 species of plants were reported: 14 tree species, 10 shrub species, and 33 herb species. In the tropical and sub-tropical regions, Acacia catechu was the dominant tree while Ougeinia oojeinensis in the tropical region and Terminalia belerica in the sub-tropical region were least dominant reported. In the temperate region, Quercus leucotrichophora was the dominant tree and Pyrus pashia the least dominant tree. A total of 10 shrubs were recorded in all three regions: Adhatoda vasica was common species in the tropical and sub-tropical regions however, Rhus parviflora was common species in the sub-tropical and temperate regions. Among the 33 herbs, Sida cordifolia was dominant in the tropical and sub-tropical regions, while Barleria prionitis the least dominant in tropical and Phyllanthus amarus in the sub-tropical region. In temperate region, Vernonia anthelmintica was dominant and Imperata cylindrica least dominant. The consensus survey indicated that the inhabitants have a high level of agreement regarding the usages of single plant. The index value was high (1.0) for warts, vomiting, carminative, pain, boils and antiseptic uses, and lowest index value (0.33) was found for bronchitis.
The medicinal plants treated various ailments. These included diarrhea, dysentery, bronchitis, menstrual disorders, gonorrhea, pulmonary affections, migraines, leprosy. The ecological studies showed that the tree density and total basal cover increased from the tropical region to sub-tropical and temperate regions. The species composition changed with climatic conditions. Among the localities used for data collection in each climatic region, many had very poor vegetation cover. The herbaceous layer decreased with increasing altitude, which might be an indication that communities at higher elevations were harvesting more herbaceous medicinal plants, due to the lack of basic health care facilities. Therefore, special attention needs to be given to the conservation of medicinal plants in order to ensure their long-term availability to the local inhabitants. Data on the use of individual species of medicinal plants is needed to provide an in-depth assessment of the plants availability in order to design conservation strategies to protect individual species.
Experimental reality in molecular and cell biology, as revealed by advanced research technologies and methods, is manifestly inconsistent with the design perspective on the cell, thus creating an apparent paradox: where do order and reproducibility in living systems come from if not from design?
I suggest that the very idea of biological design (whether evolutionary or intelligent) is a misconception rooted in the time-honored and thus understandably precious error of interpreting living systems/organizations in terms of classical mechanics and equilibrium thermodynamics. This error, introduced by the founders and perpetuated due to institutionalization of science, is responsible for the majority of inconsistencies, contradictions, and absurdities plaguing modern sciences, including one of the most startling paradoxes - although almost everyone agrees that any living organization is an open nonequilibrium system of continuous energy/matter flow, almost everyone interprets and models living systems/organizations in terms of classical mechanics, equilibrium thermodynamics, and engineering, i.e., in terms and concepts that are fundamentally incompatible with the physics of life.
The reinterpretation of biomolecules, cells, organisms, ecosystems, and societies in terms of open nonequilibrium organizations of energy/matter flow suggests that, in the domain of life, order and reproducibility do not come from design. Instead, they are natural and inevitable outcomes of self-organizing activities of evolutionary successful, and thus persistent, organizations co-evolving on multiple spatiotemporal scales as biomolecules, cells, organisms, ecosystems, and societies. The process of self-organization on all scales is driven by economic competition, obeys empirical laws of nonequilibrium thermodynamics, and is facilitated and, thus, accelerated by memories of living experience persisting in the form of evolutionary successful living organizations and their constituents.
The concept of lamellar keratoplasty (LK) is not new. However, it had been abandoned and largely replaced by the time-honored technique of penetrating keratoplasty (PK) because LK is technically demanding, time consuming and gives suboptimal visual outcomes due to interface irregularity arising from manual lamellar dissection. Recent improvements in surgical instruments and introduction of new techniques of maximum depth of corneal dissection as well as inherent advantages such as preservation of globe integrity and elimination of endothelial graft rejection have resulted in a re-introduction of LK as an acceptable alternative to conventional PK. This review article describes the indications, different techniques, clinical outcomes and complications of deep anterior LK.
Anwar's Big-bubble Technique; Deep Anterior Lamellar Keratoplasty; Lamellar Keratoplasty; Melles'Technique; Penetrating Keratoplasty
The problem of reconstructing the dorsum of the nose is complex and a source of frustration for both patients and surgeons. Dorsal deficiencies due to various etiologies and the need for dorsal contouring cause the plastic surgeon to look to time-honored techniques such as osseocartilaginous rib grafts while also searching for other options that may be less technically challenging and have the benefit of temporal success. Diced cartilage wrapped with deep temporal fascia is just such a method to achieve reliable dorsal reconstructions. The various ways to use diced cartilage and deep temporal fascia are discussed.
Dorsum; radix; cartilage grafts; diced cartilage; fascia
Posterior urethral injuries are seen in trauma cases with pelvic fracture. The time-tested and honored method of management is immediate supra-pubic diversion followed by delayed repair. Immediate alignment as a management option is not new. It was abandoned 30 years ago due to high incidence of incontinence and impotence. However, of late there is a tendency towards immediate management of these injuries with various endoscopic maneuvers. Unfortunately, there is little evidence supporting this. Even these evidences are of limited in number and of limited duration of follow-up.
Delayed repair; immediate/early alignment; posterior urethral injury
Giant basilar aneurysms are infrequently seen in children. We present the endovascular management of an adolescent who presented comatose with pinpoint pupils due to a ruptured giant basilar trunk aneurysm. A noncontrast head CT disclosed a large prepontine lesion with brainstem hemorrhage. Catheter angiography showed a 4.5 cm irregular, fusiform basilar trunk aneurysm. With SSEP, BAER, and MEP monitoring, the patient underwent bilateral temporary vertebral artery occlusion, followed by GDC embolization of the aneurysm. Postprocedure internal carotid angiograms showed adequate blood supply to the basilar apex via patent posterior communicating arteries. On postprocedure day two, the patient was following commands.
The remainder of his hospital course was uneventful. Postoperative angiograms showed no residual filling of the aneurysm. At 12 months the patient was neurologically intact and at baseline function as an honor student and follow-up angiogram showed persistent occlusion of the aneurysm from the circulation. Successful endovascular treatment has been considered a less invasive and safer alternative to surgical management of some complex vascular lesions. While most reports on reversing basilar artery flow have been carried out in awake patients with neurological examinations, this is not possible in a patient presenting in a comatose state. This report suggests that SSEPs, BAERs and MEP may be of use in such patients in safely carrying out basilar artery occlusion.
giant basilar aneurysm, aneurysm coiling, SSEP, BAER, MEP
All over the world motorcycle accident are one of the major causes of road death and injury. This study aimed to determine the pattern of Motorcycle Fatal Accidents in Mashhad-Iran.
This descriptive cross-sectional study was carried out in 2006 to analyze the epidemiological pattern of the motorcycle accident in Mashhad, North-Eastern Iran. Three hundred fifty cases of motorcycle accidents were included. Data gathering tool was a standard questionnaire. The compiled data were analyzed using SPSS11 and χ2 test. The significance level was considered 0.05 in all statistical tests.
In the time span of the study, 350 cases of motorcycle accident occurred, most of which happened at 8pm to 12pm. In 119 cases, the motorcyclist was the blameful rider. Generally, 84.2% of the motorcycle riders did not have safety helmets. About two third of blameful motorcycle riders (63.1%) were less than 25 years old. The major cause of the accidents (55.1%) was due to neglecting the Yield Right of Way. Motorcycle riders endanger pedestrian, other drivers, passengers and their own life.
Paying attention to cultural and instructional issues of correct motorcycle riding and performing appropriate monitoring in traffic and transportation system such as honoring our and others safety and setting limitations on using this vehicle by the youth is of great importance.
Motorcycle; Road accident; Iran
Although intermediate filaments are one of three major cytoskeletal systems of vertebrate cells, they remain the least understood with respect to their structure and function. This is due in part to the fact that they are encoded by a large gene family which is developmentally regulated in a cell and tissue type specific fashion. This article is in honor of Ueli Aebi. It highlights the studies on IF that have been carried out by our laboratory for more than 40 years. Many of our advances in understanding IF are based on conversations with Ueli which have taken place during adventurous and sometimes dangerous hiking and biking trips throughout the world.
intermediate filaments; vimentin; keratin; cell motility; phosphorylation
Traditional Samoan tattoos, or tatau, are created by master tattooists, or tufuga ta tatau, and their assistants using multi-pointed handmade tools. These tools are used to tap tattoo pigment into the skin, usually over several days. This traditional process is considered an honor to the one receiving the tatau. Unfortunately, as it is typically practiced according to cultural traditions, the sanitary practices are less than ideal. There have been several reported cases of severe infection, sepsis, shock, and even death as a result of traditional Samoan tattoos. Although Hawai'i is the home of the second largest Samoan population in the United States, short of only American Samoa, literature review found no published case reports in this state. Presented is a case of a 46-year-old man, who, after undergoing a modified version of traditional Samoan tattooing for 5 days, was admitted to the intensive care unit with severe septic shock due to poly-microbial bacteremia with Group A Streptococcus and Methicillin-sensitive Staphylococcus Aureus. In addition, we will discuss the previously reported cases, mainly documented in New Zealand, and review some of the mandatory sanitary standards put into place there.
Samoa; Tattoos; Tattooing, complications; Tattooing, adverse reactions; Cellulitis; Bacteremia, Group A streptococcus; Bacteremia, Methicillin- Sensitive Staphylococcus aureus
In 1937 Butler and Marrian found large amounts of the steroid pregnanetriol in urine from a patient with the adrenogenital syndrome, a virilizing condition known to be caused by compromised adrenal secretion even in this pre-cortisol era. This introduced the concept of the study of altered excretion of metabolites as an in vivo tool for understanding sterol and steroid biosynthesis. This approach is still viable and has experienced renewed significance as the field of metabolomics. From the first cyclized sterol lanosterol to the most downstream product estradiol, there are probably greater than 30 steps. Based on a distinctive metabolome clinical disorders have now been attributed to about seven post-squalene cholesterol (C) biosynthetic steps and around 15 en-route to steroid hormones or needed for further metabolism of such hormones. Forty years ago it was widely perceived that the principal steroid biosynthetic defects were known but interest rekindled as novel metabolomes were documented. In his career this investigator has been involved in the study of many steroid disorders, the two most recent being P450 oxidoreductase deficiency and apparent cortisone reductase deficiency. These are of interest as they are due not to mutations in the primary catalytic enzymes of steroidogenesis but in ancillary enzymes needed for co-factor oxido-reduction A third focus of this researcher is Smith-Lemli-Opitz syndrome (SLOS), a cholesterol synthesis disorder caused by 7-dehydrocholesterol reductase mutations. The late George Schroepfer, in whose honor this article has been written, contributed greatly to defining the sterol metabolome of this condition. Defining the cause of clinically severe disorders can lead to improved treatment options. We are now involved in murine gene therapy studies for SLOS which, if successful could in the future offer an alternative therapy for this severe condition.
Cholesterol synthesis; Steroid biosynthesis; Steroid metabolism
Focus Areas: Integrative Approaches to Care, Pediatrics, Alleviating Pain
A 16-year-old previously healthy white female presented to our office with complaints of a 1-year history of chronic severe pelvic pain, leg pain, and severe daily headaches that were adversely affecting her school performance. Her leg and pelvic pain caused weakness and discomfort to the point that she used a walker or a wheelchair when she had to ambulate distances longer than 20 feet. She had been disenrolled from school where she had been an honor student. She had seen several specialists in areas including gynecology, neurology, pain management, and pelvic floor physical therapy. Extensive laboratory workup, including testing for Lyme disease, was negative. Exploratory laparoscopy did not elucidate any significant pelvic pathology. Medical management with appropriate doses of non-steroidal antiinflammatory medication, amitriptyline, lyrica, oral contraceptives, and Depo-Provera did not provide any significant relief. Through a series of visits to our office, it was determined that she was incredibly motivated to return to school but was having significant difficulty managing her advanced school work due to severe headaches and trouble with concentration. She denied any specific triggering factor for her symptoms and did not have a mood disorder. With behavior-modification recommendations, she worked independently on increasing her daily activities and has been able to rehabilitate to the point that she no longer uses a walker or a wheelchair to move around. This case demonstrates the potential that a therapeutic relationship can have for facilitating patient recovery. The importance of open communication with the patient and family, addressing their concerns, and seeking a source and treatment regimen outside of a paradigm of a psychosocial trauma were highlighted by this process.
Since 2006, over 600 biodegradable vascular scaffolds (BVS) have been implanted worldwide in clinical trials such as ABSORB cohort A and B, ABSORB Extend and ABSORB II RCT. Due to completely changed construction and mechanical properties of BVS, the choice of proper scaffold diameter and its implantation differ significantly from those used in the case of metal stents (bare metal stent (BMS) or drug eluting stent (DES)). Furthermore, all data concerning BVS efficacy and safety come from clinical trials, conducted in a selected group of patients. In 2012 BVS ABSORB™ was approved as the first biodegradable scaffold for the treatment of coronary artery disease in EU and other countries, with a limitation of use only for experienced and trained interventional cardiologists. As one of the most experienced clinical centers in Europe and the first one that in 2006 implanted BVS ABSORB™ in Poland we have a great pleasure and honor to share our experience with interventional cardiologists who would like to prepare for BVS ABSORB™ implantation in their centers. In this article we wanted to summarize the clinical data from already finished and ongoing trials, give a short overview of patient selection, and provide a detailed description of the implantation process with tips which could be helpful during BVS use.
biodegradable vascular scaffold; percutaneous coronary intervention
Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly-funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.
We constructed a cost effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a post-partum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.
With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.
A revised Medicaid sterilization policy could potentially honor women's reproductive decisions, reduce the number of unintended pregnancies, and save a significant amount of public funds.
Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly-funded, post-partum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to a cost savings of $215 million each year.
Tubal sterilization; unfulfilled sterilization; cost analysis