Sensitivity analysis in the cost-effectiveness of breast cancer screening.
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Breast Neoplasms↗
Biomedical subjects
M L Brown
Publications and source records attributed to M L Brown.
Legal aspects, legislative effect, cost effectiveness, and barriers to breast cancer screening.
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Breast Neoplasms↗
Alternative splicing of the mRNA encoding the human cholesteryl ester transfer protein.
The plasma cholesteryl ester transfer protein (CETP) is known to facilitate the transfer of lipids between plasma lipoproteins. The human CETP gene is a complex locus encompassing 16 exons. The CETP mRNA is found in liver and small intestine as well as in a variety of peripheral tissues. While the CETP cDNA from human adipose tissue was being cloned, a variant CETP cDNA was discovered which excluded the complete sequence encoded by exon 9, but which was otherwise identical to the full-length CETP cDNA, suggesting modification of the CETP gene transcript by an alternative RNA splicing mechanism. RNase protection analysis of tissue RNA confirmed the presence of exon 9 deleted transcripts and showed that they represented a variable proportion of the total CETP mRNA in various human tissues including adipose tissue (25%), liver (33%), and spleen (46%). Transient expression of the exon 9 deleted cDNA in COS cells or stable expression in CHO cells showed that the protein encoded by the alternatively spliced transcript was inactive in neutral lipid transfer, smaller, and poorly secreted compared to the protein derived from the full-length cDNA. Endo H digestion suggested that the inactive, cell-associated protein was present within the endoplasmic reticulum. The experiments show that the expression of the human CETP gene is modified by alternative splicing of the ninth exon, in a tissue-specific fashion. The function of alternative splicing is unknown but could serve to produce a protein with a function other than plasma neutral lipid transfer, or as an on-off switch to regulate the local concentration of biologically active protein.
Adipose Tissue↗
Metabolic requirements for macrophage presentation of Listeria monocytogenes to immune CD8 cells.
Though ingested Ag are readily degraded into peptides within endocytic vesicles, APC usually cannot present these fragments to CD8 cells. Despite this generalization, some exceptions have been noted. For example, murine macrophage targets readily process heat-killed Listeria monocytogenes (HKLM) into a form recognizable by immune CD8 CTL. Using an assay of Listeria-specific, CD8-mediated cytotoxicity to quantitate Ag presentation by C57Bl/6 macrophage targets, we have examined some of the cellular requirements for this form of Ag processing. To assess whether the physical form of the Ag is an important determinant of processing, we compared the ability of macrophages to present intact HKLM, fractionated L. monocytogenes (LM) membranes, and octyl-beta-d-thioglucopyranoside-solubilized extracts of LM membranes. Macrophages presented each Ag form in a similar manner indicating that processing is not critically dependent on the presence of intact bacteria or even on the introduction of Ag in a particulate form. To gain insight into the metabolic requirements for Ag processing, we examined the effects of several inhibitors. As might be expected, listerial Ag presentation was blocked by brefeldin, a known inhibitor of the endogenous pathway of Ag processing. LM Ag presentation, however, was also blocked by inhibitors of endosomal acidification (chloroquine, ammonium chloride, and monensin) and by the acid protease inhibitor pepstatin A, suggesting that endocytic processing may play an essential role in CD8 recognition of this Ag. To formally establish that this pattern of exogenous Ag processing requires the presence of a class I MHC product, we demonstrated that beta-2 microglobulin-deficient macrophages, which lack class I MHC product expression, cannot present HKLM to CD8 cells. However, we could not block Ag presentation by incubating macrophages with monoclonal anti-H-2K or H-2D antibodies, suggesting that LM Ag presentation may be mediated by some other class I MHC product. Additional characterization of this pathway of Ag presentation is warranted in view of its possible role in initiating CD8-mediated immunity against microbial Ag.
Animals↗
Ileocolonic transit does not change after right hemicolectomy.
The role of the human ileocolonic junction in the transit of solid contents through the entire gut was evaluated. Eight patients, well compensated after right hemicolectomy for localized colon cancer, and eight age-matched healthy controls were enrolled. Scintigraphic transit was quantified after subjects ingested a mixed meal containing 111In-labeled Amberlite beads (average diameter, 1 mm; Sigma Chemical Co., St. Louis, MO). Gastric emptying was initially faster in the postoperative group, but overall emptying was not different from controls; small bowel transit also did not differ between the groups. In patients in whom the distal ileum, ileocolonic sphincter, and proximal colon were absent, isotopes moved from small to large bowel in a manner that was qualitatively and quantitatively no different from that of controls. Major episodes of coloileal reflux could not be identified in either group. After hemicolectomy, the residual transverse colon, and to a lesser degree the descending colon, were able to store solid residue, although in lesser amounts than the unoperated large bowel. The ileocolonic sphincter in humans appears to play only a minor role, at most, in ileocolonic transit, and the colon remaining after right hemicolectomy stores residue so that bowel habits are not greatly disturbed.
Aged↗
Human gastric and jejunal transit and motility after Roux gastrojejunostomy.
Upper gut transit and motility among 10 symptomatic and 9 asymptomatic patients with Roux gastrectomy were compared with those among 10 healthy, unoperated controls. Gastric emptying of solids and Roux limb and small intestinal transit of liquids were assessed scintigraphically. Motor patterns in the Roux limb or healthy jejunum were recorded manometrically. Whereas gastric emptying was sometimes faster and sometimes unchanged after Roux gastrectomy compared with controls, Roux limb transit in patients was consistently slower than jejunal transit in controls. Postprandially, the Roux limb showed decreased overall motility, fewer clustered waves, and less aboral migration of clustered waves than the healthy jejunum. Symptomatic Roux patients had jejunal transit and motor patterns similar to those of asymptomatic patients. Nonetheless, reflux from Roux limb to gastric remnant occurred in 4 of 10 symptomatic patients but in none of the asymptomatic patients. In conclusion, stasis and dysmotility are present in the Roux limb after Roux gastrectomy and Roux-gastric reflux can occur. Other factors, however, must have a role in determining whether symptoms appear.
Adult↗
Transit through the proximal colon influences stool weight in the irritable bowel syndrome.
The inherent variability of symptoms and motor abnormalities in patients with the irritable bowel syndrome has hampered the demonstration of motor abnormalities that could underlie symptoms. The aim in the current study was to evaluate whether altered regional capacitance or transit of solid residue through the unprepared human gut were factors in the diarrhea of patients with the irritable bowel syndrome. In 10 such patients and in 5 healthy controls, gastric and small bowel transits were evaluated scintigraphically by means of a mixed meal containing 99mTc-labeled resin pellets. Regional colonic transit was quantitated by 111In-labeled pellets delivered to the ileocecal region by a pH-sensitive, methacrylate-coated capsule. Symptomatic patients did not have significantly altered gastric or small bowel transits, but colonic transit was accelerated in 7 of 10 persons with the irritable bowel syndrome (P less than 0.02), in the proximal colon of five patients and in the left colon of two patients. The 24-hour stool weight was positively correlated with the rate at which solid residue emptied from the ascending and transverse colons (r = 0.78; P less than 0.01). There was also an inverse relationship between emptying rates and maximal volumes accommodated by the proximal colon (r = -0.58; P less than 0.05), although the maximum volume of the proximal colon was not significantly different in patients and healthy subjects. Thus, accelerated transit through the proximal colon is a factor in the pathophysiology of the irritable bowel syndrome and influences the stool weight of such patients. The capacitance of the proximal colon presumably influences its storage capacity and, hence, the rate at which it empties.
Adult↗
Endothelium-derived nitric oxide and cyclooxygenase products modulate corpus cavernosum smooth muscle tone.
Relaxation of penile corpus cavernosum smooth muscle is controlled by nerve and endothelium derived substances. In this study, endothelium-dependent relaxation of corporal smooth muscle was characterized and the role of arachidonic acid products of cyclooxygenase in endothelium-dependent relaxation was examined. Endothelium removal from rabbit corpora was performed by infusion with 3-[(3-cholamidopropyl)-dimethylammonio]-1-propane sulfonate and was confirmed by transmission electron microscopy. Strips of human and rabbit corporal tissues were studied in the organ chambers for isometric tension measurement. The accumulation of cyclic guanosine monophosphate (cGMP) and the release of eicosanoids from corporal tissue was measured by radioimmunoassay and correlated to smooth muscle relaxation. Our study showed that relaxation of corpus cavernosum tissue to acetylcholine, bradykinin and substance P was endothelium-dependent; potentiated by indomethacin; and inhibited by NG-monomethyl-L-arginine, methylene blue or LY83583. Relaxation to papaverine and sodium nitroprusside was endothelium-independent, and unaffected by NG-monomethyl-L-arginine. Relaxation to vasoactive intestinal polypeptide was partially endothelium-dependent; potentiated by indomethacin; attenuated by NG-monomethyl-L-arginine or methylene blue. The tissue level of cGMP was enhanced by acetylcholine and nitric oxide. Methylene blue inhibited both basal and drug-stimulated levels of cGMP. The release of eicosanoids was enhanced by acetylcholine and blocked by indomethacin. In conclusion, nitric oxide or a closely related substance accounts for the activity of endothelium-derived relaxing factor in the corporal tissue. Inhibition of the release of eicosanoids potentiates the relaxing effect of nitric oxide. Nitric oxide increases tissue cGMP which appears to modulate corporal smooth muscle relaxation.
Acetylcholine↗
Distribution of mesalamine enemas in patients with active distal ulcerative colitis.
Mesalamine (5-aminosalicylic acid), a topically administered anti-inflammatory agent, is effective treatment by enema for distal ulcerative colitis; it lacks many of the side effects of orally administered sulfasalazine. In this study, we determined the colonic distribution of a 60-ml mesalamine enema in eight patients (five women and three men, 18 to 48 years old) with active distal ulcerative colitis that ranged from 12 to 40 cm proximal to the anal verge. On 3 consecutive days, each patient self-administered a 4-g (60-ml) 5-aminosalicylic acid enema that contained 3.7 MBq of [99mTc]technetium-sulfur colloid. Anterior and posterior images were obtained at 0, 30, 60, 120, and 240 minutes. During the 4-hour study period, all patients retained the enemas. The enemas spread to the sigmoid region in 24 of 24 studies, to the splenic flexure region in 22 of 24, and to the transverse colon in 1 of 24. Most of the enema was retained in the sigmoid colon. Therefore, we conclude that a 60-ml enema, when administered as recommended clinically, routinely flows retrograde as far as the splenic flexure but rarely spreads beyond this point. These results support the use of intrarectally administered 5-aminosalicylic acid for segmental colitis of the descending colon.
Adolescent↗
Aldose reductase and myo-inositol in endothelial cell dysfunction caused by elevated glucose.
A possible relationship between aldose reductase activity and myo-inositol levels and endothelium-dependent relaxations was examined in isolated rabbit aorta incubated with elevated concentrations of glucose (44 mM) for 6 hr to mimic hyperglycemic conditions. Rings of aorta incubated in elevated glucose and contracted submaximally by phenylephrine showed significantly decreased endothelium-dependent relaxations induced by acetylcholine compared with aorta incubated in control (5.5 or 11 mM) glucose. Acetylcholine-induced relaxations of aorta incubated in hyperosmotic mannitol (44 mM) were not different from those incubated in control glucose. Treatment with two structurally unrelated aldose reductase inhibitors, sorbinil or zopolrestat, or supplementation with myo-inositol, prevented the abnormal acetylcholine relaxations of aortic rings caused by elevated glucose. No effects of sorbinil, zopolrestat or myo-inositol were observed on the response to acetylcholine of aorta incubated in control glucose. Neither sorbinil nor myo-inositol affected the increase in release of vasoconstrictor prostanoids caused by elevated glucose. These findings suggest that sorbitol accumulation and myo-inositol depletion contribute to the abnormal endothelial cell function caused by exposure to elevated glucose. The increased release of vasoactive prostanoids is either independent of, or possibly contributes to, the abnormal aldose reductase activity and/or myo-inositol depletion in intact blood vessels exposed to elevated concentrations of glucose.
Acetylcholine↗
Economic considerations in breast cancer screening of older women.
The incidence of breast cancer increases with age, tending to result in more favorable cost-effectiveness outcomes with more advanced age of the screened population. On the other hand, the decreased remaining life expectancy of older women can be expected to reduce the cost effectiveness of screening. To assess these competing factors, the cost effectiveness of a long-term breast cancer screening program was evaluated using a computerized simulation model. The cost per life year saved decreased when the 65-69 year age group was added to a program screening women aged 50-64. For older age groups, however, cost effectiveness became relatively less favorable. The cost per life year saved of screening the 80-84 year age group was 55% higher than for the 65-69 group.
Aged↗
Supporting statements and rationale.
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Aged↗
Dosimetry and biodistribution of an iodine-123-labeled somatostatin analog in patients with neuroendocrine tumors.
A modified method for the preparation of a radiolabeled analog of somatostatin (123I-octreotide) is described. The pharmacokinetics and dosimetry of this analog were evaluated in patients with neuroendocrine tumors. Thirty patients had multiple blood and urine samples and sequential anterior and posterior whole-body scintigraphy up to 40 hr postinjection of 123I-octreotide. Region of interest analysis of the whole-body images was used to determine organ and tumor doses. The 123I-octreotide was rapidly cleared from the blood with a T 1/2 of 10 min by the hepatobiliary system. By 40 hr, approximately 55% was eliminated in the feces. The gallbladder wall received the highest dose (0.48 rad/mCi), with other organs receiving doses of 0.12 rad/mCi or less. Tumors were identified in 25 of 28 satisfactory studies. Tumor doses ranged from 0.1 to 0.6 rad/mCi. Calculations with 131I instead of 123I indicated that the gallbladder wall would receive 2 rad/mCi, while average tumor doses would range from 0.9 to 5.0 rad/mCi. Iodine-123-octreotide is a useful agent for the visualization of neuroendocrine tumors. The rapid washout of this agent from tumors precludes the possibility of radiotherapy with 131I-octreotide in these patients.
Endocrine Gland Neoplasms↗
[Transit of solids through the human colon: simplification of a technique].
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Colon↗
End-tidal carbon dioxide monitoring in the detection of anesthesia-related critical incidents.
A prospective study was undertaken in an effort to determine the usefulness of the end-tidal carbon dioxide monitor in detecting anesthesia-related critical incidents. The critical incident technique was employed in the evaluation of 2,334 anesthetics. Anesthesia providers completed a critical incident questionnaire following each anesthetic. All questionnaires were analyzed for the occurrence of a critical incident. The anesthesia provider was interviewed and the patient record reviewed in all cases of reported critical incidents to determine (1) the frequency of specific anesthesia-related critical incidents, and (2) the usefulness of the end-tidal carbon dioxide monitor in detecting such events. The critical incident technique revealed 79 such incidents. Monitoring of end-tidal carbon dioxide was found to be useful in confirming the occurrence of already suspected critical incidents 58% of the time. The end-tidal carbon dioxide monitor was also found to be the initial detector of 27% of the reported anesthesia-related critical incidents. Monitoring of end-tidal carbon dioxide proved to be beneficial in detecting and confirming critical incidents during anesthetic management.
Anesthesia↗
The supply of mammography resources in West Virginia.
The distribution of mammography machines and related resources in West Virginia, along with the distribution of breast cancer screen-eligible women, are examined using county-specific data. This data placed on a state map shows that it is not necessary to cross more than one county line anywhere within West Virginia in order to visit a mammography facility. The overall density of these machines is 20 per 100,000 women over 45, almost double the capacity needed for screening mammography. After taking into account the projected demand for mammography, the current average cost per exam is around $65-$100. If mammography machines were placed in all the counties without machines, the cost in those countries would be around $140 per exam. It would be cheaper to provide a travel allowance to women in rural counties than to install machines in these areas. Machines that are accredited by the American College of Radiologists, the most available indicator of quality mammography, are located only in densely populated areas of the state.
Accreditation↗
Role of dipyridamole thallium-201 imaging in left bundle branch block.
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Aged↗
Diagnostic accuracy of exercise thallium-201 single-photon emission computed tomography in patients with left bundle branch block.
Recent reports have proposed that abnormal apical or anterior wall perfusion with exercise thallium-201 imaging may increase diagnostic accuracy for disease of the left anterior descending artery in patients with left bundle branch block (LBBB). To evaluate these suggestions, 83 patients with LBBB who underwent thallium-201 single-photon emission computed tomography and coronary angiography within an interval of 3 months were retrospectively reviewed. There were 59 men and 24 women aged 33 to 84 years (mean 65). Myocardial perfusion to the apex, anterior wall and anterior septum were scored qualitatively by consensus of 2 experienced observers and by quantitative analysis in comparison with a normal data base. The sensitivity, specificity and accuracy of perfusion defects in these segments were then expressed according to angiographic findings. Significant stenosis of vessels within the left anterior descending artery territory was present in 38 patients. By receiver-operator characteristic analysis, a fixed or reversible defect within the apex by the qualitative method was the best criterion for coronary artery disease. However, although highly sensitive (79 and 85% by the qualitative and quantitative methods, respectively), an apical defect was neither specific (38 and 16%, respectively), nor accurate (57 and 46%, respectively). Perfusion abnormalities in the anterior wall and septum were also of limited diagnostic accuracy. Thus, modified interpretative criteria in patients with LBBB are not clinically useful in the assessment of left anterior descending artery disease.
Adult↗