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Background In recent years, most U.S. states have passed autism mandates requiring private insurers to cover autism spectrum disorders (ASD). Little is known about the post-mandate changes in healthcare expenditures. Method This study utilized 2006–2012 de-identified insurance claims data from the largest private insurer in Pennsylvania (PA), where the mandate went into effect in mid 2009. Healthcare expenditures were defined as the amount the insurer paid for healthcare services and were adjusted to 2012 price level. A mixed effects model was used to analyze the expenditures. Results A total of 9471 children with ASD were included. Although the pre-mandate total expenditures per child with ASD were similar, the post-mandate expenditures significantly increased for groups subject to the autism mandate (87% increase from $7754 in 2008 to $14,486 in 2010) compared to the exempt groups (27% increase from $7238 to $9171). By insurance type, the change from 2008 to 2010 in ASD-related expenditures per child with ASD was $8439 for fully insured large employer sponsored plans and $43 for the Children’s Health Insurance Program (CHIP), both subject to the PA mandate; and $2631 for the self-insured, $980 for small-employers, and $-92 for individual plans, all of which are exempt from the mandate. These increases were due to outpatient services but not inpatient or drug costs. Conclusions Healthcare expenditures increased significantly following the PA autism mandate. Nonexempt, large employer groups had the largest increase in spending. Some exempt, self-insured companies may have voluntarily covered ASD services, leading to a moderate increase.

Agreement between the final DSM-5 ASD criteria, Childhood Autism Rating Scale (CARS), and Checklist for Autism Spectrum Disorder (CASD) was assessed in 143 children with ASD and other disorders (e.g., ADHD, intellectual disability, and oppositional defiant disorder). Diagnostic agreement between the CARS and CASD was high (94%), but their agreement with the DSM-5 was lower (84% and 88%). Agreement between the DSM-5 and both the CARS and CASD increased to 94% and diagnostic accuracy increased from 92% to 96% when one less DSM-5 social communication and interaction symptom was required for a diagnosis. Children with ASD not meeting DSM-5 criteria most often did not have criterion A2 (deficits in nonverbal social communication). Total scores on the DSM-5, CASD, and CARS were far higher for children with mild ASD (formerly PDDNOS) than no ASD, indicating that these children are clearly on the autism spectrum and are quite different from children with other disorders. However, only one child with mild ASD was identified by the DSM-5. This study and 11 others show that the DSM-5 under-identifies children with ASD, particularly children at the mild end of the spectrum. This can be rectified by requiring one less social communication and interaction symptom for a diagnosis.

Background: Soy isoflavones are naturally occurring phytochemicals with weak estrogenic cellular effects. Despite numerous clinical trials of short-term isoflavone supplementation, there is a paucity of data regarding longer-term outcomes and safety. Objective: Our aim was to evaluate the clinical outcomes of soy hypocotyl isoflavone supplementation in healthy menopausal women as a secondary outcome of a trial on bone health. Design: A multicenter, randomized, double-blind, placebo-controlled 24-mo trial was conducted to assess the effects of daily supplementation with 80 or 120 mg aglycone equivalent soy hypocotyl isoflavones plus calcium and vitamin D on the health of 403 postmenopausal women. At baseline and after 1 and 2 y, clinical blood chemistry values were measured and a well-woman examination was conducted, which included a mammogram and a Papanicolaou test. A cohort also underwent transvaginal ultrasound measurements to assess endometrial thickness and fibroids. Results: The baseline characteristics of the groups were similar. After 2 y of daily isoflavone exposure, all clinical chemistry values remained within the normal range. The only variable that changed significantly was blood urea nitrogen, which increased significantly after 2 y (P = 0.048) but not after 1 y (P = 0.343) in the supplementation groups. Isoflavone supplementation did not affect blood lymphocyte or serum free thyroxine concentrations. No significant differences in endometrial thickness or fibroids were observed between the groups. Two serious adverse events were detected (one case of breast cancer and one case of estrogen receptor–negative endometrial cancer), which was less than the expected population rate for these cancers. Conclusion: Daily supplementation for 2 y with 80–120 mg soy hypocotyl isoflavones has minimal risk in healthy menopausal women. This trial was registered at clinicaltrials.gov as {"type":"clinical-trial","attrs":{"text":"NCT00665860","term_id":"NCT00665860"}}NCT00665860

Maternal ratings of anxiety, depression, and irritability were analyzed in 1390 children (6–16 years of age), including 233 children with high functioning autism (HFA, IQ ≥ 80), 117 children with low functioning autism (LFA, IQ

Soy isoflavones have functional similarity to human estrogens and may protect against breast cancer as a result of their antiestrogenic activity or increase risk as a result of their estrogen-like properties. We examined the relation between isoflavone supplementation and mammographic density, a strong marker for breast cancer risk, among postmenopausal women. The Osteoporosis Prevention Using Soy (OPUS) study, a multi-site, randomized, double-blinded, and placebo-controlled trial assigned 406 postmenopausal women to 80 or 120 mg/d of isoflavones each or a placebo for 2 y. Percent densities were assessed in digitized mammograms using a computer-assisted method. The mammogram reader did not know the treatment status and the time of mammograms. We applied mixed models to compare breast density by treatment while considering the repeated measures. The mammographic density analysis included 358 women, 88.2% of the OPUS participants; 303 had a complete set of 3 mammograms, 49 had 2, and 6 had only 1 mammogram. At baseline, the groups were similar in age, BMI, and percent density, but mean breast density differed by study site (P = 0.02). A model with all mammograms did not show a treatment effect on any mammographic measure, but the change over time was significant; breast density decreased by 1.6%/y across groups (P < 0.001). Stratification by age and BMI did not reveal any effects in subgroups. In this randomized 2-y trial, isoflavone supplements did not modify breast density in postmenopausal women. These findings offer reassurance that isoflavones do not act like hormone replacement medication on breast density.

OBJECTIVES To determine the provider cost of administering intensive care unit (ICU) services, comparing 3 different staffing models for ICU coverage, and to compare the costs of using house staff vs nonphysician providers (NPPs). METHODS Data were collected on total staff composition and number of beds in ICUs from January 1, 2004, through December 31, 2004, at the 3 Mayo Clinic sites: Rochester, Minn; Jacksonville, Fla; and Scottsdale, Ariz. Institutional or national average staff salaries were used to determine total staffing costs per ICU bed per year at each site. Medicare medical education reimbursements were also taken into account. RESULTS Costs per ICU bed for physician staffing were $18,630 in Rochester, $37,515 in Jacksonville, and $38,010 in Scottsdale. When NPPs were substituted for house staff, the costs per bed were $72,466 in Rochester, $61,291 in Jacksonville, and $49,909 in Scottsdale. Incremental costs per ICU bed using NPPs were $53,836 in Rochester, $23,776 in Jacksonville, and $11,899 in Scottsdale. CONCLUSION Use of residents and fellows in ICU staffing at a major tertiary health center is more cost-efficient than use of NPPs. This finding could have implications for the cost of physician services in nonteaching community hospitals and the methods by which care is provided.

Evaluation of analgesic agents is multifactorial. The authors know of no direct comparisons among the choices in analgesic agents that suggest one therapy over another in global outcomes such as mortality or morbidity. Therefore, until further outcome differentiation between agents is proved, understanding the primary difference of delivery routes, mechanisms of action, pharmacokinetics, and adverse effects serves as the best guide for selecting the appropriate agent for each patient.

Study objectives To investigate whether a diet enriched with fish and borage oils, with their high polyunsaturated fatty acid (PUFA) content, alters surfactant composition and function during endotoxemia. Design Prospective, randomized, blinded, controlled animal study. Setting Research laboratory at a medical center. Participants Thirty-six 15- to 25-kg, disease-free, castrated male pigs. Diets and measurements Three groups of pigs (n = 12 per group) were fed for 8 days diets containing either ω-6 fatty acids (FAs) (corn oil; diet A), orω -3 FAs (fish oil; diet B), or a combination of ω-6 and ω-3 FAs (borage and fish oils; diet C). Eight of 12 pigs in each group received a 0.1-mg/kg bolus of Escherichia coli endotoxin followed by a continuous infusion (0.075 mg/kg/h). One lung was subsequently isolated ex vivo , and pressure-volume curves were measured. The contralateral lung was lavaged, and surfactant was analyzed for total and individual phospholipids and FA composition. Minimum and maximum surface tension was measured by bubble surfactometry. Results Pigs fed either diet B or C had increased oleic acid (C 18:1 ω-9), eicosapentaenoic acid (EPA; C 20:5 ω-3), docosahexaenoic acid (C 22:6 ω-3), and total ω-3 and monounsaturated FAs in their surfactant PUFA pools. The relative percentage of linoleic acid (C 18:2 ω-6) and total ω-6 FAs were significantly lower from pigs fed diets B and C compared with diet A. Palmitic acid (C 16:0 ) concentrations, the primary FA in surfactant, had a tendency to be lower in pigs fed diets B and C. There were no demonstrable effects on surfactant function or pulmonary compliance. Conclusions Diets containing EPA or EPA and γ-linolenic acid altered the PUFA composition of pulmonary surfactant, but without demonstrable effects on surfactant function during porcine endotoxemia.

Conventional surgical or flexible endoscopic approaches to the gastrointestinal tract of birds are frequently ineffective or too traumatic. Fine-diameter rigid endoscopes combined with an instrument delivery system provide a superior method to examine, sample, and treat a variety of gastrointestinal problems in small avian patients. Common approaches and indications for gastrointestinal endoscopy are reviewed.

Avian renal disease may occur as a result of bacterial, viral, or parasitic infections; metabolic dysfunction; congenital deformity; toxic insults; or nutritional deficiencies or excesses. In an attempt to diagnose these maladies, a number of ancillary techniques have been advocated for use by the avian clinician. Serum or plasma biochemical parameters, such as uric acid, urea, creatinine, or creatine are either nondiagnostic or do not elevate until pathology has become substantial. Alterations in the urine, as noted in the urinalysis, further aid in the detection of renal disease, but are also typically nonspecific. Other noninvasive diagnostic imaging techniques, such as radiography, ultrasonography, computed tomographic (CT) scans, or magnetic resonance imaging, play limited roles as a result of their cost or inability to provide a definitive diagnosis in most cases. Rigid endoscopy with its inherent focal, directed illumination with magnification allows the clinician the opportunity to directly visualize the urinary system, as well as to collect biopsy specimens that may provide an etiopathogenic diagnosis.

Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure.BackgroundPatients with acute renal failure (ARF) have high morbidity and mortality rates, particularly if they have serious comorbid conditions. Several studies indicate that in rats with ARF caused by ischemia or certain nephrotoxins, insulin-like growth factor-I (IGF-I) enhances the recovery of renal function and suppresses protein catabolism.MethodsOur objective was to determine whether injections of recombinant human IGF-I (rhIGF-I) would enhance the recovery of renal function and is safe in patients with ARF. The study was designed as a randomized, double-blind, placebo-controlled trial in intensive care units in 20 teaching hospitals. Seventy-two patients with ARF were randomized to receive rhIGF-I (35 patients) or placebo (37 patients). The most common causes of ARF in the rhIGF-I and placebo groups were, respectively, sepsis (37 and 35% of patients) and hypotension or hemodynamic shock (42 and 27% of patients). At baseline, the mean (± sd) APACHE II scores in the rhIGF-I and placebo-treated groups were 24 ± 5 and 25 ± 8, respectively. In the rhIGF-I and placebo groups, the mean (median) urine volume and urinary iothalamate clearances (glomerular filtration rate) were 1116 ± 1037 (887) and 1402 ± 1183 (1430)ml/24hr and 6.4 ± 5.9 (4.3) and 8.7 ± 7.2 (4.4)ml/min and did not differ between the two groups. Patients were injected subcutaneously every 12hours with rhIGF-I, 100 μg/kg desirable body weight, or placebo for up to 14days. Injections were started within six days of the onset of ARF. The primary end-point was a change in glomerular filtration rate from baseline. Other end points included changes from baseline in urine volume, creatinine clearance and serum urea, creatinine, albumin and transferrin, frequency of hemodialysis or ultrafiltration, and mortality rate.ResultsDuring the treatment period, which averaged 10.7 ± 4.1 and 10.6 ± 4.5days in the rhIGF-I and placebo groups, there were no differences in the changes from baseline values of the glomerular filtration rate, creatinine clearance, daily urine volume, or serum urea nitrogen, creatinine, albumin or transferrin. In patients who did not receive renal replacement therapy, there was also no significant difference in serum creatinine and urea between the two groups. Twenty patients in the rhIGF-I group and 17 placebo-treated patients underwent dialysis or ultrafiltration. Twelve rhIGF-I–treated patients and 12 placebo-treated patients died during the 28days after the onset of treatment.ConclusionsrhIGF-I does not accelerate the recovery of renal function in ARF patients with substantial comorbidity.

Concerns about the utility of pulmonary artery catheters (PAC) stimulated us to assess the impact of one of the parameters measured by the PAC, the pulmonary capillary wedge pressure (PCWP), on our clinical practice.The PCWP was recorded at 4- to 6-hour intervals on 50 patients for the first 48 hours following aortic aneurysm repair. We then reviewed the patients' records looking for evidence that the PCWP measurements were used to guide therapy. For the purpose of the study, we anticipated the administration of diuretics for PCWPor =218 mm Hg and volume resuscitation for PCWPor =8 mm Hg. Data were correlated using Pearson rank correlation coefficient using a P0.05 to determine statistical significance.Patients with PCWPs8 mm Hg were more likely to be treated with volume resuscitation (P0.05). There was no other correlation between PCWP measurements and fluid or pharmacologic management.Data derived from the PAC are infrequently used to guide therapy in patients who undergo abdominal aortic reconstructive surgery.

Alterations of dietary lipids have been advocated to manipulate platelet release of thromboxane A2. We studied the effects of incubating platelets with several different polyunsaturated fatty acids on platelet-lipid profile and release of thromboxane A2 in response to platelet stimulation. Porcine platelets were isolated by centrifugation, washed three times in Tyrode's solution, and incubated with fatty acids (500 microM) in Tyrode's solution with albumin. Seven polyunsaturated fatty acids of varying lengths (18-, 20-, and 22-carbon chain) of the omega3 and omega6 families were incubated for 60 min at concentrations of 0, 10, 30, and 100 microM with saturated fatty acids comprising the remainder of the 500 microM fatty acids. The platelets were then stimulated for 5 min with A23187 (30 microM). Indomethacin was added, and the platelets were pelleted. Platelet lipids were extracted in hexane, transesterified and quantified by gas chromatography. Using radioimmunoassay, we measured thromboxane B2, the stable metabolite of thromboxane A2, in the platelets' supernatant. A 1-h incubation in each of the seven polyunsaturated fatty acids had no significant effect on platelet-lipid composition. We found a significant increase in thromboxane B2 production in arachidonic acid (100 microM) incubated platelets (324.0 +/- 63.8% of baseline) that was inhibited by eicosapentaenoic acid (81.0 +/- 26.8%, P0.01) and to a lesser extent by dihomogammalinolenic acid (189.8 +/- 28.3%, P0.03). We conclude that in altering diets to affect platelet release of thromboxane, the two fatty acids of interest are the 20-carbon chain fatty acids, dihomogammalinolenic acid and eicosapentaenoic acid. The ideal amount of each of these fatty acids to be incorporated entails supraphysiologic but pharmacologically achievable levels of fatty acids in plasma.

One of the most important aspects of the practice of avian medicine and surgery is the ability to safely collect a variety of specimens from the bird for use in the laboratory setting. The indications, contraindications, techniques, and concerns for specimen handling for samples collected from the peripheral blood, bone marrow, respiratory system, and gastrointestinal system are presented. No attempt has been made to discuss the interpretation of results obtained from these techniques. Additionally, use of other ancillary diagnostic techniques, such as endoscopy, diagnostic imaging, and electrocardiography, are beyond the scope of this presentation.

Sedative and neuromuscular blocking (NMB) drugs may be life-saving when given to intensive care unit (ICU) patients with certain medical conditions. Because of this, their use has increased recently. Sedative and NMB drugs are administered often to patients with severe concurrent organ dysfunction; however, there is increased recognition of unexpected complications associated with the prolonged administration of these drugs. An understanding of the potential side effects is crucial if sedative and NMB drugs are used to manage patients in the ICU.

Most patients in the intensive care unit experience pain and anxiety, which are treated most commonly with an opioid or a benzodiazepine. These compounds are effective and have a well-established safety record. With the exception of associated respiratory depression, they have a relatively wide therapeutic window. New approaches and formulations for opioids and benzodiazepines are being used with continued success in the clinical setting.

Objective: The study's objective was to determine the prothrombin time (PT) and activated partial thromboplastin time (aPTT) values that differentiated normal from excessively bleeding patients immediately after cardiopulmonary bypass (CPB). Design: A prospective blinded study. Setting: A large academic medical center. Participants: 148 patients were studied. Interventions: aPTT and PT were determined by the hospital laboratory and the Biotrack 512 Coagulation Monitor (Ciba Corning Diagnostics, Medfield, MA) from an arterial whole blood sample obtained 10 minutes after protamine administration. Patients were subjectively and objectively defined as “bleeders” or “nonbleeders” with blinded observers. Measurements and Main Results: The specificity and sensitivity were determined by a receiver operating characteristic (ROC) analysis. Twenty-three of 148 patients (14.9%) were characterized as bleeders. The laboratory PT had a maximal specificity and sensitivity of 78% and 75%, respectively, at a value of 15.4 s, with a negative and positive predictive value of 93% and 33%, respectively. The maximal specificity and sensitivity of the laboratory aPTT was 64% and 76%, respectively, at a value of 46 s, with a negative and positive predictive value of 89% and 33%, respectively. aPTT and PT approached normal values after 12 hours in the intensive care unit. Conclusion: The aPTT and PT values that produce the maximal sensitivity and specificity in the ROC analysis may be helpful to differentiate patients who are bleeding excessively from those patients who are not after CPB and to guide transfusion of blood products. New whole blood coagulation devices with rapid turn-around times had similar predictive value for bleeding tendency compared with standardized laboratory tests.

Although the association between advanced paternal age and serious birth defects has received less attention than the effect of maternal age on such defects, this association has been demonstrated. This, as well as the potential decline in fertility among older men, should be borne in mind by men electing to defer establishing a family.

Paraplegia secondary to spinal cord ischemia is a common occurrence following proximal aortic surgery. Recent research has suggested that modest reductions in neuronal temperature (ie, a 2 to 5 degrees C reduction) may protect the central nervous system from ischemic injury, and several medical centers are now using modest whole body hypothermia in an attempt to protect the spinal cord during aortic surgery. However, to date, there are no reports to validate that reductions in core temperature will reduce intrathecal temperature during aortic surgery. In the present study, the correlation between core temperature, assessed with a pulmonary artery thermistor, and intrathecal temperature, assessed with a lumbar intrathecal thermocouple, were evaluated. Both devices were corrected for bias using a mercury thermometer standard. It was found that there was excellent correlation between pulmonary artery temperature and intrathecal temperature during all portions of the surgery (r = 0.948; P < 0.001). The regression line for the relationship was defined by the formula: intrathecal temperature = 0.98 x pulmonary artery temperature + 0.65. Furthermore, there was excellent correlation between bias-corrected intrathecal temperature and the temperature measured by commercially available, bias-uncorrected thermistors placed in the esophagus (r = 0.869; P < or = 0.001), urinary bladder (r = 0.873; P < 0.001), and pulmonary artery (r = 0.929; P < 0.001). Based on these data, it is concluded that there is a close correlation between intrathecal temperature and core temperatures during proximal aortic surgery, and commercially available thermistors provide sufficient accuracy to assess spinal cord cooling during attempts to protect the spinal cord from ischemic injury.

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Our objective was to determine the chirality of many popular antihypertensive drugs, that is, whether they contained an asymmetric carbon atom and therefore would exist as more than one enantiomer (isomers that are mirror images of one another, like the right hand to the left hand). After conducting a literature search and contacting several pharmaceutical companies and individual authorities on the subject, we tabulated the chiral identity of 27 antihypertensive drugs. Results indicate that 14 (52%) of the 27 antihypertensive agents studied are marketed as racemic mixtures. Because enantiomers generally have disparate clinical and biologic activities, and because information about the relative efficacy and adverse effects of specific enantiomers is generally lacking in the medical literature, we urge that single enantiomers be used in future clinical trials and pharmacologic studies. Rational therapeutics require the study of the individual components of racemic combinations before such compounds are marketed.

The efficacy of combined methods of spinal cord protection during thoracoabdominal aortic reconstruction was evaluated because a recent clinical study failed to substantiate the value of cerebrospinal fluid drainage when used alone in the prevention of paraplegia. The effect of cerebrospinal fluid drainage and aortofemoral shunting were analyzed with regard to neurologic outcome and spinal cord blood flow in a model of thoracic aortic occlusion. In addition, we studied the use of motor-evoked potentials as compared with somatosensory-evoked potentials in monitoring cord perfusion. Thirty-two dogs underwent proximal and distal thoracic aortic Occlusion for 60 minutes. The control group (n = 8) underwent thoracic aortic cross-clamping only. Spinal cord protection was used in three groups: cerebrospinal fluid drainage alone (n = 8), aortofemoral shunting alone (n = 8), and cerebrospinal fluid drainage and aortofemoral shunting (n = 8). Neurologic outcome improved in all treatment groups as compared with controls (p J Vasc Surg 1992;15:789–99.)

Recent studies have demonstrated that small (i.e., 2-5 degrees C) reductions in temperature may protect the brain and spinal cord from ischemic injury. The present study evaluated the physiologic response of anesthetized animals to convective-based cooling and warming. Six shaved, isoflurane-anesthetized (1.50% end-expired; 1 MAC), pancuronium-paralyzed dogs were subjected to temperature manipulation. The flow of cool (13-14 degrees C) or warm (39-41 degrees C) air was uniformly applied to the the dorsal and lateral surfaces of the dog using an inflatable blanket with perforations in the interior surface. Convective cooling reduced pulmonary artery temperature (Tpa) from 37.0 +/- 0.2 degrees C (Mean +/- S.D.) to 33.0 +/- 0.0 degrees C over a 93 +/- 18 min period. Thereafter, the active cooling was discontinued and passive cooling resulted in a further reduction in Tpa to 32.4 +/- 0.3 degrees C over the next 60 min. Institution of convective warming resulted in an increase in Tpa from 32.4 +/- 0.3 to 33.0 +/- 0.0 degrees C in 23 +/- 14 min and from 33.0 to 37.0 +/- 0.0 in an additional 137 +/- 26 min. During the periods of active cooling, passive cooling and active warming, there were strong correlations between Tpa and temperature within the brain, cisterna magna, parietal epidural space, lumbar subarachnoid space and other commonly used temperature measurement sites non-invasively monitored (e.g. tympanic membrane, esophagus, rectum) r greater than or equal to 0.97; P less than 0.0001). The combination of isoflurane anesthesia (a potent EEG-suppressor) plus mild hypothermia (less than 34 degrees C) resulted in an EEG attenuation in five dogs, two of which progressed to burst suppression. The magnitude of EEG changes correlated with the degree of temperature reduction. Upon rewarming to 37 degrees C, all dogs had normal EEG activity and normal brain concentrations of high energy phosphates, glucose and lactate. Blood pressure and cardiac output did not change during the study and no dog exhibited acid-based anomalies or blood lactate accumulation. Whole body oxygen consumption and heart rate decreased in a temperature-dependent fashion. Cardiac rhythm disturbances were rare. The authors conclude that convection-based corporeal cooling and rewarming are efficacious methods for non-invasively and uniformly altering CNS temperatures without adversely affecting cerebral or systemic physiology.

To manage pain in an ICU setting effectively, one must first understand the unique features associated with the disease process for which patients are admitted. Although there are certain common denominators, a postoperative patient is different from a patient with an acute myocardial infarction. This article reviews the aspects of pain associated with the individual syndromes of patients admitted to an ICU.

The control group consisted of patients whose cycles took place during calendar years 1997 and 1998. Similar protocols were used; however, all transfers were performed 72 hours after aspiration. All subjects underwent standard COH with leuprolide down-regulation followed by hMG or FSH stimulation. Embryos were cultured in 50 mL drops of media under oil, with P1 and blastocyst media used sequentially. Two blastocysts were transferred in 22 cases (88%), 3 in 2 cases, and 4 in one case. The clinical pregnancy rate was 18/25 (72%), the multiple gestation rate was 11/18 (61%), and the implantation (chorionic sac per embryo) rate was 30/54 (56%). Of the 18 clinical pregnancies, 7 (38.9%) were singletons and 8 (44.4%) were twins. There were 3 high-order multiple gestations, all associated with monozygotic twinning (3/18 [16.7%]; 95% CI 4–41%), a rate which is significantly higher than the established rate of 0.4% in the general population. Two of these had 2 blastocysts transferred, resulting in 2 sacs and 3 viable fetuses. The third patient had a known balanced chromosomal translocation and underwent transfer of 4 blastocysts, resulting in 3 chorionic sacs and 4 viable fetuses. There were 59 clinical pregnancies in the control group, with 7 high-order multiple gestations but only 1 monozygotic twin (1.7%; P,.05 vs. blastocyst transfer). We conclude that clinical blastocyst transfer 1) maintains good pregnancy rates in this group of patients and 2) is associated with a statistically significant increased rate of monozygotic twinning. PII S0015-0282(00) 00443-X

We studied the effect of thoracic aortic occlusion and cerebrospinal fluid (CSF) drainage on regional spinal cord blood flow and its correlation with neurologic outcome. Using isotope-tagged microspheres, we determined blood flow to the gray and white matter of five regions of the spinal cord in dogs: group I (control), group II (cross-clamp only), group III (cross-clamp plus CSF drainage). At 60 minutes after thoracic aortic occlusion in group II, median gray matter blood flow (GMBF) in the lower thoracic and lumbar cord decreased from 23.1 and 27.0 ml/100 gm/min at baseline to 4.0 and 2.5 ml/100 gm/min, respectively. The addition of CSF drainage improved GMBF during aortic cross-clamping in the lower thoracic and lumbar cord to 11.3 ( p p p

The influence of a single intraperitoneal injection of zine (0.5, 1.5 and 4.5 mg/kg) on the metastasis and subsequent growth of radiolabelled melanoma cells was examined in mice receiving tumor cells s.c. or i.v. 24 h following zinc treatment. Parenteral zinc resulted in increased tumor cell survival in the liver, spleen and lungs of zinc-treated mice 1 day post-injection, while 21-day cell survival was enhanced in the spleens of s.c. injected, zinc-treated mice. Regardless of zinc exposure, relative numbers of s.c. injected tumor cells decreased with time in the lungs and spleen, while increasing in the liver and kidneys. A single dose of zinc can modify the organ distribution and viability of metastatic tumor cells in mice.

The decision about whether to institute aggressive nutritional support, with its attendant expense and potential morbidity, in critically ill patients remains controversial. We studied numerous commonly used variables for assessment of nutrition to identify critically ill patients at increased risk for the development of infection, for becoming ventilator dependent, and for mortality. We enrolled 111 patients in this study on their third day in the intensive-care unit (ICU). No attempt was made to influence nutritional support, nor was adequacy of such support studied. Although several measurements correlated with outcome, the serum albumin correlated with number of ICU days (r = -0.38; P less than 0.001), with the number of days on a ventilator, and with the number of hospital days. It was the only measurement that correlated with the development of both a new infection (P less than 0.05) and ventilator dependency (P = 0.002). Although the use of the serum albumin concentration in this setting has limitations, it is still the best, most commonly used measurement of nutrition available.