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Fertility results using bovine semen cryopreserved with extenders based on egg yolk and soy bean extract.

Semen extenders containing components such as egg yolk and skim milk are difficult to standardize and they introduce the risk of microbial contamination. A well-defined extender not originating from animal tissues would present a valuable contribution to the AI industry. We evaluated the fertility of bovine semen cryopreserved with 3 different extenders: 1) TRIS-Standard, prepared at 2 local AI laboratories, containing 20% (v/v) pasteurized egg yolk, 2) TRIS-Concentrate, prepared by adding 20% (v/v) pasteurized egg yolk and 1:5 (v/v) nonpyrogenic water, and 3) Biociphos Plus, a soybean extract containing extender, prepared by adding 1:5 nonpyrogenic water. Ejaculates of 4 Holstein bulls were split into 3 aliquots and cryopreserved with the 3 extenders. Prior to this study, the semen dose-response curve for each of the 4 bulls was developed in a field trial by freezing the semen and randomly distributing the straws throughout the Netherlands for insemination. Optimal semen doses were thus established to detect the effect of extenders on fertility, evaluated by 56-day non-return rate (NR56), and by the estimated conception rate and the calving rate, given a conception. We used the multiphasic model developed by Grossman et al. (7). A total of 22,246 first and second inseminations were recorded. The NR56 ranged among bulls from 67.0 to 70.1% for Tris-Standard, from 67.5 to 69.9% for Tris-Concentrate and from 60.2 to 66.7% for Biociphos Plus. No significant differences in NR56 were detected between Tris-Standard and Tris-Concentrate (P=0.54), whereas Biociphos Plus resulted in a significantly lower NR56 than Tris-Standard and Tris-Concentrate (P<0.05). Estimated conception rate was 72.1, 73.6 and 69.6% and estimated calving rate, given a conception was 80.6, 78.3 and 77.1 for Tris-Standard, Tris-Concentrate and Biociphos Plus, respectively. These results indicate that 1) semen extended with a custom made TRIS-Concentrate can be succesfully used in the field resulting in comparable fertility with Tris-Standard; 2) semen extended with Biociphos Plus results in a significant reduction in the NR56; 3) extender source may affect both conception rate and calving rate, given a conception, i.e., extrinsic and intrinsic sperm factors (4).

Animals↗

Effect of extender composition and equilibration time on fertilization ability and enzymatic activity of rainbow trout cryopreserved spermatozoa.

The effects of extender composition and equilibration time on fertilizing ability of cryopreserved spermatozoa from rainbow trout, Oncorhynchus mykiss, were investigated. In addition, enzyme activity in supernatants from thawed sperm was assessed. The use of the two extenders: Erdahl & Graham's + 10% DMA (dimethyl acetamide) + 10% egg yolk and 0.3 M glucose + 10% DMA yielded the highest post-thaw fertilization rates. We observed interactions between extender constituents and the equilibration of diluted semen. This indicates a multifactorial effect of the extender constituents on spermatozoal resistance against injuries. The 10-min equilibration of spermatozoa in extender before freezing generally lowered the fertilization ability of spermatozoa, except for DMA-based extenders. The addition of egg yolk to the extender was generally beneficial, especially in DMA- and DMSO-based extenders. The use of low-density lipoprotein fraction showed no advantage to full-yolk or free-of-yolk extenders. Aspartate aminotransferase and lactate dehydrogenase leakage from damaged spermatozoa correlated negatively with the ability of cryopreserved spermatozoa to fertilize eggs. Each factor tested, when analyzed separately, did not give general information about its effect on the fertilization ability of cryopreserved sperm. The multifactorial analysis of the important factors in cryopreservation of trout spermatozoa showed their cumulative effect. This is the most likely reason for divergent information reported elsewhere on the effect of various factors in the cryopreservation of rainbow trout spermatozoa.

Acetamides↗

Effect of different extenders and storage temperatures on sperm viability of liquid ram semen.

Semen was collected with an artificial vagina from four adult rams. The ejaculates were pooled and diluted, using a split-sample technique, in four different extenders: one for milk (Mi), one for sodium citrate (Na), and two for Tris-based extenders (T1 and T2) including egg yolk. Thereafter, the diluted semen was stored at 5 and 20 degrees C, respectively. We evaluated sperm viability after 0, 6, 12, 24 and 30 h of storage. We assessed sperm motility subjectively, and we determined sperm membrane integrity using both the hypo-osmotic resistance test (ORT) and a fluorophore staining (SYBR-14 and propidium iodide) technique. We evaluated acrosomal status with Spermac and capacitation status with Chlortetracycline (CTC assay). All sperm viability parameters were influenced by storage time and extender, while sperm motility was the only evaluated parameter that was influenced by the interaction between extender and temperature. Semen that was diluted and stored in the commercially available Tris-based extender (T2) maintained sperm motility for a longer period of time, and acrosome and membrane integrity was higher during storage for up to 30 h as compared to the other extenders independent of storage temperature. In general, however, storage of ram semen at 5 degrees C seemed to influence sperm viability parameters less than storage at 20 degrees C. In conclusion, the results of the present study indicate that Tris-based extenders, especially T2, preserved sperm viability better than both the sodium citrate- and the milk-based extender did when liquid ram semen was stored up to 30 h at 5 and 20 degrees C. Whether the differences found between the extenders will be reflected in the fertility results after AI is yet unknown and needs to be further studied.

Acrosome↗

Assessment of sperm viability, mitochondrial activity, capacitation and acrosome intactness in extended boar semen during long-term storage.

The purpose of this study was to assess sperm quality in extended boar semen during in vitro storage in order to determine which extender should be used and how long boar semen can be stored. Freshly ejaculated boar semen was diluted with equal volumes of Beltsville thaw solution (BTS), Androhep, KIEV or Zorlesco extenders and stored at 17 degrees C for up to 15 days. Sperm quality was evaluated by examining viability using SYBR-14/PI and Hoechst 33258 staining, mitochondrial activity using 5,5',6,6'-tetrachloro-1,1',3,3'-tetraethylbenzimidazolyl-carbocyanine iodide (JC-1) staining, acrosome intactness by Coomassie blue staining, and capacitation status by chlortetracycline (CTC) staining. There were over 50% viable spermatozoa in boar semen extended with Zorlesco and Androhep extenders on Day 13 of storage. The percentage of JC-1-stained spermatozoa was 53.8 +/- 2.1% for Zorlesco and 57.7 +/- 1.60% for Androhep extenders on Day 13 of storage. The percentage of acrosome-intact spermatozoa detected by Coomassie blue staining was higher than that in the SYBR-14PI-, Hoechst 33258-, and JC-1-stained samples in our study. The results from SYBR-14/PI, Hoechst 33258, JC-1, and Coomassie blue staining were highly correlated (r > or = 0.9461). There were less than 15% capacitated spermatozoa in the semen extended with BTS, Androhep and Zorlesco extenders during 9 days of storage. However, most viable boar spermatozoa became capacitated by Day 13 of storage. The rank order of four extenders for maintaining sperm viability and mitochondrial activity was as follows: Androhep, Zorlesco, BTS, KIEV.

Acrosome↗

Advances in cooled semen technologies: seminal plasma and semen extender.

This study evaluated motility and fertility of uncentrifuged and centrifuged equine semen following dilution in a skim milk-glucose extender with or without supplemental Tyrode's medium. In addition, the effect of seminal plasma addition to each extender was evaluated. For Experiment 1, motility of 48h cooled, stored spermatozoa was evaluated following eight dilution treatments: uncentrifuged and diluted 1:4 (v/v) in skim milk-glucose extender (EZ Mixin CSTJ; CST-1:4) or in CST supplemented 65:35 (v/v) with modified Tyrode's medium (KMT-1:4); uncentrifuged and diluted to 25x10(6) spermatozoa/ml in CST (CST-1:9) or in KMT (KMT-1:9); centrifuged and diluted in CST with 0% seminal plasma (CST-0) or 20% seminal plasma (CST-20) or centrifuged and diluted in KMT containing 0% seminal plasma (KMT-0) or in KMT containing 20% seminal plasma (KMT-20). Sperm motility parameters evaluated included percentage of total motile sperm (% TMOT), percentage of progressively motile sperm (% PMOT), curvilinear velocity (VCL) and straight-line velocity (VSL). Mean % PMOT was lower (P<0.05) for spermatozoa extended in CST-1:4 compared to CST-1:9, whereas, all motility parameters were reduced (P<0.05) in KMT-1:4 compared to KMT-1:9. Spermatozoa extended in CST-1:4 had greater % TMOT, % PMOT and VSL (P<0.05) than in KMT-1:4. Spermatozoa extended in CST-1:9 had greater (P<0.05) % PMOT than in KMT-1:9, however, VCL was greater (P<0.05) in KMT-1:9. Mean VCL and VSL were lower (P<0.05) for spermatozoa extended in CST-0 compared with CST-20, whereas, spermatozoa extended in KMT-0 had greater (P<0.05) % TMOT, % PMOT and VSL compared to spermatozoa extended in KMT-20. Mean % TMOT and % PMOT were greater (P<0.05) in CST-20 compared to KMT-20, however, KMT-0 increased (P<0.05) velocity measures (VCL and VSL) compared to CST-0. In Experiment 2, fertility of centrifuged spermatozoa diluted in either CST-20 or KMT-0 was similar (P>0.05). We conclude that modified Tyrode's medium was not detrimental to establishment of pregnancy. Use of modified Tyrode's medium may improve spermatozoal motility and pregnancy rates for cooled transport of semen from stallions in which all seminal plasma must be removed because of suspected toxic effects of seminal plasma on spermatozoal viability, however, Tyrode's medium may be detrimental to sperm motility when seminal plasma is present.

Animals↗

Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group.

OBJECTIVE: The study was conducted to determine whether the performance of an extended lymphadenectomy and retroperitoneal soft-tissue clearance in association with a pancreatoduodenal resection improves the long-term survival of patients with a potentially curable adenocarcinoma of the head of the pancreas. SUMMARY BACKGROUND DATA: The usefulness of performing an extended lymphadenectomy and retroperitoneal soft-tissue clearance in conjunction with a pancreatoduodenal resection in the treatment of ductal adenocarcinoma of the head of the pancreas is still unknown. Published studies suggest a benefit for the procedure in terms of better long-term survival rates; however, these studies were retrospective or did not prospectively evaluate large series of patients. MATERIALS AND METHODS: Eighty-one patients undergoing a pancreatoduodenal resection for a potentially curable ductal adenocarcinoma of the head of the pancreas were randomized to a standard (n = 40) or extended (n = 41) lymphadenectomy and retroperitoneal soft-tissue clearance in a prospective, multicentric study. The standard lymphadenectomy included removal of the anterior and posterior pancreatoduodenal, pyloric, and biliary duct, superior and inferior pancreatic head, and body lymph node stations. In addition to the above, the extended lymphadenectomy included removal of lymph nodes from the hepatic hilum and along the aorta from the diaphragmatic hiatus to the inferior mesenteric artery and laterally to both renal hila, with circumferential clearance of the origin of the celiac trunk and superior mesenteric artery. Patients did not receive any postoperative adjuvant therapy. RESULTS: Demographic (age, gender) and histopathologic (tumor size, stage, differentiation, oncologic clearance) characteristics were similar in the two patient groups. Performance of the extended lymphadenectomy added time to the procedure, although the difference did not reach statistical significance (397 +/- 50 minutes vs. 372 +/- 50 minutes, p > 0.05). Transfusion requirements, postoperative morbidity and mortality rates, and overall survival did not differ between the two groups. When subgroups of patients were analyzed, using an a posteriori analysis that was not planned at the time of study design, there was a significantly (p < 0.05) longer survival rate in node positive patients after an extended rather than a standard lymphadenectomy. The survival curve of node positive patients after an extended lymphadenectomy could be superimposed onto the curves of node negative patients. Survival curves in node negative patients did not differ according to the magnitude of the lymphadenectomy. Multivariate analysis of all patients showed that long-term survival was affected by tumor differentiation (well vs. moderately vs. poorly differentiated, p > 0.001), diameter (< or = 2.0 cm. vs. > 2.0 cm., p < 0.01), lymph node metastasis (absent vs. present, p < 0.01) and need for 4 or more units of transfused blood (< 4 vs. > or = 4, p <0.01). CONCLUSIONS: The addition of an extended lymphadenectomy and retroperitoneal soft-tissue clearance to a pancreatoduodenal resection does not significantly increase morbidity and mortality rates. Although the overall survival rate does not differ in the two groups, there appears to be a trend toward longer survival in node positive patients treated with an extended rather than a standard lymphadenectomy.

Adenocarcinoma↗

HLA-DQA1, DQB1 and DPB1 alleles on HLA-DQ2- and DQ9-carrying extended haplotypes.

DQA1, DQB1 and DPB1 alleles were investigated in a large panel of samples carrying HLA-DQ2- and HLA-DQ9-bearing extended haplotypes. Every instance of the [HLA-B8, SCO1, DR3, DQ2a] and [HLA-B18, F1C30, DR3, DQ2b] extended haplotypes carried the DQA1*0501 allele, while every instance of [HLA-B44, FC31, DR7, DQ2c], [HLA-B47, FC91,0, DR7, DQ2c] and [HLA-B57, SC61, DR7, DQ2d] carried the DQA1*0201 allele. All HLA-DR3, DQ2 and HLA-DR7, DQ2 extended haplotypes carried the DQB1*0201 allele. Every example of [HLA-B57, SC61, DR7, DQ9] carried the DQB1*0303 allele. Several associations between the DPB1 alleles and some HLA-DQ2- and DQ9-carrying extended haplotypes were identified. HLA-DPw2-encoding alleles, DPB1*0202 (50%, p < 0.001) and 0201 (30%), were found on the [HLA-B18, F1C30, DR3, DQ2b] extended haplotype. Every instance of the [HLA-B57, SC61, DR7, DQ9] extended haplotype carried the DPB1*0401 allele. Also, we have confirmed the associations of the DPB1*0101 and DPB1*0401 alleles with the [HLA-B8, SC01, DR3, DQ2a] extended haplotype. The analysis of homozygous typing cells carrying the [HLA-B44, FC31, DR7, DQ2c] extended haplotype showed that the DPB1*0401 and 0201 alleles were present at similar frequencies (37.5%), while the DPB1*1101 allele was found in only 25% of these haplotypes analyzed. Our results suggest that the constancy of the DNA of the HLA-B, DR, DQ regions may extend to the DP region and that the extent of such fixity varies, perhaps as the result of ethnic variability of the population studied.

Alleles↗

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.

BACKGROUND: A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (> or =24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. METHODS AND FINDINGS: We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3-3.7) and 7.5 (95% CI, 7.2-7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4-22) and 7.0 (95% CI, 4.3-11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. CONCLUSIONS: In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education.

Adult↗

Dissolution profiles of nonprescription extended-release niacin and inositol niacinate products.

PURPOSE: The dissolution profiles of nonprescription extended-release niacin and inositol niacinate products were studied using the prescription extended-release niacin, Niaspan, as a reference. METHODS: Seven nonprescription extended-release and 12 nonprescription inositol niacinate products were collected from community and online pharmacies in the United States. Extended-release Niaspan was used as a reference. Dissolution profiles were examined by the United States Pharmacopoeia dissolution test, using a paddle method. Release samples were removed every 30 minutes for up to 240 minutes. Niacin was quantified by high-performance liquid chromatography. RESULTS: Ten out of the 12 inositol niacinate products were capsules and 6 of the 7 extended-release formulations were tablets. During the initial 30-minute dissolution study of inositol niacinate products, free niacin was released to various degrees. One product achieved fast dissolution, with >30% cumulative release of niacin. The cumulative percentage of niacin released at 240 minutes of all inositol niacinate products was statistically different (p < 0.0001). The majority of these products reached a plateau of releasing niacin in one to two hours, which was maintained until the end of the study. Six out of the seven extended-release niacin products had extended-release profiles. Five products showed a statistically higher dissolution rate (p < 0.05) than that of Niaspan. CONCLUSION: Significant variations in dissolution profiles were noted among the 7 nonprescription extended-release and 12 nonprescription inositol niacinate products in vitro, and their dissolution rates were not comparable to that of the prescription extended-release niacin. Further studies are warranted to correlate such dissolution data with their in vivo efficacy.

Delayed-Action Preparations↗

Use of boar spermatozoa for artificial insemination. III. Fecundity of boar spermatozoa stored in Beltsville liquid and Kiev extenders for three days at 18 C.

A field trial was conducted on several hundred farms in The Netherlands to compare the fertilizing capacity of boar spermatozoa stored for 1, 2, or 3 d at 18 C in either Kiev or Beltsville liquid extender (BL-1). Two storage volumes (25 and 100 ml) were used. Twelve Dutch Landrace boars, all in routine commercial artificial insemination service, provided the semen in twice-a-week collections. Over an 8-wk period in March and April, 1979, 2,849 sows and gilts were inseminated. Farrowing rates were higher (P less than .0001) with Kiev extender than with BL-1 extender (69.3 vs 60.5%) when semen was used over a 3 d period. The volume at which the semen was extended and stored had no effect on any parameter. Farrowing rate declined significantly when semen stored at 18 C for more than 2 d was used (74.5% vs 64.7% with semen stored for 1 and 3 in Kiev extender; 65.9% vs 52.7% with semen stored for 1 and 3 d in BL-1 extender). The farrowing rate, total number of pigs/litter and live pigs/litter were significantly higher for sows than for gilts inseminated with similar extended semen. On the basis of the results of this trial, Kiev extender appears to be more suitable as a diluent for liquid semen than does BL-1. AI with semen extended and stored for 3 d at 18 C can be expected to result in a lower farrowing rate than AI with semen stored for 1 or 2 d.

Animals↗

Effects of egg yolk-citrate and milk extenders on chromatin structure and viability of cryopreserved bull sperm.

Semen from four Holstein bulls was evaluated to compare effects of four extender treatments on postthaw semen quality. Extender fractions A and B, either heated whole milk or 20% egg yolk-citrate, were combined to yield the extender treatments 1) milk and milk, 2) milk and egg yolk-citrate, 3) egg yolk-citrate and milk, and 4) egg yolk-citrate and egg yolk-citrate. Semen was evaluated at thawing and after 30, 60, 120, and 180 min of incubation at 38.5 degrees C. Flow cytometry showed that acridine orange-stained sperm were most susceptible to in situ DNA denaturation when fraction A was milk. For sperm stained with rhodamine 123, flow cytometry showed that the proportion with intact mitochondrial membrane potential was lowest of all treatments at thawing but greatest at 180-min incubation with milk and milk extender. Flow cytometry of propidium iodine-stained sperm showed greatest proportion of cell membrane intact sperm when fraction A was egg yolk-citrate. Light microscopy showed the lowest proportion of cell membrane intact sperm with milk and milk extender after eosin-aniline blue vital staining. Postthaw motility scores tended to be reduced when both extender fractions were egg yolk-citrate. Results demonstrate differential extender effects on postthaw semen quality and indicate that altering extender composition or sequence of adding extender components may improve postthaw quality of cryopreserved sperm.

Analysis of Variance↗

Selective activation of the extended ventrolateral preoptic nucleus during rapid eye movement sleep.

We found previously that damage to a cluster of sleep-active neurons (Fos-positive during sleep) in the ventrolateral preoptic nucleus (VLPO) decreases non-rapid eye movement (NREM) sleep in rats, whereas injury to the sleep-active cells extending dorsally and medially from the VLPO cluster (the extended VLPO) diminishes REM sleep. These results led us to examine whether neurons in the extended VLPO are activated during REM sleep and the connectivity of these neurons with pontine sites implicated in producing REM sleep: the laterodorsal tegmental nucleus (LDT), dorsal raphe nucleus (DRN), and locus ceruleus (LC). After periods of dark exposure that triggered enrichment of REM sleep, the number of Fos-positive cells in the extended VLPO was highly correlated with REM but not NREM sleep. In contrast, the number of Fos-positive cells in the VLPO cluster was correlated with NREM but not REM sleep. Sixty percent of sleep-active cells in the extended VLPO and 90% of sleep-active cells in the VLPO cluster in dark-treated animals contained galanin mRNA. Retrograde tracing from the LDT, DRN, and LC demonstrated more labeled cells in the extended VLPO than the VLPO cluster, and 50% of these in the extended VLPO were sleep-active. Anterograde tracing showed that projections from the extended VLPO and VLPO cluster targeted the cell bodies and dendrites of DRN serotoninergic neurons and LC noradrenergic neurons but were not apposed to cholinergic neurons in the LDT. The connections and physiological activity of the extended VLPO suggest a specialized role in the regulation of REM sleep.

Animals↗

Glycine-extended gastrin exerts growth-promoting effects on human colon cancer cells.

BACKGROUND: Since human colon cancers often contain significant quantities of progastrin-processing intermediates, we sought to explore the possibility that the biosynthetic precursor of fully processed amidated gastrin, glycine-extended gastrin, may exert trophic effects on human colonic cancer cells. MATERIALS AND METHODS: Binding of radiolabeled glycine-extended and amidated gastrins was assessed on five human cancer cell lines: LoVo, HT 29, HCT 116, Colo 320DM, and T 84. Trophic actions of the peptides were assessed by increases in [3H]thymidine incorporation and cell number. Gastrin expression was determined by northern blot and radioimmunoassay. RESULTS: Amidated gastrin did not bind to or stimulate the growth of any of the five cell lines. In contrast, saturable binding of radiolabeled glycine-extended gastrin was seen on LoVo and HT 29 cells that was not inhibited by amidated gastrin (10(-6) M) nor by a gastrin/CCKB receptor antagonist (PD 134308). Glycine-extended gastrin induced a dose-dependent increase in [3H]thymidine uptake in LoVo (143 +/- 8% versus control at 10(-10) M) and HT 29 (151 +/- 11% versus control at 10(-10) M) cells that was not inhibited by PD 134308 or by a mitogen-activated protein (MAP) or ERK kinase (MEK) inhibitor (PD 98509). Glycine-extended gastrin did stimulate jun-kinase activity in LoVo and HT 29 cells. The two cell lines expressed the gastrin gene at low levels and secreted small amounts of amidated gastrin and glycine-extended gastrin into the media. CONCLUSIONS: Glycine-extended gastrin receptors are present on human colon cancer cells that mediate glycine-extended gastrin's trophic effects via a MEK-independent mechanism. This suggests that glycine-extended gastrin and its novel receptors may play a role in colon cancer cell growth.

Animals↗

Physician extenders: who is using them?

BACKGROUND: Nurse practitioners and physician assistants (physician extenders) are playing an increased role in medical care. The purpose of this research was to determine the proportion of adults who have received health care from physician extenders. METHODS: This study used the subject population of the 1990 Kentucky Health Survey, a probability survey of all households in Kentucky. Study personnel contacted subjects using random digit telephone dialing. Subjects were then interviewed to ascertain whether subjects had received health care from physician extenders and whether they were satisfied with that care. RESULTS: Of 687 participating subjects, 25% had received care from physician extenders during the previous two years, primarily for minor problems and routine checkups. More than 90% of these subjects reported satisfaction with the care they received. Users of physician extenders did not differ from nonusers with respect to income, education, insurance status, self-assessment of health status, or rural versus urban location. Men used physician extenders more frequently than women. CONCLUSIONS: A substantial proportion of the population has used physician extenders. Patient satisfaction with physician extenders is high. Use of physician extenders may be an effective strategy for improving delivery of primary care.

Adult↗

Surgical treatment of aortic coarctation in infants younger than three months: 1985 to 1990. Success of extended end-to-end arch aortoplasty.

There remains controversy regarding the appropriate surgical treatment of coarctation of the aorta in infants. In 1985 we introduced the extended end-to-end repair into our practice and now wish to present a review of our recent experience. One hundred fifty-one infants younger than 3 months of age underwent repair of coarctation between 1985 and 1990. In 25% and 33% of the patients, there was hypoplasia of the isthmus and of the transverse arch, respectively. Surgical procedures were as follows: subclavian flap angioplasty in 15 patients, resection with a traditional end-to-end anastomosis in 43, and resection with an extended end-to-end anastomosis into the arch in 77. In 30 patients, the extension was proximal to the origin of the left carotid artery (radically extended end-to-end anastomosis). Other procedures were used in 16 patients. Mortality (13 early and 12 late deaths) was related on multivariate analysis to the presence of an associated major heart defect, preoperative resuscitation, and direct postoperative gradient over the arch. This immediate postoperative gradient was significantly lower after both extended and radically extended end-to-end anastomosis if there was a hypoplastic isthmus, and after radically extended end-to-end anastomosis if the transverse arch was hypoplastic. Actuarial freedom from recoarctation at 4 years was 57% (confidence limits 28% to 78%) after subclavian flap angioplasty, 77% (confidence limits 60% to 87%) after end-to-end anastomosis, 83% (confidence limits 66% to 92%) after extended end-to-end anastomosis and 96% (confidence limits 77% to 100%) after radically extended end-to-end anastomosis. We conclude that the extended end-to-end anastomosis and radical end-to-end anastomosis appear to offer the best prognosis for all infants with coarctation. The technique can be applied successfully to almost all types of arch anomalies.

Age Factors↗

Experience with a make-it-yourself scalp extender with hooks.

BACKGROUND: Silicone scalp extenders have been shown to facilitate the process of scalp reduction surgery. OBJECTIVE: This report demonstrates how scalp extender devices can easily be made in the physician's office out of materials that are commercially available. METHODS: A scalp extender is made by bonding a narrow strip of Dacron-reinforced Duralastic silicone sheeting to each end of a long strip of plain Duralastic silicone sheeting. A stainless steel plate of hooks is then secured to each end of the extender. At the time of the first standard scalp reduction surgery, one extender device about 3.0 x 5.0 cm is placed in the subgaleal plane, in the transauricular direction, with hooks piercing the galea 1 cm caudad to the dense-in-quantity hair fringe margin. The circumferencial approach will accommodate the placement of a second extender device in the anterior-posterior direction to elevate the posterior hair fringe. To prevent adhesion of the galea to the periosteum around the devices, a sheet of plain silicone 15 x 20 cm is placed over the periosteum before the extenders are inserted. The extenders are replaced with shorter devices 3-4 weeks later. RESULTS: Usually the average width of bald scalp can be closed fringe to fringe in three operations as compared with five or six operations when using standard scalp reduction procedures. CONCLUSIONS: The scalp extender device described can be custom made in many different sizes. Its use has significantly changed the author's surgical treatment of pattern alopecia.

Alopecia↗

A comparison of conventional and disposable extended wear contact lenses.

The charts of 126 extended wear contact lens patients (65 disposable and 61 conventional extended wear lens users) were reviewed for subjective and objective contact lens problems. We found that the number of complication events per person per year of lens wear was higher for conventional extended lens wearers than for disposable extended wear patients. There was a trend in both groups toward decreased numbers of complications in the second and third years of lens wear. Within each group, we also examined first time lens wearers and patients with a history of contact lens related complications. Both of these subgroups also fared better with disposable lenses, with fewer complication events per year and fewer complications overall. Of the 20 individual signs and symptoms that were analyzed, 13 occurred more frequently among conventional extended wear lens users; this difference was statistically significant for itching, burning and dryness, poor vision, foreign body sensation, torn and lost lenses, giant papillary conjunctivitis, mucus, and superficial punctate keratopathy. Five signs were more frequent among the disposable extended wear lens users, but the difference was not statistically significant. There were no cases of ulcerative keratitis in either group. The average wearing time was 11.2 +/- 5.9 days for conventional extended wear patients and 6.7 +/- 2.3 days in the disposable group. The difference in wearing time between the two groups may have been a factor in the higher complication rate among conventional extended wear lens patients.

Adolescent↗

Corneal stress test for extended wear.

PURPOSE: The relationship between overnight contact lens wear and infectious corneal ulcers has been widely reported. Corneal hypoxia during sleep with contact lenses is believed to be an important predisposing factor for infectious corneal ulcers. We designed a provocative test to identify corneas at risk for significant oxygen deprivation during extended wear. METHODS: We measured the baseline corneal thickness of 161 eyes (82 patients). Extended wear soft lenses were then fit and pachymetry was repeated after 1 night of extended wear. Patients were instructed to continue extended wear for 6 additional nights. RESULTS: Seventeen of 161 eyes could not continue extended wear for the full 7 nights. All failures were due to corneal decompensation. There were no failures in the group of 133 eyes with corneal swelling of 5% or less after 1 day of extended wear. All four eyes with swelling greater than 13% failed, while the failure rates for the 24 eyes with swelling between 6-13% was about 50%. The thicker hyperopic lenses produced the majority of failures. CONCLUSIONS: Measuring corneal swelling after 1 night of extended wear may identify those corneas at risk for significant oxygen deprivation during overnight contact lens wear. Corneal swelling of 5% or less seems to indicate that the cornea can tolerate 7 nights of extended wear (significant to P < 0.001).

Circadian Rhythm↗