Business models and provider satisfaction in in vitro fertilization centers in the USA.

PURPOSE: The number of in vitro fertilization (IVF) cycles is increasing and the majority of patients undergoing IVF pay out of pocket. Reproductive endocrinology and infertility practitioners employ different business models to help create financial pathways for patients needing IVF but details regarding the different types of business models being used and physician satisfaction with those models have not been described previously. METHODS: A cross-sectional survey was sent to members of the Society of Reproductive Endocrinology and Infertility. The survey included 30 questions designed to assess demographics, practice patterns, and business models utilized. RESULTS: A total of 222/736 (30%) physicians responded to the survey. The majority of physicians offer a-la-carte (67%), bundled services (69%), grants (57%), and cost/risk-sharing (50%). The majority answered that the single ideal business model is bundled services (53%). There was no significant association between financial package offered and region of practice or state-mandated insurance. The largest barrier to care reported was cost with or without state-mandated coverage (94% and 99%, respectively). The majority of practices are satisfied with their business model (75%). Higher physician satisfaction was associated with private practice [69% vs 27%; OR (95%CI) = 3.8 (1.7, 8.6)], male gender [59% vs 30%; OR = 2.4 (1.1, 5.4)], and offering bundled services [83% vs 59%; OR = 2.8 (1.2, 6.7)]. CONCLUSIONS: Physicians utilize a variety of business models and most are satisfied with their current model. Cost is the major barrier to care in states with and without mandated coverage.

An epidemiological study of A. cantonensis in Jamaica subsequent to an outbreak of human cases of eosinophilic meningitis in 2000.

The infection status of angiostrongylosis in Jamaica was assessed in wild rats and molluscs in the 5 years following the major outbreak of eosinophilic meningitis (EM) in 2000. Parasitological analyses of 297 Rattus rattus and 140 Rattus norvegicus, and 777 terrestrial molluscs from all 14 Parishes on the island revealed Angiostrongylus cantonensis in 32·0% of the rats and in 12·5% of the molluscs. Multivariate analyses confirmed that A. cantonensis occurred significantly more frequently in R. rattus (Odds Ratio [OR] = 1·76), while mean infection intensity in R. rattus was also significantly higher (16·8) than R. norvegicus (11·3) (Mann-Whitney U-test: P = 0·01). Third-stage larvae of A. cantonensis were detected in 29% of 86 Pleurodonte spp.; in 20% of five Poteria spp.; in 18·7% of 369 Thelidomus asper; in 11% of 18 Sagda spp.; and in 6% of 24 veronicellid slugs. Most rodent infections occurred in Northeastern Jamaica (OR = 11·66), a region where infected molluscs were also abundant. Given the prevalence of A. cantonensis infection in rats has significantly increased since the 2000 outbreak, and that a survey of human infections revealed at least ten autochthonous cases in the last 15 years, angiostrongylosis persists as an important zoonosis in Jamaica.

Gastrointestinal helminths of wild hogs and their potential livestock and public health significance in Jamaica.

An investigation into the potential for transmission of gastrointestinal helminths from wild hogs to livestock and humans was prompted by concerns of recreational wild-hog hunting in the Caribbean region and the recent practice, by livestock farmers in Jamaica, of co-rearing wild and domesticated swine. Thirty-one wild hogs from the Hellshire Hills, a dry limestone forest in southern Jamaica, were necropsied during the period June 2004 to August 2006. Thirteen of the captured animals were male and 18 female. Four species of adult helminths were recovered from the gastrointestinal tracts of the wild hogs: Hyostrongylus rubidus (77%), Globocephalus urosubulatus (48%), Oesophagostomum dentatum (42%) and Macroacanthorhynchus hirudinaceus (77%). Two (6.2%), ten (32.2%) and 18 (58.0%) hogs harboured one, two and three species of helminths, respectively. Mean infection intensities varied from 8.1 for M. hirudinaceus, to 115.5 for O. dentatum. There was no association between any of the recovered helminths and sex of the host; however, a multivariate analysis indicated a positive association between the prevalence of G. urosubulatus and host age (odds ratio (OR) = 6.517). Domesticated hogs co-reared with wild hogs are potentially at risk of infection with all four helminths, while wild-hog hunters and pig farmers may be exposed to M. hirudinaceus.

Eryngial (trans-2-dodecenal), a bioactive compound from Eryngium foetidum: its identification, chemical isolation, characterization and comparison with ivermectin in vitro.

Methanol-water (4:1, v/v) crude extracts (50 mg mL(-1)) of 25 Jamaican medicinal plants were screened in vitro for anthelmintic activity using infective third-stage larvae of Strongyloides stercoralis. The most effective extract was further chemically scrutinized to isolate and identify the source of the bioactivity, and the efficacy of this compound was compared with ivermectin. Eosin exclusion (0.1 mg mL(-1)) served as the indicator of mortality in all bioassays. A crude extract of Eryngium foetidum (Apiaceae) was significantly (Probit Analysis, P<0.05) more potent than the other plant extracts, taking 18.9 h to kill 50% (LT50) of the larvae. Further, the petrol extract of E. foetidum was significantly more effective (Probit Analysis, P<0.05) at killing the larvae (LT50, 4.7 h) than either its methanol-water or dichloromethane extract. The latter two effected less than 1% larval mortality after 120 h. With bioassay-driven column chromatography of the petrol extract, trans-2-dodecenal (eryngial) was identified and chemically isolated as the main anthelmintic compound in E. foetidum. There was a significant difference between the 24 h LD50 values (mm) of trans-2-dodecenal (0.461) and ivermectin (2.251) but there was none between the 48 h LD50 values (mm): trans-2-dodecenal (0.411) and ivermectin (0.499) in vitro.

Non-equilibrium phonon generation and detection in microstructure devices.

We demonstrate a method to excite locally a controllable, non-thermal distribution of acoustic phonon modes ranging from 0 to ~200 GHz in a silicon microstructure, by decay of excited quasiparticle states in an attached superconducting tunnel junction (STJ). The phonons transiting the structure ballistically are detected by a second STJ, allowing comparison of direct with indirect transport pathways. This method may be applied to study how different phonon modes contribute to the thermal conductivity of nanostructures.

Response of zooplankton and phytoplankton communities to creosote-impregnated Douglas fir pilings in freshwater microcosms.

Creosote has been used extensively as an industrial wood preservative for the protection of marine pilings, railway ties, and utility poles and is a common source of polycyclic aromatic hydrocarbons (PAHs) into aquatic environments. At present, there is little information by which to judge the potential for creosote leached from impregnated pilings to cause toxicity to biota in aquatic environments. The objective of the current study was to assess the effects of creosote on zooplankton and phytoplankton populations in freshwater microcosms in relation to changes in the concentration and composition of PAHs leached from creosote-impregnated Douglas fir pilings during an 83-day exposure period. The study consisted of single microcosms containing one half, one, two, three, four, and six treated pilings. Two microcosms that received untreated pilings were used as controls. The total surface area of pilings in each microcosm was normalized by adding the appropriate number of untreated pilings. Samples were collected periodically between -14 and 83 days pre- and postexposure to determine aqueous concentrations of 15 priority PAHs and to assess the response of zooplankton and phytoplankton communities. Plankton community response to creosote was analyzed using principle responses curves. Peak aqueous concentrations of sigmaPAH occurred at day 7, ranging from 7.3 to 97.3 microg/L. Zooplankton abundance decreased in all microcosms after introduction of the impregnated pilings, with the magnitude of response varying as a function of aqueous creosote concentration. Using inverse regression, a no-observed-effect concentration for the zooplankton community of 11.1 microg/L was estimated. In contrast, algal abundance and diversity increased in all treatments between 7 and 21 days and attained levels up to twice that in control microcosms. This trend most likely reflected decreased grazing pressure because of the decrease in zooplankton populations, but it may also have reflected growth stimulation resulting from exposure to various constituents within the creosote mixture. Our results indicate that creosote leached from impregnated pilings deployed under typical conditions (e.g., wharves) may cause transient toxicity to benthic or limnetic communities shortly after deployment, but this likely poses few long-term risks to aquatic freshwater plankton communities.

Response of zooplankton communities to liquid creosote in freshwater microcosms.

In this study, the response of zooplankton communities to single applications of liquid creosote in model aquatic ecosystems (microcosms) was evaluated. Liquid creosote was applied to 14 microcosms at concentrations ranging from 0.06 to 109 mg/L. Two microcosms served as controls. Zooplankton samples were collected from each microcosm on days 7 and 1 before treatment and on days 2, 5, 7, 14, 21, 28, 43, 55, and 83 following treatment. Temporal changes (response-recovery) in composition of the zooplankton community were assessed using principal response curves (PRC). Creosote induced a rapid, concentration-dependent reduction in zooplankton abundance and number of taxa, with maximum response (50-100% reduction in population densities) occurring between 5 and 7 d after treatment. Taxa that dominated at the time of treatment experienced the greatest impact, as indicated by large, positive species weight values (> 1) from the PRC analysis. Many of these taxa recovered to pretreatment or control levels during the posttreatment period, with the degree and duration of recovery being strongly dependent on concentration. Creosote had little effect on species composition at less than 1.1 mg/L, because changes in the types and relative proportion of species contributed from Cladocera, Rotifera, and Copepoda were comparable to those observed in control microcosms. However, a significant shift in species composition was observed at concentrations greater than 1.1 mg/L; these microcosms were generally dominated by low numbers of rotifers, some of which had not been collected before treatment. Community-level effect concentrations (EC50s) were 44.6 and 46.6 micrograms/L at 5 and 7 d, respectively, based on nominal creosote. Corresponding no-effect concentrations were 13.9 and 5.6 micrograms/L. The results of this field study indicate that creosote may pose a significant risk to zooplankton communities at environmental concentrations potentially encountered during spills and/or leaching events.

Response of phytoplankton communities to liquid creosote in freshwater microcosms.

We assessed the response of phytoplankton communities in aquatic microcosms to single applications of liquid creosote. The creosote was applied to 14 microcosms at concentrations ranging from 0.06 to 109 mg/L. Two microcosms served as controls. Phytoplankton samples were collected from each microcosm one week and 1 d before treatment and at 7 and 21 d after treatment. Temporal changes (response-recovery) in phytoplankton community composition were assessed with principal response curves. Creosote had no direct toxic effect on the phytoplankton community based on total abundance and number of taxa. Population levels declined in all treatments between day -1 and day 7, but this trend mirrored a similar decline in the control microcosms. At both 7 and 21 d after treatment, population densities and number of taxa in most treatments exceeded those in the controls and exhibited a parabolic relationship relative to creosote concentration. This relationship was most pronounced at 21 d, at which time population densities and number of taxa at intermediate concentrations were up to twice those at low and high concentrations. This response pattern seems to represent an indirect response to impacts on zooplankton and a corresponding reduction in grazing pressure. In contrast, total algal biomass declined 52 to 97% relative to the controls at all but the lowest creosote concentration at 7 d. This apparent decline was due to a significant proliferation of the alga Closterium moniliforme in the controls and low creosote concentration. At 21 d, no difference was found in total biomass between treated and control microcosms. The results of this study suggest that creosote does not pose a significant direct risk to phytoplankton at concentrations likely to be encountered in most contaminated aquatic environments; however, stimulation of algal populations could occur in situations of long-term chronic exposure or spill events that remove predatory zooplankton populations.

Association of metformin and pregnancy in the polycystic ovary syndrome. A report of three cases.

BACKGROUND: Infertility is a common manifestation of the polycystic ovary syndrome (PCOS), a condition characterized by chronic anovulation, hyperinsulinemia and hyperandrogenism. Hyperinsulinemia leads to increased ovarian androgen production, resulting in follicular atresia and anovulation. Metformin, a medication that improves insulin sensitivity and decreases serum insulin levels, restores menstrual cyclicity and ovulatory function and may improve fertility rates in women with PCOS. We present three consecutive cases from our clinic that support this premise. CASES: Three patients were seen in the reproductive endocrinology clinic with documented PCOS, long-standing infertility and clinically diagnosed insulin resistance. The first patient had hyperandrogenic, insulin-resistant acanthosis nigricans syndrome and had been resistant to multiple courses of clomiphene citrate; the second exhibited hypertension, hyperlipidemia and glucose intolerance along with anovulation; and the third presented with poorly controlled type 2 diabetes and a desire to conceive. Each patient received metformin, which led to restoration of menstrual cyclicity and conception in all three cases. CONCLUSION: These three patients reflect the heterogeneous nature of PCOS, and treating their underlying insulin resistance with metformin resulted in pregnancy. These findings suggest that metformin may be a useful adjunct for treatment of infertility in patients with PCOS.

Development of brief stress management support groups for couples undergoing in vitro fertilization treatment.

OBJECTIVE: To develop and assess the efficacy of couples stress management groups offered concurrently with IVF treatment. DESIGN: Couples in IVF treatment were given the option of participating in a biweekly stress management group. SETTING: The IVF treatment clinic at Wilford Hall Medical Center, San Antonio, Texas. PATIENT(S): One or both members of 17 couples participated in the program in one of four group cycles. INTERVENTION(S): A cognitive behavioral treatment model was used to help couples process their feelings and cognitions about the impact of infertility on their life and explore their expectations about their future options for becoming parents. MAIN OUTCOME MEASURE(S): Couples were asked to anonymously evaluate the efficacy of the group after they had completed their IVF cycle. RESULT(S): Participants reported that the group helped them deal with the stress of infertility and that they valued the social bonds they formed with other group members. CONCLUSION(S): These data suggest that brief focused group therapy, offered while couples are undergoing IVF, is an effective way to help people deal with the stress of infertility treatment.

A military health care facility has high in vitro fertilization success rates.

The purpose of this study is to describe in vitro fertilization (IVF) success rates at our military health care facility. A retrospective analysis was performed for all IVF cycles initiated at Wilford Hall Medical Center from January 1, 1996, to December 31, 1998. During this period, there were 214 IVF cycles initiated with gonadotropin therapy. The overall pregnancy rate, with an intrauterine pregnancy identified by transvaginal ultrasonography, was 45.3%. IVF services can be provided at a military health care facility with a high rate of success.

Differences in virulence between two Candida albicans strains in experimental keratitis.

PURPOSE: To study the differences in disease caused by two wild-type strains of Candida albicans in a model of contact lens-facilitated keratitis in rabbits. METHODS: Two strains, SC5314 and VE175, were examined. Standardized inocula were placed on the debrided corneal surface of one eye in Dutch belted rabbits and covered with a contact lens. A temporary tarsorrhaphy was opened after 24 hours with removal of the contact lens. Six days later, corneas were photographed and animals killed. Corneas were bisected with one half for quantitative isolate recovery and the other for stromal penetration by hyphae. RESULTS: Strain SC5314 was significantly more virulent. The mean hyphal penetration into the cornea was 24.4% +/- 8.5% of the corneal thickness, and in three of six corneas hyphae penetrated through the entire cornea. In contrast, for VE175, the mean hyphal penetration was 2.6% +/- 1.2%. The difference between these two strains was statistically significant (P = 0.0297). Hyphae did not penetrate into the deep layers of the cornea in any of the six rabbits infected with VE175. The grading of clinical disease was consistent with histology, in that strain SC5314 caused more severe infection than VE175 and the difference was statistically significant (P = 0.0048). There was no difference in isolate recovery. CONCLUSIONS: Wild-type strains of C. albicans can differ significantly in virulence as measured by depth of fungal invasion into corneas and clinical evaluation of infection. Further characterization of the intrinsic genetic differences between such strains may help identify factors responsible for fungal virulence.

Seroepidemiology of Helicobacter pylori infection in a Jamiaican community

We researched epidemiologic associations between environmental and demographic factors and prevalence of Helicobacter pylori infection in a suburban Jamaican community. Using a clustered sampling technique, 22 domestic yards enclosing 60 separate households were randomly selected from a local community. All household members (n=346) were invited to participate following informed consent; the overall compliance rate was 58.9 percent. A commercial enzyme immunoassay (HM-CAP) was used to detect IgG antibodies raised against H. pylori. Environmental and demographic information was obtained by questionnaire. The seroprevalence of H. pylori was 69.9 percent (n=202). Analysis of the independent variables revealed three major components. Component 1 described, collectively, good personal hygiene and sanitation, indoor water supply and absence of straying animals in the peridomestic area; Component 2 included older age, good personal hygiene and large yard size; Component 3 the presence of domestic animals (cats and dogs) and, again large yard size. These three complexes explained 42.2 percent of the variability in the data set. Logistic regression showed that Components 2 and 3 were independently associated with H. pylori seropositivity, indicating that a combination of demographic environmental and zoonotic factors is involved in the spread of H. pylori infections at the tropical community level (AU)

Contact lens-induced infection--a new model of Candida albicans keratitis.

PURPOSE: A model of experimental keratomycosis was established that mimics human disease in which the only fungi present are those that are actively growing within the cornea. METHODS: Dutch-belted rabbits received a subconjunctival injection of triamcinolone acetonide to one eye. One day later the epithelium was removed from the central cornea and a standardized inoculum of Candida albicans blastoconidia was placed on the corneal surface and covered with a contact lens. The lids were closed with a lateral tarsorrhaphy. After 24 hours, the lid sutures and contact lens were removed. Five days later the animals were killed, and their corneas were subjected to separate isolate recovery and histology studies. A group of similarly infected rabbits without corticosteroid injection served as controls. RESULTS: Both groups developed invasive corneal disease. Although isolate recovery was not significantly different from corticosteroid-treated rabbits compared with controls, fungal biomass was increased. Hyphal invasion was limited to the anterior cornea in control eyes, but penetrated deep stroma in most of the corticosteroid-treated rabbits. CONCLUSIONS: Invasive corneal disease can be established with a surface inoculum. Corticosteroid administration increased corneal penetration of hyphae. Quantitative isolate recovery is not a reliable measure of the fungal load within the cornea.

Seroepidemiology of Helicobacter pylori infection in a Jamaican community.

We researched epidemiologic associations between environmental and demographic factors and prevalence of Helicobacter pylori infection in a suburban Jamaican community. Using a clustered sampling technique, 22 domestic yards enclosing 60 separate households were randomly selected from a local community. All household members (n = 346) were invited to participate following informed consent; the overall compliance rate was 58.9%. A commercial enzyme immunoassay (HMáCAP) was used to detect IgG antibodies raised against H. pylori. Environmental and demographic information was obtained by questionnaire. The seroprevalence of H. pylori was 69.9% (n = 202). Analysis of the independent variables revealed three major components: Component 1 described, collectively, good personal hygiene and sanitation, indoor water supply and absence of straying animals in the peridomestic area; Component 2 included older age, good personal hygiene and large yard size; Component 3 the presence of domestic animals (cats and dogs) and, again, large yard size. These three complexes explained 42.2% of the variability in the data set. Logistic regression showed that Components 2 and 3 were independently associated with H. pylori seropositivity, indicating that a combination of demographic, environmental and zoonotic factors is involved in the spread of H. pylori infections at the tropical community level.

DNA cytometry and chromosome 9 aberrations by fluorescence in situ hybridization of irrigation specimens from bladder cancer patients.

OBJECTIVES: To determine the sensitivity and specificity of combining fluorescence in situ hybridization (FISH) measurement of chromosome 9 and DNA cytometry of bladder irrigation specimens in the detection of bladder cancer. METHODS: Bladder irrigation specimens were obtained from 37 normal control patients and 317 bladder cancer patients during cystoscopic examinations. Bladder cancer patients were sampled in the absence of observable tumor (256 specimens) and concurrently with tumor (204 specimens). Chromosome 9 copy number was determined on a cellular basis by FISH, and cellular DNA content was determined by Feulgen DNA staining and image cytometry. RESULTS: Sensitivity of chromosome 9 FISH was 42% for all tumors and was not correlated to transitional cell carcinoma tumor grade, while the sensitivity of DNA cytometry was 55% and improved with increasing grade from 38% for grade 1 to 90% for grade 3 tumors. The results of FISH and DNA cytometry were combined, resulting in specificity of 92% and sensitivity of 69% for grade 1, 76% for grade 2, and 97% for grade 3 tumors. CONCLUSIONS: The lack of increase with grade in the percentage of positive specimens by FISH supports the hypothesis that chromosome 9 aberrations are critical events in bladder tumorigenesis for many patients. These data demonstrate the presence of cells in irrigation specimens with specific genomic lesions of chromosome 9 and DNA content. Combining FISH on chromosome 9 and DNA cytometry provides an increase in sensitivity to transitional cell carcinoma over either test alone.

Humoral responses in human strongyloidiasis: correlations with infection chronicity.

Strongyloides stercoralis L3-specific antibody isotype responses amongst individuals with known long-standing (28-46 years) infection were compared with those of 'young' (6-29 years of age) and 'old' (30-80 years of age) infected individuals from an endemic Jamaican population. Characterization of age-dependent isotype patterns in the endemic community showed that immunoglobulin (Ig) G1 responses were significantly inversely correlated with age. Additionally, a trend towards lower IgE levels in the older age group was observed. Comparison with responses amongst known chronically infected individuals showed that IgG1 and IgE levels were similar to those of the 'old' endemic group, but were significantly lower than those of the 'young' group. In contrast, IgA levels were similar in both endemic groups, but were elevated in chronically infected individuals. IgG4 levels were similar in all groups studied. These findings suggest that age correlates with infection chronicity in communities endemic for S. stercoralis, and that individuals acquire infection early in their lives and remain infected into adulthood. Early and sustained upregulation of IgG4 may facilitate the establishment of infection and, in combination with developing IgE hyporesponsiveness, may promote chronic asymptomatic strongyloidiasis. Conversely, upregulated IgA may be involved in controlling chronic infection levels which are reflected in reduced IgG1 production.

Short report: long-term serum antibody isotype responses to Strongyloides stercoralis filariform antigens in eight patients treated with ivermectin.

The enzyme-linked immunosorbant assay was used to investigate long-term changes in serum immunoglobulin G1 (IgG1), IgG4, IgE, and IgA against Strongyloides stercoralis phosphate-buffered saline-soluble filariform larval antigens in eight Jamaican patients treated with ivermectin. Patients were followed for periods of between 170 and 542 days. Based on repeated formalin-ether concentration and agar plate culture, all patients were found to be uninfected up to 18 months following chemotherapy. Generally, all antibody isotype levels decreased following treatment, although there was considerable heterogeneity among patients. In a single patient with hyperinfection, the decrease in IgG4 was marginal and may represent a treatment failure. Reduction in serum antibody isotype responses to S. stercoralis following treatment may be used to assess the effectiveness of ivermectin in treating endemic strongyloidiasis.