Access to Electronic Personal Health Records Among Patients With Multiple Chronic Conditions: A Secondary Data Analysis

BACKGROUND

In the United States, national incentives for offering access to electronic personal health records (ePHRs) through electronic means are geared toward creating a culture of patient engagement. One group of patients who stand to benefit from online access to ePHRs is the growing population with multiple chronic conditions (MCC). However, little is known about the current availability and use of ePHRs and patient portals among those managing MCC.

OBJECTIVE

The aim was to determine the associations between number of chronic conditions and sociodemographic characteristics and usage of ePHRs, and to assess how the public's use of ePHRs varies across subpopulations, including those with MCC.

METHODS

This study used data collected from the 2014 Health Information National Trends Survey (HINTS), and assessed differences in use of ePHRs between those with and without MCC (N=3497) using multiple logistic regression techniques. Variables associated with health care systems (insurance status, having a regular provider) and patient-reported self-efficacy were included in the statistical models.

RESULTS

Those with MCC (n=1555) had significantly higher odds of accessing their records three or more times in the past year compared to those reporting no chronic conditions (n=1050; OR 2.46, 95% CI 1.37-4.45), but the overall percentage of those with MCC using ePHRs remained low (371 of 1529 item respondents, 25.63% weighted). No difference in odds of accessing their records was found between those reporting one chronic condition (n=892) and those reporting none (n=1050; OR 1.02, 95% CI 0.66-1.58). Significant differences in odds of accessing ePHRs were seen between income and age groups (P<.001 and P=.05, respectively), and by whether respondents had a regular provider (P=.03).

CONCLUSIONS

We conclude that ePHRs provide a unique opportunity to enhance MCC patient self-management, but additional effort is needed to ensure that these patients are able to access their ePHRs. An increase in availability of patient access to their ePHRs may provide an opportunity to increase patient engagement and support self-management for all patients and especially those with MCC.

Public use of electronic personal health information: Measuring progress of the Healthy People 2020 Objectives

Use of the internet for seeking and managing health information in the U.S., Europe, and emerging and developing nations is growing. Recent global trends indicate more interactive uses of the internet including online communication with providers. In the U.S., The Healthy People 2020 (HP2020) initiative was created by the Department of Health and Human Services to provide 10-year goals for improving the health of American citizens. Two goals of HP2020 were to increase the proportion of individuals who use the Internet to keep track of their personal health information (PHI) online and to increase the proportion of individuals who use the internet to communicate with their healthcare provider. In the present study, we use data from the seven administrations of the Health Information National Trends Survey (HINTS) to assess progress towards these goals. These data were analyzed using descriptive, bivariate, and logistic regression analytic techniques. Results of this study suggested that the HP2020 target of having 15.7% of individuals manage their PHI online by 2020 has already been exceeded (28.1%); similarly, the goal for proportion of individuals communicating with their provider using the internet (15.0%) was exceeded by 2014 (29.7%). While progress towards these goals was positive in all sociodemographic groups for both goals, differences in the rate of progress were seen by gender, race/ethnicity, income, and education, but not by age group. The rapidly increasing proportion of individuals globally who use the internet to manage their health information provides unique opportunities for patient-centered health information technology interventions.

Differences in Access to and Use of Electronic Personal Health Information Between Rural and Urban Residents in the United States

PURPOSE

The increase in use of health information technologies (HIT) presents new opportunities for patient engagement and self-management. Patients in rural areas stand to benefit especially from increased access to health care tools and electronic communication with providers. We assessed the adoption of 4 HIT tools over time by rural or urban residency.

METHODS

Analyses were conducted using data from 7 iterations of the National Cancer Institute's Health Information National Trends Survey (HINTS; 2003-2014). Rural/urban residency was based on the USDA's 2003 Rural-Urban Continuum Codes. Outcomes of interest included managing personal health information online; whether providers maintain electronic health records (EHRs); e-mailing health care providers; and purchasing medicine online. Bivariate analyses and logistic regression were used to assess relationships between geography and outcomes, controlling for sociodemographic characteristics.

FINDINGS

In total, 6,043 (17.6%, weighted) of the 33,749 respondents across the 7 administrations of HINTS lived in rural areas. Rural participants were less likely to report regular access to Internet (OR = 0.70, 95% CI = 0.61-0.80). Rural respondents were neither more nor less likely to report that their health care providers maintained EHRs than were urban respondents; however, they had decreased odds of managing personal health information online (OR = 0.59, 95% CI = 0.40-0.78) and e-mailing health care providers (OR = 0.62, 95% CI = 0.49-0.77).

CONCLUSIONS

The digital divide between rural and urban residents extends to HIT. Additional investigation is needed to determine whether the decreased use of HIT may be due to lack of Internet connectivity or awareness of these tools.

The Health Information National Trends Survey (HINTS): A Resource for Consumer Engagement and Health Communication Research

The contemporary healthcare system can help improve health literacy outcomes in two ways: first, by nurturing the skills and motivations needed for patients to be actively engaged in their own health and healthcare decisions; and, second, by creating a prepared and proactive healthcare system that adapts to patients' capacities and needs in efficacious ways. In 2001, the National Cancer Institute launched the Health Information National Trends Survey (HINTS) as a way for researchers and planners to understand how the public is interacting with a rapidly changing health information environment. Original iterations of the HINTS national probability sampling strategies took place on a biennial basis, but in subsequent years the protocol moved to a yearly administration. This yields a rich resource of cross-sectional, national surveillance data to evaluate for trends across and within vulnerable populations. Sixteen studies are presented from the published literature to illustrate how HINTS data were used to explore constructs of direct interest to health literacy researchers. Suggestions are given for how this ongoing public surveillance mechanism can be used: (a) to provide a sentinel view of how the public is interacting with information in the environment to address their health needs; (b) to generate research questions and hypotheses for further exploration using complementary methodologies; and

Progress on Broadband Access to the Internet and Use of Mobile Devices in the United States

Healthy People 2020 (HP2020) aims to improve population health outcomes through several objectives, including health communication and health information technology. We used 7 administrations of the Health Information National Trends Survey to examine HP2020 goals toward access to the Internet through broadband and mobile devices (N = 34 080). We conducted descriptive analyses and obtained predicted marginals, also known as model-adjusted risks, to estimate the association between demographic characteristics and use of mobile devices. The HP2020 target (7.7% of the US population) for accessing the Internet through a cellular network was surpassed in 2014 (59.7%), but the HP2020 target (83.2%) for broadband access fell short (63.8%). Sex and age were associated with accessing the Internet through a cellular network throughout the years (Wald F test, P <.05). The increase in the percentage of people accessing the Internet through mobile devices presents an opportunity for technology-based health interventions that should be explored.

The Value of Systematic Reviews in Estimating the Cost and Barriers to Translation in Tissue Engineering

Little quantitative data exist concerning barriers that impede translation from bench to bedside. We systematically reviewed synthetic or biosynthetic polymer nerve scaffolds for peripheral nerve repair to study a defined research area that is beyond the discovery phase and has potential for clinical application. Using electronic and manual search methods, we identified published English language articles, where scaffolds were tested in preclinical animal models. A systematic review of these 416 reports estimated all costs related to the use of animals, surgery, and evaluation methods. The research studied 17 different nerves in eight animal species, with use of 65 evaluation methods at an estimated cost of $61,264,910 for the preclinical studies. A total of 127 surveys were sent to authors, of whom 12 could not be accessed electronically and 45 (39%) responded. Major causes for failure to translate included lack of a commercial partner, insufficient financial resources, a research program not involved in translation, and lack of expertise in regulatory affairs. This review emphasizes the urgent need for standardization of preclinical models and the need to establish better collaboration between laboratory investigators, clinicians, and the companies involved in commercialization. It identifies important areas for education of future investigators in the process of translation from discovery to improved health such as those funded by the National Institutes of Health Clinical and Translational Science Awards.

Common medications and prostate cancer mortality: a review

PURPOSE

Most prostate cancer patients also have comorbidities that are treated with both prescription and nonprescription medications; furthermore, many use dietary supplements. We assess their association with prognosis after prostate cancer diagnosis, and we discuss methodological challenges and clinical implications.

METHODS

We reviewed high-quality observational studies investigating the association of commonly used medications and supplements with prostate cancer-specific mortality.

RESULTS

There is preliminary evidence that statins and metformin use may be associated with lower risk of cancer-specific mortality after prostate cancer diagnosis; conversely, high calcium and multivitamin supplementation may be associated with increased risk. Evidence is inconclusive for nonsteroidal anti-inflammatory drugs, acetylsalicylic acid (aspirin), insulin, antihypertensives such as angiotensin-converting enzyme inhibitors and beta-blockers, digoxin, and warfarin. Common limitations of the internal validity of studies examined include unmeasured confounding and confounding by indication, competing risks, and time-related biases such as immortal time bias. The majority of studies focused on Caucasian men with specific comorbidities, while heterogeneity among patients and tumors was mostly not assessed.

CONCLUSIONS

Commonly prescribed medications and over-the-counter supplements may influence prognosis among prostate cancer patients. Further well-designed pharmacoepidemiologic studies and randomized controlled trials of selected medications in appropriate patient groups are necessary before these drugs can bear new indications for prostate cancer treatment. We discuss considerations when deciding about use of these drugs in clinical practice at the present time.

The association of copy number variation and percent mammographic density

Background

Percent mammographic density (PD) estimates the proportion of stromal, fat, and epithelial breast tissues on the mammogram image. Adjusted for age and body mass index (BMI), PD is one of the strongest risk factors for breast cancer [1]. Inherited factors are hypothesized to explain between 30 and 60% of the variance in this trait [2–5]. However, previously identified common genetic variants account for less than 6% of the variance in PD, leaving much of the genetic contribution to this trait unexplained. We performed the first study to examine whether germline copy number variation (CNV) are associated with PD. Two genome-wide association studies (GWAS) of percent density conducted on the Illumina 660W-Quad were used to identify and replicate the association between candidate CNVs and PD: the Minnesota Breast Cancer Family Study (MBCFS) and controls from the Mayo Venous Thromboembolism (Mayo VTE) Case–Control Study, with 585 and 328 women, respectively. Linear models were utilized to examine the association of each probe with PD, adjusted for age, menopausal status and BMI. Segmentation was subsequently performed on the probe-level test statistics to identify candidate CNV regions that were associated with PD.

Results

Sixty-one probes from five chromosomal regions [3q26.1 (2 regions), 8q24.22, 11p15.3, and 17q22] were significantly associated with PD in MBCFS (p-values <0.0001). A CNV at 3q26.1 showed the greatest evidence for association with PD; a region without any known SNPs. Conversely, the CNV at 17q22 was largely due to the association between SNPs and PD in the region. SNPs in the 8q24.22 region have been shown to be associated with risk of many cancers; however, SNPs in this region were not responsible for the observed CNV association. While we were unable to replicate the associations with PD, two of the five CNVs (3q26.1 and 11p15.3) were also observed in the Mayo VTE controls.

Conclusions

CNVs may help to explain some of the variability in PD that is currently unexplained by SNPs. While we were able to replicate the existence of two CNVs across the two GWAS studies, we were unable to replicate the associations with PD. Even so, the proximity of the identified CNV regions to loci known to be associated with breast cancer risk suggests further investigation and potentially shared genetic mechanisms underlying the PD and breast cancer association.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1212-y) contains supplementary material, which is available to authorized users.

Clinical Course and Prognosis of Non-Secretory Multiple Myeloma

OBJECTIVE

To determine the prognosis of patients with non-secretory myeloma. Methods: We studied 124 patients diagnosed with multiple myeloma who had no monoclonal protein detected on serum and urine immunofixation at diagnosis and on all subsequent follow up testing (non-secretory myeloma). The overall survival (OS) of patients with non-secretory myeloma was compared with 7075 patients with typical myeloma seen during the same time period in whom a monoclonal protein was detected at the time of diagnosis.

RESULTS

One hundred and twenty four patients met criteria for non-secretory multiple myeloma. The median follow-up was 102 months (range, 1-204 months). The median progression free survival with initial therapy was 28.6 months, and the median OS was 49.3 months. There was a significant improvement in OS since 2001; median survival 99.2 versus 43.8 months (prior to 2001) versus 99.2 months (2001-2012), P<0.001. OS was superior in patients with a normal baseline FLC ratio (n=10) compared to patients with an abnormal ratio (n=19), medians not reached in both groups. Prior to 2001, OS was similar in non-secretory myeloma (n=86) and secretory myeloma (n=4011), median 3.6 versus 3.5 years, respectively, P=0.63. However, among patients diagnosed between 2001-2012, OS was superior in non-secretory myeloma (n=36) compared to secretory myeloma (n=2942), median 8.3 versus 5.4 years, respectively, P=0.03.

CONCLUSIONS

Non-secretory myeloma is an uncommon subtype of multiple myeloma. In the last decade, there has been an improvement in the survival of non-secretory myeloma, and appears superior to secretory myeloma. This article is protected by copyright. All rights reserved.

Clinical course and prognosis of non-secretory multiple myeloma

OBJECTIVE

To determine the prognosis of patients with non-secretory myeloma.

METHODS

We studied 124 patients diagnosed with multiple myeloma who had no monoclonal protein detected on serum and urine immunofixation at diagnosis and on all subsequent follow-up testing (non-secretory myeloma). The overall survival (OS) of patients with non-secretory myeloma was compared with 6953 patients with typical myeloma seen during the same time period in whom a monoclonal protein was detected at the time of diagnosis.

RESULTS

One hundred and twenty-four patients met criteria for non-secretory multiple myeloma. The median follow-up was 102 months (range, 1-204 months). The median progression-free survival with initial therapy was 28.6 months, and the median OS was 49.3 months. There was a significant improvement in OS since 2001; median survival 43.8 months (prior to 2001) vs. 99.2 months (2001-2012), P < 0.001. OS was superior in patients with a normal baseline FLC ratio (n = 10) compared to patients with an abnormal ratio (n = 19), medians not reached in both groups. Prior to 2001, OS was similar in non-secretory myeloma (n = 86) and secretory myeloma (n = 4011), median 3.6 vs. 3.5 yr, respectively, P = 0.63. However, among patients diagnosed between 2001 and 2012, OS was superior in non-secretory myeloma (n = 36) compared to secretory myeloma (n = 2942), median 8.3 vs. 5.4 yr, respectively, P = 0.03.

CONCLUSIONS

Non-secretory myeloma is an uncommon subtype of multiple myeloma. In the last decade, there has been an improvement in the survival of non-secretory myeloma and appears superior to secretory myeloma.

Responsiveness of cytogenetically discrete human myeloma cell lines to lenalidomide: lack of correlation with cereblon and interferon regulatory factor 4 expression levels

The introduction of novel immunomodulatory drugs (IMiDs) has dramatically improved the survival of patients with multiple myeloma (MM). While it has been shown that patients with specific cytogenetic subtypes, namely t(4;14), have the best outcomes when treated with bortezomib-based regimens, the relationship between cytogenetic subtypes and response to IMiDs remains unclear. Using DNA synthesis assays, we investigated the relationship between cytogenetic subtype and lenalidomide response in a representative panel of human myeloma cell lines (HMCLs). We examined HMCL protein expression levels of the lenalidomide target cereblon (CRBN) and its downstream target interferon regulatory factor-4 (IRF4), which have previously been shown to be predictive of lenalidomide response in HMCLs. Our results reveal that lenalidomide response did not correlate with specific cytogenetic translocations. There were distinct groups of lenalidomide-responsive and non-responsive HMCLs, as defined by inhibition of cellular proliferation; notably, all of the hyperdiploid HMCLs fell into the latter category. Repeated dosing of lenalidomide significantly lowered the IC50 of the responsive HMCL ALMC-1 (IC50 = 2.6 μm vs. 0.005 μm, P < 0.0001), but did not have an effect on the IC50 of the non-responsive DP-6 HMCL (P > 0.05). Moreover, no association was found between lenalidomide responsiveness and CRBN and IRF4 expression. Our data indicate that lenalidomide sensitivity is independent of cytogenetic subtype in HMCLs. While CRBN and IRF4 have been shown to be associated with response to lenalidomide in patients, these findings do not translate back to HMCLs, which could be attributable to factors present in the bone marrow microenvironment.

Rituximab for non-Hodgkin's lymphoma: a story of rapid success in translation

Translational stories range from straightforward to complex. In this commentary, the story of the rapid and successful translation of rituximab therapy for the treatment of non-Hodgkin's lymphoma (NHL) is examined. Development of this monoclonal antibody therapy began in the late 1980s. In 1994, rituximab received its first approval for the treatment of NHL by the United States Food and Drug Administration (FDA). Rituximab has since been approved for additional indications and has transformed medical practice. However, the social and political implications of these rapid successes are only beginning to become clear. In this commentary, key events in the rapid translation of rituximab from the bench to bedside are highlighted and placed into this historical framework. To accomplish this, the story of rituximab is divided into the following six topics, which we believe to be widely applicable to case studies of translation: (1) underlying disease, (2) key basic science, (3) key clinical studies in translation, (4) FDA approval process, (5) changes to medical practice, and (6) the social and political influences on translation.

Relationship between initial clinical presentation and the molecular cytogenetic classification of myeloma

Multiple myeloma (MM) consists of several distinct cytogenetic subtypes, and we hypothesized that each subtype may have a unique mode of initial presentation and end-organ damage. We studied 484 patients with newly diagnosed MM to determine the relationship between specific myeloma-defining event (MDE) and the cytogenetic subtype. Patients were divided into four non-overlapping groups based on the MDE at diagnosis: isolated renal failure, isolated anemia, isolated lytic bone disease or a combination (mixed). MM with translocations without trisomies accounted for 30% of all patients, but accounted for 50% of patients with renal failure. Specifically, the t(14;16) translocation accounted for only 5% of all MM patients, but was present in 13.5% of patients with renal failure as MDE. Among patients with t(14;16), 25% presented with renal failure only as MDE. Patients with isolated renal failure as MDE had significantly poorer survival compared with all other groups, whereas patients with bone disease as MDE had the best outcome (P<0.001). Our findings support the hypothesis that in addition to prognostic differences, there is significant heterogeneity in clinical presentation associated with the cytogenetic subtype, suggesting that MM encompasses a group of cytogenetically and phenotypically distinct disorders rather than a single entity.

Differences in the distribution of cytogenetic subtypes between multiple myeloma patients with and without a family history of monoclonal gammopathy and multiple myeloma

We previously reported an increased risk of monoclonal gammopathy of undetermined significance (MGUS) in first-degree relatives of MGUS and multiple myeloma patients. Here, we examine whether primary cytogenetic categories of myeloma differ between patients with and without a family history of MGUS or myeloma. We studied 201 myeloma patients with available data on family history and molecular cytogenetic classification. Myeloma with trisomies was more common in probands who had an affected first-degree relative with MGUS or myeloma compared with those without a family history (46.9% vs. 33.5%, P = 0.125); however, the difference was not statistically significant. Additional studies on the cytogenetic types of myeloma associated with familial tendency are needed.

Pathways of translation: deep brain stimulation

Electrical stimulation of the brain has a 2000 year history. Deep brain stimulation (DBS), one form of neurostimulation, is a functional neurosurgical approach in which a high-frequency electrical current stimulates targeted brain structures for therapeutic benefit. It is an effective treatment for certain neuropathologic movement disorders and an emerging therapy for psychiatric conditions and epilepsy. Its translational journey did not follow the typical bench-to-bedside path, but rather reversed the process. The shift from ancient and medieval folkloric remedy to accepted medical practice began with independent discoveries about electricity during the 19th century and was fostered by technological advances of the 20th. In this paper, we review that journey and discuss how the quest to expand its applications and improve outcomes is taking DBS from the bedside back to the bench.

Abstract 5485: Increased prevalence of light chain monoclonal gammopathy of undetermined significance (MGUS) in first-degree relatives of individuals with multiple myeloma or MGUS

Monoclonal gammopathy of undetermined significance (MGUS) is a precursor to multiple myeloma and related diseases. The majority of MGUS cases are characterized by the expression of immunoglobulin heavy chain (IgH); however, approximately one-fifth of MGUS cases do not present with IgH expression. These individuals have light chain MGUS (LC-MGUS), a precursor to light-chain MM (LC-MM). LC-MGUS is characterized by an absence of IgH and an abnormal free light chain ratio (FLC-R), indicating excessive expression of either κ or ≤ free light chains. LC-MGUS has a prevalence of 0.8% in the general population over the age of 50, as compared with a prevalence of 3.2% for heavy-chain MGUS (HC-MGUS) (Dispenzieri, 2010). There is currently little understanding of the association between family history of HC-MGUS or multiple myeloma (MM) and LC-MGUS. We investigated whether the prevalence of LC-MGUS is elevated in first-degree relatives of patients with either HC-MGUS or MM. HC-MGUS probands expressed IgH and were recruited through a population-based study of Olmsted County residents; MM probands consisted of both HC-MM and LC-MM and were recruited through the Mayo Clinic Hematology practice. Serum samples were collected from first-degree relatives of probands older than 40 years of age and subjected to electrophoresis, immunofixation, and free light chain assay. Prevalence of LC-MGUS was calculated in all first-degree relatives combined, and in relatives from both HC-MGUS and MM families separately. We compared the prevalence in family members to that in a well-defined Olmsted County, MN cohort (Dispenzieri, 2010) of patients aged 50 and over. A total 911 relatives of 232 MM and 97 MGUS patients were studied. LC-MGUS was detected in 17/911 (1.9%) relatives, for an age- and sex-adjusted prevalence of 1.7% (95% CI, 0.9% to 2.6%). Prevalence among relatives of MM probands (age- and sex- adjusted rate 2.1%; 95% CI, 1.0% to 3.2%) was higher than among relatives of MGUS probands (age- and sex- adjusted rate 0.6%; 95% CI, 0.0%-1.6%). There was an increased risk of LC-MGUS in relatives compared to the reference population which was predominantly due to the increased risk among relatives of MM probands (risk ratio=3.4, 95% CI 2.0, 5.51) as opposed to relatives of MGUS probands (risk ratio=1.1, 95% CI, 0.3 to 4.5). Among MM probands, there was no significant difference between the prevalence increase in relatives of the 32 probands with LC-MM and that of the relatives of the 200 probands with HC-MM (3.8 vs 3.3, ratio=1.2, 95% CI: 0.3-5.1, p=0.85). We conclude that the prevalence of LC-MGUS is significantly higher among first degree family members of all MM probands compared to the general population.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5485. doi:1538-7445.AM2012-5485

Linking expression of FOXM1, CEP55 and HELLS to tumorigenesis in oropharyngeal squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

To investigate the relationship between the expression of FOXM1, CEP55, and HELLS in oropharyngeal squamous cell carcinoma to human papillomavirus (HPV), smoking, and tumor stage.

STUDY DESIGN

Retrospective cohort study.

METHODS

Transcriptome data were analyzed from matched tumor-normal samples taken from patients with oropharyngeal squamous cell carcinoma. Data were previously generated using deep-sequencing techniques (mRNA-Seq). Transcript levels of all three genes were validated using the NanoString nCounter system in a larger group of patients. Analyses were conducted to assess possible associations between expression levels and HPV infection status, smoking status, or tumor staging.

RESULTS

FOXM1, CEP55, and HELLS were all overexpressed in oropharyngeal squamous cell carcinoma tissue when compared to normal tissue. Significant trends were found between expression levels of FOXM1, CEP55, and HELLS and tumor staging. Tumors staged 3 or greater showed significantly higher levels of expression compared with those staged 1. No significant association or trend was found between expression of any genes of interest and etiologic subgroupings (i.e., HPV, smoking).

CONCLUSIONS

FOXM1, CEP55, and HELLS were all overexpressed in oropharyngeal squamous cell carcinoma. Gene expression is related to tumor stage. The significant association between the expression of these genes and advanced tumor stage suggest that they may play a role in tumorigenesis.

Disparities in the prevalence, pathogenesis and progression of monoclonal gammopathy of undetermined significance and multiple myeloma between blacks and whites

There is marked racial disparity in the incidence of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma, with a two to threefold increased risk in blacks compared with whites. The increased risk has been seen both in Africans and African Americans. Similarly, an increased risk of monoclonal gammopathies in blacks compared with whites has been noted after adjusting for socioeconomic and other risk factors, suggesting a genetic predisposition. The higher risk of multiple myeloma in blacks is likely a result of the higher prevalence of the premalignant MGUS stage; there are no data to suggest that blacks have a higher progression rate of MGUS to myeloma. Studies are emerging that suggest the baseline cytogenetic characteristics, and progression may differ by race. In contrast, to the increased risk noted in blacks, studies suggest that the risk may be lower in certain racial and ethnic groups, notably persons from Japan and Mexico. We review the literature on racial disparity in the prevalence, pathogenesis and progression of MGUS and multiple myeloma between blacks and whites. We also discuss future directions for research that could inform management of these conditions and positively influence patient outcomes.

Translating gene transfer: a stalled effort

The journey of gene transfer from laboratory to clinic has been slow and fraught with many challenges and barriers. Despite the development of the initial technology in the early 1970s, a standard clinical treatment involving "gene therapy" remains to be seen. Furthermore, much was written about the technology in the early 1990s, but since then, not much has been written about the journey of gene transfer. The translational path of gene transfer thus far, both pitfalls and successes, can serve as a study not only in navigating ethical and safety concerns, but also in the importance of scientist-public interactions. Here, we examine the translational progress of gene transfer and what can be gleaned from its history.

GAGA factor isoforms have distinct but overlapping functions in vivo

The Drosophila melanogaster GAGA factor (encoded by the Trithorax-like [Trl] gene) is required for correct chromatin architecture at diverse chromosomal sites. The Trl gene encodes two alternatively spliced isoforms of the GAGA factor (GAGA-519 and GAGA-581) that are identical except for the length and sequence of the C-terminal glutamine-rich (Q) domain. In vitro and tissue culture experiments failed to find any functional difference between the two isoforms. We made a set of transgenes that constitutively express cDNAs coding for either of the isoforms with the goal of elucidating their roles in vivo. Phenotypic analysis of the transgenes in Trl mutant background led us to the conclusion that GAGA-519 and GAGA-581 perform different, albeit largely overlapping, functions. We also expressed a fusion protein with LacZ disrupting the Q domain of GAGA-519. This LacZ fusion protein compensated for the loss of wild-type GAGA factor to a surprisingly large extent. This suggests that the Q domain either is not required for the essential functions performed by the GAGA protein or is exclusively used for tetramer formation. These results are inconsistent with a major role of the Q domain in chromatin remodeling or transcriptional activation. We also found that GAGA-LacZ was able to associate with sites not normally occupied by the GAGA factor, pointing to a role of the Q domain in binding site choice in vivo.

Tuberculosis transmission among five school bus drivers and students in two New York counties

OBJECTIVE

Between November 1994 and April 1995, more than 3300 students in 49 schools in two counties in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students.

METHODS

Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as >/=10 mm induration, and a converter was an individual with an increase in reaction size of >/=10 mm in the past 2 years.

RESULTS

The rates of positive skin tests were 0.8%, 0.3%, 9.9%, 1.1%, and 0.7% among US-born students exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for students exposed to driver 3, and the only secondary case identified among students was exposed to driver 3. The DNA fingerprint patterns of isolates from drivers 3 and 4 matched.

CONCLUSION

There was no clear evidence of transmission of M tuberculosis to students from drivers 1, 2, 4, or 5. However, evidence suggests that driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures.

Tuberculosis in a correctional facility

BACKGROUND

After the identification of five suspected cases of tuberculosis (TB) in a Nassau County (New York) jail during a 3-week period, an epidemiologic investigation was begun to document the number of cases of TB infection and disease associated with the jail, the characteristics of current or former inmates with TB disease, and the factors contributing to TB transmission in the jail.

METHODS

The county TB register was matched against the inmate files of the jail. Medical records from hospitals, the health department, and the jail were then reviewed. All inmates in the jail were skin tested during a mass screening.

RESULTS

From January 1, 1988, through March 16, 1990, of 205 TB cases in the county, 49 (24%) were associated with the jail. Forty of the cases occurred among current or former inmates, one in a corrections officer, and eight among community contacts of inmates. The 40 inmates with TB were predominantly nonwhite (75%), unmarried (80%) men (90%), with a median age of 32 years. Twenty-three (58%) had a history of injecting drug use, and 14 (35%) were known to be seropositive for the human immunodeficiency virus. Thirty (75%) of the inmates had culture-confirmed pulmonary TB. Five (29%) of 17 Mycobacterium tuberculosis isolates had the same phage type and DNA fingerprint, which was consistent with transmission of infection within the jail. The mass screening revealed that 374 (20%) of 1855 inmates were tuberculin positive.

CONCLUSIONS

Without an effective program of TB control, jails can act as reservoirs of disease for inmates and staff, and for the community into which the inmates are released.

High prevalence of syphilis detected through a jail screening program. A potential public health measure to address the syphilis epidemic

BACKGROUND

In June 1990, a syphilis initiative was undertaken to help control New York's most extensive syphilis epidemic since the 1940s.

METHODS

To evaluate the usefulness of syphilis screening in local jails, were reviewed demographic and syphilis screening data from a county jail in an area with a high prevalence of syphilis that has routinely tested incoming inmates.

RESULTS

Of 12,685 inmates, 9797 (77%) were screened for syphilis, and 321 (3.3%) had a positive test result; 258 (80%) of the positive results were confirmed. Data were available for 244 of the inmates with a confirmed positive result: 162 (67%) had newly diagnosed syphilis (overall rate, 1.6%), 112 of whom had early syphilis; 50 (20%) had been previously treated for syphilis; and 32 (13%) were unavailable for follow-up. Of 162 inmates with newly diagnosed syphilis, 122 (75%) were treated in jail, and 40 were treated after their release from jail. The median time from screening to treatment was 17 days. The median jail stay was 45 days for inmates who were evaluated for treatment vs 5 days for those who were unavailable for follow-up.

CONCLUSIONS

Screening inmates for syphilis was a productive public health measure, as inmates accounted for 20% of the county's syphilis morbidity. Given the high prevalence of syphilis among inmates and the inability to reach them for treatment after release, strategies are needed to rapidly screen and treat inmates before their release from jail.

Echovirus type 30 infection associated with aseptic meningitis in Nassau County, New York, USA

An outbreak of echovirus type 30, primarily affecting infant under 1 year old, was documented in Nassau County, N.Y., USA. Twenty-four of the 40 infected patients were definitively diagnosed with aseptic meningitis. A positive correlation was found between the proportion of polymorphonuclear leukocytes and the overall cerebrospinal fluid white cell count.

An oligosaccharide biosynthetic defect in concanavalin A-resistant Chinese hamster ovary (CHO) cells that enhances NK reactivity in vitro and in vivo

We have examined a concanavalin A-resistant (Con AR) Chinese hamster ovary cell (CR-7) that has a defect in the synthesis of asparagine-linked oligosaccharides and consequently an altered expression of membrane carbohydrate. The CR-7 mutant, which has a decreased ability to incorporate mannose into oligolipid and membrane glycoprotein and an increased membrane fucose, was more sensitive to natural killer (NK) cell lysis than the parental wild type (CHO-WT). Splenocytes mediating the lysis of the CR-7 line were asialo GM1+, nonadherent, IFN stimulatable, absent in the bg/bg mutant, and co-fractionated on Percoll density gradients with cells mediating lysis of the YAC-1 murine lymphoma. The increase in NK lysis correlated with enhanced binding of NK cells to the mutant determined by adsorption on tumor monolayers, cold target inhibition, and target binding analysis. A revertant of CR-7 (RCR-7), which showed wild-type levels of NK lysis, was intermediate in its ability to bind or cold target inhibit NK cells. The CR-7, CHO-WT, and RCR-7 lines were equally sensitive to hypotonic lysis and cytotoxicity by human lymphokine-activated killer (LAK) cells suggesting that the mutation did not nonspecifically alter membrane fragility. The NK-sensitive CR-7 line was less tumorigenic after subcutaneous injection in nude mice when compared with the parental CHO-WT or RCR-7 lines. This decreased tumorigenicity could be reversed by the i.v. injection of antiserum directed at the NK cell determinant asialo GM1. In conclusion, a ConAR tumor cell with a demonstrable oligosaccharide biosynthetic defect, exhibited enhanced NK lytic sensitivity and was poorly tumorigenic in vivo, a feature which may also be a consequence of its altered NK reactivity.

An oligosaccharide biosynthetic defect in concanavalin A-resistant Chinese hamster ovary (CHO) cells that enhances NK reactivity in vitro and in vivo

We have examined a concanavalin A-resistant (Con AR) Chinese hamster ovary cell (CR-7) that has a defect in the synthesis of asparagine-linked oligosaccharides and consequently an altered expression of membrane carbohydrate. The CR-7 mutant, which has a decreased ability to incorporate mannose into oligolipid and membrane glycoprotein and an increased membrane fucose, was more sensitive to natural killer (NK) cell lysis than the parental wild type (CHO-WT). Splenocytes mediating the lysis of the CR-7 line were asialo GM1+, nonadherent, IFN stimulatable, absent in the bg/bg mutant, and co-fractionated on Percoll density gradients with cells mediating lysis of the YAC-1 murine lymphoma. The increase in NK lysis correlated with enhanced binding of NK cells to the mutant determined by adsorption on tumor monolayers, cold target inhibition, and target binding analysis. A revertant of CR-7 (RCR-7), which showed wild-type levels of NK lysis, was intermediate in its ability to bind or cold target inhibit NK cells. The CR-7, CHO-WT, and RCR-7 lines were equally sensitive to hypotonic lysis and cytotoxicity by human lymphokine-activated killer (LAK) cells suggesting that the mutation did not nonspecifically alter membrane fragility. The NK-sensitive CR-7 line was less tumorigenic after subcutaneous injection in nude mice when compared with the parental CHO-WT or RCR-7 lines. This decreased tumorigenicity could be reversed by the i.v. injection of antiserum directed at the NK cell determinant asialo GM1. In conclusion, a ConAR tumor cell with a demonstrable oligosaccharide biosynthetic defect, exhibited enhanced NK lytic sensitivity and was poorly tumorigenic in vivo, a feature which may also be a consequence of its altered NK reactivity.

Total lymphatic irradiation and bone marrow in human heart transplantation

Six patients, aged 36 to 59 years, had heart transplants for terminal myocardial disease using total lymphatic irradiation (TLI) and donor bone marrow in addition to conventional therapy. All patients were poor candidates for transplantation because of marked pulmonary hypertension, unacceptable tissue matching, or age. Two patients are living and well more than four years after the transplants. Two patients died of infection at six and seven weeks with normal hearts. One patient, whose preoperative pulmonary hypertension was too great for an orthotopic heart transplant, died at 10 days after such a procedure. The other patient died of chronic rejection seven months postoperatively. Donor-specific tolerance developed in 2 patients. TLI and donor bone marrow can produce specific tolerance to donor antigens and allow easy control of rejection, but infection is still a major problem. We describe a new technique of administering TLI with early reduction of prednisone that may help this problem.

The effects of ketamine enantiomers on schedule-controlled behavior in the rat

Male Sprague-Dawley rats were trained to barpress under a FL-300 sec schedule of food presentation until responding patterns were stable. The effects of the ketamine optical isomers (enantioners) on this schedule-controlled behavior were examined over a dose range of 3.75 to 60 mg/kg i.p. At doses of 15 mg/kg and above, (-)-ketamine increased rate of responding, with a maximum increase of about 3 times control rate. This effect was rate-dependent, being more marked at lower control rates. In contrast (+)-ketamine did not increase overall fixed-interval response rate at any dose, but decreased rate of responding in a rate-dependent fashion at doses of 30 mg/kg and above. Spontaneous locomotor activity was increased about equally by equimolar doses of both enantiomers.

Distinctive medium chain wax esters, triglycerides, and diacyl glyceryl ethers in the head fats of the Pacific beaked whale, Berardius bairdi

Lipids were extracted from the mandibular fat body (jaw), the fatty forehead (melon), and the dorsal blubber of a Pacific beaked whale (Berardius bairdi) and separated into lipid classes by preparative thin layer chromatogrphy. The head fats were mixtures of wax esters and triglycerides with a very small amount of diacyl glyceryl ether. The blubber fat contained 97% wax ester and 3% triglyceride. Gas liquid chromatography (GLC) of the intac lipid classes indicated an unusually low C26-C30 range for most of the jaw and melon wax esters compared to the more normal C32-C40 molecules found in the blubber. Distinctive lower molecular weight C24-C40 triglycerides occurred in the head fats vs. the usual C44-C58 range in the blubber. Most diacyl glyceryl ethers were in the C35-C46 range, below the molecular weight of hexadecyldipalmitoyl glyceryl ether (C48). GLC of the derived fatty acid methyl esters showed that the lower molecular weight neutral lipids in the head fats were due to high levels of iso-10:0, n-10:0, iso-11:0, iso-12:0, N-12:0, and iso-13:0 acids. The wax ester fatty alcohols and the alkoxy chains of the glyceryl ethers were mostly the C14-C20 chain lengths commonly observed in marine organisms. The distinctive medium chain neutral lipids in the jaw and melon fats of this whale may be related to the postulated acoustical role of these tissues in echolocation.

Determination of urinary indolic metabolites

A rapid mass spectral assay for tryptophol, 5-hydroxytryptophol, and 3-indoleacetic acid, employing stable-isotope labeled internal standards, is described. The compounds were extracted from urine or buffer with ethyl acetate and quantitatively measured by chemical-ionization mass spectrometry. The calibration curves were linear over a range of 0.06--2.8 microgram/ml. The technique was applied to the analysis of urine from patients with carcinoid tumors. In addition, the first synthesis of 5-methoxy-3-indoleacrylic acid is reported.

Renal clearance of cystathionine in homozygous and heterozygous cystathioninuria, cystinuria, and the normal state

Cystathionine is more readily cleared from the plasma than other amino acids. This is because the amino acid has a very low tubular maximum (Tm), in the order of 1 mumole per minute per 1.73 square meters body surface area (BSA). No essential differences in the reabsorption of cystathionine were observed in four normal subjects, two patients with homozygous cystathioninuria, one patient with heterozygous cystathioninuria, and one patient with cystinuria. Apparent net tubular secretion of cystathionine was demonstrated in a child with homozygous cystathioninuria only after an intravenously administered load of lysine.