Baseline extracellular vesicle TGF-β is a predictive biomarker for response to immune checkpoint inhibitors and survival in non-small cell lung cancer

BACKGROUND

Immune-checkpoint inhibitors (ICIs) are an effective therapeutic strategy, improving the survival of patients with lung cancer compared with conventional treatments. However, novel predictive biomarkers are needed to stratify which patients derive clinical benefit because the currently used and highly heterogenic histological PD-L1 has shown low accuracy. Liquid biopsy is the analysis of biomarkers in body fluids and represents a minimally invasive tool that can be used to monitor tumor evolution and treatment effects, potentially reducing biases associated with tumor heterogeneity associated with tissue biopsies. In this context, cytokines, such as transforming growth factor-β (TGF-β), can be found free in circulation in the blood and packaged into extracellular vesicles (EVs), which have a specific delivery tropism and can affect in tumor/immune system interaction. TGF-β is an immunosuppressive cytokine that plays a crucial role in tumor immune escape, treatment resistance, and metastasis. Thus, we aimed to evaluate the predictive value of circulating and EV TGF-β in patients with non-small-cell lung cancer receiving ICIs.

METHODS

Plasma samples were collected in 33 patients with advanced non-small-cell lung cancer before and during treatment with ICIs. EV were isolated from plasma by serial ultracentrifugation methods and circulating and EV TGF-β expression levels were evaluated by enzyme-linked immunosorbent assay.

RESULTS

Baseline high expression of TGF-β in EVs was associated with nonresponse to ICIs as well as shorter progression-free survival and overall survival, outperforming circulating TGF-β levels and tissue PD-L1 as a predictive biomarker.

CONCLUSION

If validated, EV TGF-β could be used to improve patient stratification, increasing the effectiveness of treatment with ICIs and potentially informing combinatory treatments with TGF-β blockade.

PLAIN LANGUAGE SUMMARY

Treatment with immune-checkpoint inhibitors (ICIs) has improved the survival of some patients with lung cancer. However, the majority of patients do not benefit from this treatment, making it essential to develop more reliable biomarkers to identify patients most likely to benefit. In this pilot study, the expression of transforming growth factor-β (TGF-β) in blood circulation and in extracellular vesicles was analyzed. The levels of extracellular vesicle TGF-β before treatment were able to determine which patients would benefit from treatment with ICIs and have a longer survival with higher accuracy than circulating TGF-β and tissue PD-L1, which is the currently used biomarker in clinical practice.

Association of cardiac calcium burden with overall survival after radiotherapy for non-small cell lung cancer

Background and purpose

Coronary calcifications are associated with coronary artery disease in patients undergoing radiotherapy (RT) for non-small cell lung cancer (NSCLC). We quantified calcifications in the coronary arteries and aorta and investigated their relationship with overall survival (OS) in patients treated with definitive RT (Def-RT) or post-operative RT (PORT).

Materials and methods

We analyzed 263 NSCLC patients treated from 2004 to 2017. Calcium burden was ascertained with a Hounsfield unit (HU) cutoff of > 130 in addition to a deep learning (DL) plaque estimator. The HU cutoff volumes were defined for coronary arteries (Plaque_Coro) and coronary arteries and aorta combined (Plaque_Coro+Ao), while the DL estimator ranged from 0 (no plaque) to 3 (high plaque). Patient and treatment characteristics were explored for association with OS.

Results

The median Plaque_Coro and Plaque_Coro+Ao was 0.75 cm³ and 0.87 cm³ in the Def-RT group and 0.03 cm³ and 0.52 cm³ in the PORT group. The median DL estimator was 2 in both cohorts. In Def-RT, large Plaque_Coro (HR:1.11 (95%CI:1.04-1.19); p = 0.008), and Plaque_Coro+Ao (HR:1.06 (95%CI:1.02-1.11); p = 0.03), and poor Karnofsky Performance Status (HR: 0.97 (95%CI: 0.94-0.99); p = 0.03) were associated with worse OS. No relationship was identified between the plaque volumes and OS in PORT, or between the DL plaque estimator and OS in either Def-RT or PORT.

Conclusions

Coronary artery calcification assessed from RT planning CT scans was significantly associated with OS in patients who underwent Def-RT for NSCLC. This HU thresholding method can be straightforwardly implemented such that the role of calcifications can be further explored.

Molecular diagnosis of cytogenetic abnormalities in patients with schizophrenia

Introduction

Schizophrenia is a severe and chronic disorder causing significant disability and functional decline. Schizophrenia is a polygenic disease, with about 100 monogenic sites and 11 sites of chromosomal deletions / duplications involved in its pathogenesis identified. It is a pleiotropic disease, with causative genetic changes leading to multiple symptoms, including bipolar disorder, autism spectrum disorders, ADHD, mental retardation and epilepsy. The chromosomal microarray (CMA) technology detects submicroscopic chromosomal changes, which are involved in neurodevelopmental disorders, and are subject to prenatal diagnosis. Pathological findings in CMA are detected in 10-20% of patients with neurodevelopmental disorders and can contribute significantly to medical follow-up, prognosis assessment, influence treatment choice, and allow prenatal diagnosis. Preliminary studies in schizophrenia identified pathological CMA findings in 10–30% of patients.

Objectives

CMA testing of schizophrenia patients to detect genetic changes causing the disease.

Methods

Recruitment of schizophrenia patients from the Haifa and Western Galilee districts of Clalit, genetic counseling in Carmel Hospital, CMA testing of the consenting patients.

Results

Schizophrenia patients with and without neurodevelopmental disorders underwent CMA analysis, with the findings of significant chromosomal submicroscopic disorders (such as 22q11 microdeletion, among others) in 30% of the patients, providing the explanation for the patients’ symptoms and enabling specific medical follow-up and adjusted pharmacological treatment.

Conclusions

CMA can be used in diagnosing schizophrenia, assessing prognosis, adjusting pharmacological treatment and follow-up and providing genetic counseling including prenatal diagnosis, as in cases neurodevelopmental disorders. The findings support the application of CMA as part of a routine procedures in schizophrenia.

Disclosure

No significant relationships.

Emerging noncoding RNAs contained in extracellular vesicles: rising stars as biomarkers in lung cancer liquid biopsy

Lung cancer has a high morbidity and mortality rate, and affected patients have a poor prognosis and low survival. The therapeutic approaches for lung cancer treatment, including surgery, radiotherapy, and chemotherapy, are not completely effective, due to late diagnosis. Although the identification of genetic drivers has contributed to the improvement of lung cancer clinical management, the discovery of new diagnostic and prognostic tools remains a critical issue. Liquid biopsy (LB) represents a minimally invasive approach and practical alternative source to investigate tumor-derived alterations and to facilitate the selection of targeted therapies. LB allows for the testing of different analytes such as circulating tumor cells, extracellular vesicles (EVs), tumor-educated platelets, and cell-free nucleic acids including DNAs, RNAs, and noncoding RNAs (ncRNAs). Several regulatory factors control the key cellular oncogenic pathways involved in cancers. ncRNAs have a wide range of regulatory effects in lung cancers. This review focuses on emerging regulatory ncRNAs, freely circulating in body fluids or shuttled by EVs, such as circular-RNAs, small nucleolar-RNAs, small nuclear-RNAs, and piwi-RNAs, as new biomarkers for early detection, prognosis, and monitoring of therapeutic strategy of lung cancer treatment.

Effects of hypocholesterolemic dietary and drug therapy on measures of dysphoric emotions

The question of whether hypocholesterolemic treatment is associated with increased mortality due to suicide, violence and car accidents is controversial and of great importance. We investigated the effect of hypocholesterolemic dietary and drug therapy on dysphoric emotions. Twenty-five hypocholesterolemic men were started on a 3-month dietary modification plan; those who showed unsatisfactory cholesterol reduction were given, in addition, a hypocholesterolemic drug for up to 1 year. Lipid profile and change in dysphoric emotions were measured. During the whole period, a negative correlation was found between cholesterol level and depression. During the dietary period, a significant improvement in depression and guilt with no change in lipid profile was noted. Drug therapy significantly reduced cholesterol levels, with a trend toward increased depression (after 3 months) and a significant increase in aggression and guilt (after 1 year). We conclude that changes in dysphoric emotions occurring during hypocholesterolemic therapy cannot be completely explained by the changes in cholesterol levels.

Microarray analysis has no additional value in fetal aberrant right subclavian artery: description of 268 pregnancies and systematic literature review

OBJECTIVES

Fetal aberrant right subclavian artery (ARSA) is a relatively common sonographic finding. Several studies have reported a significant association between ARSA and Down syndrome, as well as 22q11.2 microdeletion. The objective of this study was to assess the risk of abnormal chromosomal microarray analysis (CMA) findings in a large cohort of pregnancies with fetal ARSA as an isolated, as well as a non-isolated, sonographic anomaly. A secondary objective was to review the literature, examining the frequency of chromosomal microarray aberrations in fetuses with isolated ARSA.

METHODS

Data from all pregnancies referred for invasive testing and CMA due to sonographic diagnosis of fetal ARSA, between 2013 and 2017, were obtained retrospectively from the computerized database of the Israeli Ministry of Health. The rate of clinically significant CMA findings in these fetuses was compared to that in a local control population of 2752 low-risk pregnancies with normal ultrasound and serum screening results. In addition, a literature search was conducted in PubMed, from inception to February 2018, of original studies in the English language describing the frequency and nature of microscopic and submicroscopic aberrations in fetuses with isolated ARSA.

RESULTS

Of 246 pregnancies with isolated ARSA that underwent CMA analysis, a clinically significant finding was detected in one (0.4%) pregnancy (trisomy 21). This rate did not differ significantly from that in the control population (P = 0.1574). Of 22 fetuses with non-isolated ARSA, one (4.5%) additional case of trisomy 21 was noted. The frequency of trisomy 21 in this cohort also did not differ from that in the control population (relative risk, 5.5 (95% CI, 0.8-37.6)). The literature search yielded 13 additional relevant papers, encompassing 333 cases of isolated ARSA. Of 579 cases overall (including those of the present study), 13 (2.2%) cases of trisomy 21 were detected, with no cases of 22q11.2 microdeletion.

CONCLUSION

While an association may exist between non-isolated ARSA and Down syndrome, isolated ARSA might better serve as a soft marker for Down syndrome, rather than a routine indication for invasive prenatal testing. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Relation of Body Mass Index to Development of Atrial Fibrillation in Hispanics, Blacks, and Non-Hispanic Whites

No previous studies have examined the interaction between body mass index (BMI) and race/ethnicity with the risk of atrial fibrillation (AF). We retrospectively followed 48,323 persons free of AF (43% Hispanic, 37% black, and 20% white; median age 60 years) for subsequent incident AF (ascertained from electrocardiograms). BMI categories included very severely underweight (BMI <15 kg/m²), severely underweight (BMI 15.1 to 15.9 kg/m²), underweight (BMI 16 to 18.4 kg/m²), normal (BMI 18.5 to 24.9 kg/m²), overweight (BMI 25.0 to 29.9 kg/m²), moderately obese (BMI 30 to 34.9 kg/m²), severely obese (BMI 35 to 39.9 kg/m²), and very severely obese (BMI >40 kg/m²). Cox regression analysis controlled for baseline covariates: heart failure, gender, age, treatment for hypertension, diabetes, PR length, systolic blood pressure, left ventricular hypertrophy, socioeconomic status, use of β blockers, calcium channel blockers, and digoxin. Over a follow-up of 13 years, 4,744 AF cases occurred. BMI in units of 10 was associated with the development of AF (adjusted hazard ratio 1.088, 95% confidence interval 1.048 to 1.130, p <0.01). When stratified by race/ethnicity, non-Hispanic whites compared with blacks and Hispanics had a higher risk of developing AF, noted in those whom BMI classes were overweight to severely obese. In conclusion, our study demonstrates that there exists a relation between obesity and race/ethnicity for the development of AF. Non-Hispanic whites had a higher risk of developing AF compared with blacks and Hispanics.

Histologic findings of femoral heads from patients with Gaucher disease treated with enzyme replacement

OBJECTIVES

To assess correlations of patient demographics, including enzyme replacement therapy (ERT) with bone histology, to facilitate decisions of whether and when to perform hip replacement surgery in patients with Gaucher disease.

METHODS

We examined the histology of surgically removed femoral heads and categorized findings by the presence or extent of osteonecrosis, Gaucher cell (GC) infiltration, and bone regeneration qualifiers using a tripartite histology-based scoring system.

RESULTS

Twenty-two patients with 26 bone specimens were evaluated. Seventeen patients (77%) were splenectomized, 16 (73%) received ERT, and 12 (55%) had the putatively milder genotype (N370S/N370S), with the rest putatively at increased risk for skeletal disease (N370S/other). The 3 histology subscores were applicable to all specimens. Osteonecrotic bone was seen in 19 of 26 (73%); osteoarthritis was seen in all cartilage specimens. Gaucher cell infiltration was not correlated with demographics or disease severity. A trend was noted between reduced GC infiltration and ERT (ρ = 0.407), but regeneration qualifiers were not correlated with ERT or other features.

CONCLUSIONS

Histologic findings of GC infiltration and bone regeneration qualifiers did not correlate with demographics or with exposure to ERT. Most specimens unexpectedly showed good regenerative responses to osteonecrosis despite heavy GC infiltration.

Alleviation of gut inflammation by Cdx2/Pxr pathway in a mouse model of chemical colitis

Pregnane X Receptor (PXR), a master regulator of drug metabolism and inflammation, is abundantly expressed in the gastrointestinal tract. Baicalein and its O-glucuronide baicalin are potent anti-inflammatory and anti-cancer herbal flavonoids that undergo a complex cycle of interconversion in the liver and gut. We sought to investigate the role these flavonoids play in inhibiting gut inflammation by an axis involving PXR and other potential factors. The consequences of PXR regulation and activation by the herbal flavonoids, baicalein and baicalin were evaluated in vitro in human colon carcinoma cells and in vivo using wild-type, Pxr-null, and humanized (hPXR) PXR mice. Baicalein, but not its glucuronidated metabolite baicalin, activates PXR in a Cdx2-dependent manner in vitro, in human colon carcinoma LS174T cells, and in the murine colon in vivo. While both flavonoids abrogate dextran sodium sulfate (DSS)-mediated colon inflammation in vivo, oral delivery of a potent bacterial β-glucuronidase inhibitor eliminates baicalin’s effect on gastrointestinal inflammation by preventing the microbial conversion of baicalin to baicalien. Finally, reduction of gastrointestinal inflammation requires the binding of Cdx2 to a specific proximal site on the PXR promoter. Pharmacological targeting of intestinal PXR using natural metabolically labile ligands could serve as effective and potent therapeutics for gut inflammation that avert systemic drug interactions.

A trinuclear Fe-Fe-Ni complex formed by ligand reshuffling

The title complex, dicarbonyl-3κ²C-(μ₃-3,6-dimethyl-3,6-diaza­octane-1,8-dithiol­ato-1:2:3κ⁷S:S,N,N′,S′:S,S′)(μ₂-3,6-di­methyl-3,6-diaza­octane-1,8-dithiol­ato-1:2κ⁵S,N,N′,S′:S)-1,2-diiron(II)-3-nickel(0) [Fe₂Ni(C₈H₁₈N₂S₂)₂(CO)₂], is the second example showing M(μ-SR)₂Ni⁰(CO)₂ coordination (M = any metal atom). Both Fe^II ions are five-coordinated in distorted trigonal–bipyramidal geometries by two N atoms and three S atoms. The Ni atom is four-coordinated in a distorted tetra­hedral geometry by two S atoms and two carbonyl ligands. One of the 3,6-dimethyl-3,6-diaza­octane-1,8-dithiol­ate ligands is disordered, the major component having a refined occupancy of 0.873 (2). The Fe⋯Fe distance is 3.0945 (3)Å and the Ni⋯Fe distance is 2.8505 (3) Å.

Homocysteine levels in patients with risk factors for atherosclerosis

BACKGROUND

Abundant epidemiological evidence has demonstrated that the presence of mild to moderate hyperhomocysteinemia is an independent risk factor for atherosclerosis in the coronary, cerebral, and peripheral vasculature, and for vascular disease, including coronary disease. It has been demonstrated that plasma total homocysteine level is a strong predictor of mortality in patients with angiographically confirmed coronary artery disease.

HYPOTHESIS

The study was undertaken to determine the extent of homocysteine levels in patients without documented coronary artery disease, but with at least one risk factor for atherosclerosis.

METHODS

Fasting blood samples were collected prospectively from 160 consecutive patients (50 women and 110 men, mean age 65+/-7 years) who had at least one risk factor for atherosclerosis, but had no documented coronary artery disease. Homocysteine levels were measured by an immunoassay method.

RESULTS

Of the patients studied, 78 (48.75%) with at least one risk factor for atherosclerosis had high homocysteine levels; 62 patients had mild hyperhomocysteinemia (15-30 micromol/l); and 16 patients had moderate hyperhomocysteinemia (30-100 micromol/l).

CONCLUSIONS

Our data suggest that hyperhomocysteinemia is highly prevalent in patients with risk factors for atherosclerosis. Homocysteine level (an independent convertible risk factor to atherosclerosis) should be measured routinely in patients with risk factors for atherosclerosis and treated appropriately.

Informal medicine: ethical analysis

CONTEXT

Doctors have been known to treat or give consultation to patients informally, with none of the usual record keeping or follow up. They may wish to know whether this practice is ethical.

OBJECTIVE

To determine whether this practice meets criteria of medical ethics.

DESIGN

Informal medicine is analysed according to standard ethical principles: autonomy, beneficence and non-maleficence, distributive and procedural justice, and caring.

SETTING

Hospital, medical school, and other settings where patients may turn to physicians for informal help.

CONCLUSION

No generalisation can be made to the effect that informal medicine is or is not ethical. Each request for informal consultation must be considered on its own merits.

GUIDELINES

Informal medicine may be ethical if no payment is involved, and when the patient is fully aware of the benefits and risks of a lack of record keeping. When an informal consultation does not entail any danger to the patient or others, the physician may agree to the request. If, however, any danger to the patient or others is foreseen, then the physician must insist on professional autonomy, and consider refusing the request and persuading the patient to accept formal consultation. If a reportable infectious disease, or other serious danger to the community, is involved, the physician should refuse informal consultation or treatment, or at least make a proper report even if the consultation was informal. If agreeing to the request will result in an unfair drain on the physician's time or energy, he or she should refuse politely.

Far-from-equilibrium Ostwald ripening in electrostatically driven granular powders

We report an experimental study of cluster size distributions in electrostatically driven granular submonolayers. The cluster size distribution in this far-from-equilibrium process exhibits dynamic scaling behavior characteristic of the (nearly equilibrium) Ostwald ripening, controlled by the attachment and detachment of the "gas" particles. The scaled size distribution, however, is different from the classical Wagner distribution obtained in the limit of a vanishingly small area fraction of the clusters. A much better agreement is found with the theory of Phys. Rev. E 65, 046117 (2002)] which accounts for the cluster merger.

Anti-cytomegalovirus (CMV) IgG antibody titer in patients with risk factors to atherosclerosis

Studies have demonstrated cytomegalovirus (CMV) DNA particles in restenotic lesions in atherosclerotic coronary arteries. We have shown that high (>1:800) anti-CMV IgG antibody titers in the serum are associated with active coronary disease and with post coronary angioplasty restenosis. In this study we assessed the anti-CMV antibody titer in patients with risk factors for atherosclerosis (but without documented clinical manifestations). One hundred and eighly-seven patients (men and women aged 40-80 years) that were admitted to the Department of Internal Medicine were recruited to this prospective study. All had at least one risk factor for atherosclerosis, and none had documented coronary artery disease. Fasting blood samples were drawn on admission. Risk factors included hypertension, diabetes mellitus, active smoking, hyperlipidemia, and a positive family history. Ninety-three age- and sex-matched individuals without atherosclerosis risk factors served as the control group. One Hundred and twentysix patients had high anti-CMV antibody titers (>/=1:800) compared with none in the control group. Although 80 patients (90%) in the control group were seropositive, none had anti-CMV IgG antibody titers higher than 1:400. The statistical difference between the patients and the control group was highly significant ( p<0.0001). An immunological response against CMV (expressed as an anti-CMV IgG antibody titer) could be a marker of a long-standing immunological reaction causing an inflammatory response that eventually would cause advanced clinical atherosclerosis. We suggest that anti-CMV antibody titer should be used as an early predictor of atherosclerosis. Our findings support the infectious theory and an association between CMV infection and atherosclerosis at an early stage, maybe even years before clinical events occur.

Quantitative evaluation of prostatectomy for benign prostatic hypertrophy under a national health insurance law: a multi-centre study

Assessing regional variation between various medical centres in diagnostic and surgical processes is an approach aimed at evaluating the quality of care. This study analyses the differences between eight medical centres in Israel, where all citizens are covered by medical insurance, through the National Health Insurance Law (NHIL). The analysis refers to the diagnostic process, type of surgery and immediate post-surgical complications associated with prostatectomy for benign prostatic hypertrophy (BPH), which is the most frequent surgical procedure performed on men aged 50+. The study sample was comprised of 261 consecutive prostatectomy patients operated on in eight Israeli medical centres (MC), located in various parts of the country, between November 1996 and April 1997. Co-operation with participating directors of surgical wards was obtained after confidentiality of information had been assured. Surgeons in selected departments abstracted data routinely recorded in the patient's file and filled-out a standard one-page questionnaire. The following items were included: age, the presence of accompanying chronic diseases, preoperative tests, type of operation, and post-surgical complications. In the various MCs 32.6% of the patients underwent more than five preoperative tests ranging from 8.9% to 88.9% (<0.01). Assessment of kidney and bladder normality ranged from 75% to 100% (P < 0.01). The rate of patients whose prostatic symptoms (I-PSS) were assessed ranged from 0% to 79% (P < 0.01). There were also differences in severity of prostatism between the MCs, with severe symptoms ranging from 54.0% to 89.3% (P < 0.05), for type of operation performed (for 'open' prostatectomies, 35.4% to 68.0%, P < 0.01) and post-operative complications (19.0% to 41.6%, P = 0.07). After controlling for case-mix, type of operation was the most important predictor for post-surgical complications. MCs with low volume of surgeries had a higher rate of postoperative complications. We conclude that diagnostic and type of operation and post-surgical complications differed between various MCs. Participating surgeons were willing to fill out a one-page standard questionnaire from data routinely recorded in patients' files.

Second-hand prostatism: effects of prostatic symptoms on spouses' quality of life, daily routines and family relationships

OBJECTIVES

The aim of this study was to explore the impact of male prostatic symptoms on their partners' quality of life, daily routines and family relationships.

METHODS

A structured telephone interview study was carried out on a random sample of 215 of the wives and partners of men aged 50 years or older drawn from those registered at four family medicine centres in Israel. They were asked about sleep disturbances, number of night-time wakings, and the effect on sexual relations, travel, entertainment, family and social relationships.

RESULTS

The vast majority of women (86%) were affected by their partners' prostatism, with multiple consequences for their daily routines, quality of life and relationships. Sleep was the area of greatest concern, with 46% of women regularly waking due to their partners' urination disorder. The women reported other limitations: 37% noted problems with sexual functioning; 17% were unable to take long trips with partners; 10% could not visit places without toilets; while 8% were unable to go to the cinema or theatre. Women felt that their partners' prostatic symptoms were also to be blamed for upsetting family relationships (10%) and relationships with friends (16%). There was near total correspondence between women and their male partners regarding the effects of prostatic symptoms.

CONCLUSIONS

Prostatism has an impact on men and women; strategies that consider the whole couple should be developed and utilized when considering treatment options.

Normal scaling in globally conserved interface-controlled coarsening of fractal clusters

We find that globally conserved interface-controlled coarsening of diffusion-limited aggregates exhibits dynamic scale invariance (DSI) and normal scaling. This is demonstrated by a numerical solution of the Ginzburg-Landau equation with a global conservation law. The general sharp-interface limit of this equation is introduced and reduced to volume preserving motion by mean curvature. A simple example of globally conserved interface-controlled coarsening system: the sublimation/deposition dynamics of a solid and its vapor in a small closed vessel, is presented in detail. The results of the numerical simulations show that the scaled form of the correlation function has a power-law tail accommodating the fractal initial condition. The coarsening length exhibits normal dynamic scaling. A decrease of the cluster radius with time, predicted by DSI, is observed. The difference between global and local conservation is discussed.

Characteristics of patients at a complementary medicine clinic in Beer Sheva: summary of the first two years of operation

BACKGROUND

"Complementary medicine" incorporates several methods of treatment, all of which aim to promote the health and quality of life of the patient. Public interest and demand for complementary medicine services have increased in recent years in Israel, as they have throughout the western world.

OBJECTIVE

To characterize patients attending the Complementary Medicine Clinic in southern Israel at the completion of its first 2 years of operation.

METHODS

Data for 398 patients selected at random from 4,400 patients treated in the clinic were collected retroactively from the patients' charts.

RESULTS

Of those who visited the clinic, 68% were women with an average age of 49 years. Patients attending the clinic had higher rates of hypertension (20%), diabetes (6%) and heart disease (7%) than the general population of patients insured at the Clalit Health Services in the southern region. In addition to musculoskeletal problems (47%), the other most common complaint was emotional problems (13%) such as tension and anxiety. Acupuncture and Shiatsu were the most commonly used types of treatment (61%). Homeopathy was used by 7%. Among patients with musculoskeletal problems, there were significantly more men than women (P = 0.02), the mean age was higher (P = 0.07), and more of them were referred by friends or family (P = 0.06) than those with other problems.

CONCLUSIONS

Characterizing patients attending a complementary medicine clinic is important for the planning of marketing and resource management, and can assist primary care physicians in decisions regarding the referral of patients to this type of healthcare.

Factors associated with daily smoking among Israeli adolescents: a prospective cohort study with a 3-year follow-up

BACKGROUND

A prospective, 3-year cohort study of smoking habits was conducted among 9th grade pupils in Israel.

METHODS

A self-administered questionnaire was answered by pupils in the 9th grade and again in the 11th and 12th grades.

RESULTS

The baseline questionnaire was answered by 748 9th graders. In the 11th grade 448 (60%) completed the questionnaire for the second time, and in the 12th grade 388 (52%) completed the questionnaire. In all, 312 pupils (42% of the original cohort) completed all three questionnaires. There were no significant sociodemographic differences between these 312 and the original 748. Eight 9th graders (2.6%) were active smokers (at least one cigarette daily for the last month) compared with 64 (20.5%) in the 11th grade (P < 0.0001 vs 9th grade) and 70 (22.4%) in the 12th grade (P = 0.34 vs 11th grade). Most pupils knew the health hazards of smoking. Variables associated with smoking in the 11th grade included religiosity (religion was associated with lower smoking rates, P = 0.07), past experimentation with smoking (P < 0.0001), smoking among family members (P < 0.01), perceived future smoking status (P < 0.001), self-image (P < 0.001), influence of a teacher (P = 0.07) or celebrity (P < 0.05), and effect of peer pressure (P < 0.01). These results were similar for the 12th grade students except for active or previous smoking by gender (a significantly greater proportion of females than males, P = 0.04).

CONCLUSIONS

The study design reduces the potential bias of follow-up attrition on assessment of predictors for smoking initiation. Gender, social modeling and peer pressure, past experimentation with smoking, smoking among family members, role models, and self-image were associated with smoking. These factors should be emphasized in intervention programs.

Lower urinary tract symptoms in primary care--a multicenter community-based study in Israel

BACKGROUND

Lower urinary tract symptoms are highly prevalent in older men, have been shown to affect men's quality of life, and may be associated with more serious outcomes.

OBJECTIVES

To determine the prevalence of LUTS among men aged 50 years or older registered at family practice centers in Israel and to assess the effect of these complaints on different aspects of their life.

METHODS

In a random sample cohort of men aged 50 years and older, fluent in Hebrew, drawn from those registered in four family clinics in Israel, patients identified with LUTS were interviewed by phone using a structured questionnaire.

RESULTS

The prevalence of LUTS in our study was 21%. Less than a third of these patients had low severity LUTS (28%), 59% were rated moderate, and 13% had severe symptoms. Age had a positive correlation with the severity of LUTS, and increasing severity of symptoms had a negative effect on the daily function and quality of life of patients.

CONCLUSIONS

Our community-based study shows that LUTS is a common finding among men above the age of 50 (21%) and has a significant negative effect on their quality of life and daily function. Knowledge of these data should make primary care physicians more aware of this common problem and thus improve the treatment and quality of life of these patients by better identification and prompt treatment.

Area-preserving dynamics of a long slender finger by curvature: a test case for globally conserved phase ordering

A long and slender finger can serve as a simple "test bed" for different phase-ordering models. In this work, the globally conserved, interface-controlled dynamics of a long finger is investigated, analytically and numerically, in two dimensions. An important limit is considered when the finger dynamics is reducible to area-preserving motion by curvature. A free boundary problem for the finger shape is formulated. An asymptotic perturbation theory is developed that uses the finger aspect ratio as a small parameter. The leading-order approximation is a modification of the Mullins finger (a well-known analytic solution) whose width is allowed to slowly vary with time. This time dependence is described, in the leading order, by an exponential law with the characteristic time proportional to the (constant) finger area. The subleading terms of the asymptotic theory are also calculated. Finally, the finger dynamics is investigated numerically, employing the Ginzburg-Landau equation with a global conservation law. The theory is in very good agreement with the numerical solution.

Outcomes of a brief alcohol abuse prevention program for Israeli high school students

PURPOSE

To implement a brief intervention aimed at reducing abuse of alcohol among adolescents, and to assess its effectiveness.

METHODS

One thousand 10th-grade students from seven high schools, chosen by random from the roster of all schools in southern Israel, were assigned to intervention and control groups. The intervention, which was based on Botvin's social skills theory, was conducted over 3 days and included dissemination of information, workshops, lectures by guest experts, and activity areas. It was administered by the staff of the high schools and the Psychological Counseling Service in Israel. A self-administered questionnaire was answered anonymously by students in the 10th grade (pretest) and again in the 11th and 12th grades (posttests). It included questions on sociodemographic data, alcohol-related habits, smoking habits, use of illicit drugs, knowledge, and attitudes. Data were collected between 1994 and 1997 with a 76% follow-up rate at 2 years.

RESULTS

At baseline there was no statistical difference in alcohol consumption between the intervention and control groups. At 1- and 2-year follow-up the rates of alcohol consumption did not change in the intervention group (p > .05) but rose significantly in the control group (p < .001). In multiple regression analysis the variables male gender, positive attitudes, cigarette smoking, availability of illegal drugs, and intervention group were significant predictors of alcohol consumption.

CONCLUSIONS

The results of this study show the effectiveness of this intervention program, based on reduced alcohol consumption in the intervention group at 1- and 2-year follow-up, compared with the control group. Compared with other programs, the present intervention is brief, intensive, and relatively easy to implement.

Immunodetection of living trophoblast

BACKGROUND

Human chorionic gonadotropin, the pregnancy hormone, is synthesized by trophoblast cells which make up the placenta.

OBJECTIVE

To determine whether antibody to hCG can be used to specifically detect living trophoblast in vitro by binding to the external membrane.

METHODS

Trophoblast was isolated from fresh placentas of women undergoing termination of pregnancy in the first trimester and incubated with monoclonal antibody to hCG. Anti-mouse immunoglobulin G with a fluorescent marker was then added.

RESULTS

Syncytiotrophoblast stained positive on the external surface of the cell, while controls of leukocytes, endometrial cells and hepatocytes were negative.

CONCLUSION

The hCG monoclonal antibody may be used to specifically detect hCG on the surface of living trophoblast in vitro.

Dynamics of fractal dimension during phase ordering of a geometrical multifractal

A simple multifractal coarsening model is suggested that can explain the observed dynamical behavior of the fractal dimension in a wide range of coarsening fractal systems. It is assumed that the minority phase (an ensemble of droplets) at t=0 represents a nonuniform recursive fractal set, and that this set is a geometrical multifractal characterized by an f(alpha) curve. It is assumed that the droplets shrink according to their size and preserve their ordering. It is shown that at early times the Hausdorff dimension does not change with time, whereas at late times its dynamics follow the f(alpha) curve. This is illustrated by a special case of a two-scale Cantor dust. The results are then generalized to a wider range of coarsening mechanisms.

Interruptions to the physician-patient encounter: an intervention program

BACKGROUND

Israeli physicians are very familiar with the problem of interruptions during encounters with patients. However, a thorough search of the medical literature revealed only one report of this problem from Israel, and none from other countries.

OBJECTIVES

To characterize the phenomenon of interruptions to the patient-physician encounter in a clinic in Dimona and to assess the effect of an intervention program designed to reduce the magnitude of this problem.

METHODS

During an 8 day work period in March 1997 all patient-physician encounters were recorded and characterized. An intervention program was then designed and implemented to reduce the number of interruptions. Data were again collected a year after the initial data collection.

RESULTS

During the 8 day study period prior to the intervention program there were 528 interruptions to 379 encounters (mean of 1.39 per encounter). The main causes of interruptions were entrance of uninvited patients to the examination room (31%) and telephone calls (27%). Most of the interruptions occurred during the morning hours between 8 and 10 a.m. (45%) and at the beginning of the week (Sunday 30%). After the intervention program there were 402 interruptions to 355 encounters (mean of 1.13 per appointment, P = 0.21).

CONCLUSIONS

There was no statistically significant improvement in the number of interruptions following the intervention program. This finding is either the result of a local cultural phenomenon, or it indicates a national primary care health system problem that may require a long-term educational program to resolve it. Further research is needed on the magnitude, causes and consequences of interruptions in family practice and, if warranted, methods will have to devised to cope with this serious problem.

Smoking cessation support groups in Israel: a long-term follow-up

BACKGROUND

Smoking is the most important preventable cause of chronic disease in the western world. Many smokers want to quit, but have difficulty overcoming the addictive effect of nicotine.

OBJECTIVES

To assess the quitting rate of smokers who participated in smoking cessation groups and to characterize predictors of success or failure over a 1-3 years follow-up period.

METHODS

We studied 89 participants in 7 groups. Questionnaires were completed at baseline and after a follow-up period of 1 to 3 years. Smoking cessation was determined by self-report and a carbon monoxide breath test.

RESULTS

Of the 89 participants in the support groups 76 (85%) were located. An intention-to-treat analysis was done for these participants. At follow-up 25 (33%) were non-smokers. There was a 95% agreement rate between self-report of smoking status and CO breath analysis. There were no differences between quitters and non-quitters in education level, gender, age at initiation of smoking, previous quit attempts, extent of participation in group meetings, concern about gaining weight, Fagerstrom index, or the number of close friends or relatives who smoke. Belief in one's ability to quit, satisfaction with group meetings, and spouse support were significantly associated with success (P < 0.01).

CONCLUSIONS

The quit rate was 33%. Self-report is a reliable method for assessing smoking status. Smokers' belief in their ability to quit must be reinforced. Spouse participation in some group meetings may be beneficial, as may the involvement of a dietician and an expert on exercise. Follow-up "booster" meetings may also help.

Hallway medicine: prevalence, characteristics and attitudes of hospital physicians

BACKGROUND

Hallway medicine is an integral part of physicians' medical culture, but little is known about it.

OBJECTIVE

To characterize the practice of hallway medicine among hospital physicians, both as providers and consumers.

METHODS

We conducted a survey of 112 randomly chosen hospital physicians at the Soroka Medical Center in Beer Sheva, Israel between November 1997 and May 1998. A self-administered 39-item questionnaire was used that included sociodemographic data, the extent to which hallway medicine is practiced, and satisfaction from and attitudes to it.

RESULTS

Of the 112 selected physicians, 111 responded (99.1%). Of these, 91 (82%) had been asked by their colleagues to provide hallway medicine. Most of them (91%) agreed because of "willingness to help," because "it's unpleasant to refuse," or "it's the acceptable thing to do." Most of the requests (72%) were unscheduled and time consuming (41% up to 10 minutes and 21% more than 20 minutes). Records were kept in only 36% of the cases and follow-up in 62%. Physicians who provided hallway medicine were also consumers of it (P < 0.001), based on personal acquaintance, time saved and easy accessibility. In general, the attitude to hallway medicine was negative (54%) or ambiguous (37%). Most requests for hallway medicine were made to Israeli-trained physicians, surgeons or gynecologists, and senior physicians.

CONCLUSIONS

Hallway medicine is practiced frequently among hospital physicians. A formal organization of health care service within medical centers might provide physicians with better medical care and reduce potential ethical, medical, legal, psychosocial and economic problems.

[Knowledge, attitudes and training of family physicians with regard to addiction to illicit drugs]

Substance abuse is one of the most serious problems in Israel. Recent studies show the situation is getting worse. The deleterious outcomes of psychoactive substance abuse include crime, car accidents, physical and mental illness, violence and work injuries. 48 family physicians in the Negev completed a questionnaire which included training, diagnostic and treatment skills, attitudes, knowledge and need for training in this field. 38 family physicians (81%) had had no training, most (96%) indicated the importance of such training. 34 (71%) said that their medical skills could not cope with the problems of addiction, and 29 (64.5%) claimed that the quality of care of addict patients is reduced because of lack of knowledge and diagnostic skills. These findings support the conclusion that efforts should be invested in training family physicians in the field of psychoactive drugs, licit and illicit.

Abdominal wall pain in pregnant women caused by thoracic lateral cutaneous nerve entrapment

Three pregnant women presented with disabling lower abdominal wall pain unresponsive to conventional therapies. The striking similarities among the clinical signs and symptoms prompted a review of the literature and led to the suspicion of thoracic lateral cutaneous nerve entrapment, a syndrome reported in other conditions, including after surgery, but not during pregnancy. Treatment by nerve block with local anesthetics was rapidly and completely successful in relieving the symptoms.

[Drinking and driving]

A worrisome connection between driving and drinking was found in 166 people randomly surveyed in public places in Beer Sheba. 80% of the study population stated that they drink alcoholic beverages. Of these, 45% reported drinking at least once a week, and 21% drank 3 glasses/cans at each drinking bout. We noted a trend among those who drank frequently to drink greater amounts. Of the sample, 110 interviewees stated that they had a driver's license and that they drank alcoholic drinks. 39% reported driving after a number of alcoholic drinks, and 23% of them did so invariably or frequently. 5% drank while driving. The drinkers exhibited a high-risk behavioral pattern, remaining in the car with friends (53%) or relatives (16%) also under the influence of alcohol. Those who are aware of the influence of alcohol on their driving skills and the danger of being involved in car accidents, moderate their consumption of alcohol. The results of the study confirm our hypothesis that there is an upswing in the phenomenon of high-risk driving connected with drinking alcoholic beverages.

Israeli college student alcohol use: the association of background characteristics and regular drinking patterns

In Israel, there is a lack of research regarding the association between background characteristics of university students and their use of alcohol. In response, a cohort of 1276 male and female undergraduate students was surveyed at a major university in the country. Among the study participants, 21% (270) reported regular, weekly use of alcohol. Men were much more inclined to drink on a weekly basis than women; and, 7% of the students who used alcohol regularly did so on a daily basis. Approximately 70% of the students who used alcohol drank in the company of friends; and, one-third of the alcohol using students reported that it was important to have their friends with them when they used the substance. Student background characteristics found to be associated with weekly alcohol use included: gender, age, country of origin, economic status, academic discipline, father's level of education, and parents' use of alcohol and legal medication. An important finding of this study was that 30% of the students who used alcohol reported driving a car after drinking and 3% of this sub-population drank while driving. Alcohol tends to be used and abused more than any other licit or illicit substance among Israeli university students. This issue, however, receives far less attention than illicit drug use in terms of education, public awareness. prevention and treatment activities. Alcohol use and abuse among university students in Israel is far from the major problem found elsewhere. Nevertheless, planned prevention and other forms of intervention are needed on campuses throughout the country.

A cis-acting DNA signal for encapsidation of simian virus 40

Encapsidation of simian virus 40 is a complex biological process involving DNA-protein and protein-protein interactions in the formation of a unique three-dimensional structure around the viral minichromosome. A pseudoviral system developed in our laboratory, in which the viral early and late gene products are supplied in trans (by helpers), was used to analyze the encapsidation process independent of viral gene expression. With this experimental system we have discovered a requirement for a specific DNA signal for encapsidation, ses (for simian virus 40 encapsidation signal).ses is present within a 200-bp DNA fragment, which includes, in addition to the viral origin of replication (ori), six GGGCGG repeats (GC boxes) and 26 bp of the enhancer element. Deletion of the GC boxes and the enhancer sequences almost abolished encapsidation, while DNA replication was only moderately decreased. The ability to encapsidate was not regained by reinserting a DNA fragment carrying ses in the sesdeleted plasmid 2 kbp away from the ori, suggesting that for encapsidation the two DNA elements have to be close to each other. These findings afford novel strategies for the investigation of viral encapsidation.

Helpers for efficient encapsidation of SV40 pseudovirions

Plasmid DNA that carries the simian virus 40 (SV40) ori can be packaged as SV40 pseudovirions. The pseudovirions are very efficient in gene transmission into a variety of cell types, including human hemopoietic cells. They are routinely prepared with wild-type (wt) SV40 as a helper. In the present study, several parameters required for the helper function were investigated. Plasmids that carry pBR322 sequences in addition to the late genes of SV40 were inefficient in providing helper functions, presumably because the prokaryotic sequences interfered with expression of the SV40 late genes. Efficient helpers were plasmid pSVPiC [Villarreal and Soo, Mol. Appl. Genet. 3 (1985) 62-71] and an SV40 defective virus SLT3 (presently constructed). Plasmid pSVPiC carries a duplication of the SV40 ori and enhancer regions, and pi AN7 sequences. Because of its large size it was not packaged into virion particles. However, it underwent extensive recombination generating infective SV40 particles. Almost no prokaryotic sequences are included in SLT3, that carries the SV40 late gene. In spite of its small size (3.5 kb) it was packaged efficiently, creating defective (T-antigen-negative) SV40 virions. The availability of T-antigen positive and negative pseudovirion mixtures enabled us to suggest that T-antigen drives gene amplification in the target human hemopoietic cells.

Efficient introduction of plasmid DNA into human hemopoietic cells by encapsidation in simian virus 40 pseudovirions

Introduction of DNA into human hemopoietic cells is required for the study of regulatory mechanisms operating in these cells, as well as for possible procedures of gene therapy. However, with hemopoietic cells the conventional technique of calcium phosphate precipitation is inefficient. The pathway of encapsidation of plasmid DNA as simian virus 40 (SV40) pseudovirions for the introduction of new genetic material was therefore investigated. Encapsidation was achieved in COS (monkey kidney) cells, which express SV40 large tumor (T) antigen constitutively. The vector, pSO, was introduced to the COS cells by DNA transfection. It carried the SV40 origin of replication (ori), to facilitate replication of the plasmid in the COS cells. The SV40 capsid proteins were supplied in trans by a helper SV40 virus. The bacterial chloramphenicol acetyltransferase gene cat was used as a model for gene transmission. After encapsidation, the pseudovirions were used in infection of the human erythroleukemic cell line K562 and of normal human bone marrow cells. The results demonstrate that the cat gene can be transmitted with high efficiency. Over 40% of the infected K562 cells and 30% of the infected bone marrow cells were observed to contain plasmid DNA 48 hr after infection. Moreover, the results suggest that the efficiency of gene transmission by this vector can be improved and so may approach the theoretical 100%.