Nanoparticle-based inhibition of vascular endothelial growth factor receptors alleviates osteoarthritis pain and cartilage damage

Osteoarthritis (OA) is characterized by cartilage damage, inflammation, and pain. Vascular endothelial growth factor receptors (VEGFRs) have been associated with OA severity, suggesting that inhibitors targeting these receptors alleviate pain (via VEGFR1) or cartilage degeneration (via VEGFR2). We have developed a nanoparticle-based formulation of pazopanib (Votrient), an FDA-approved anticancer drug that targets both VEGFR1 and VEGFR2 (Nano-PAZII). We demonstrate that a single intraarticular injection of Nano-PAZII can effectively reduce joint pain for a prolonged time without substantial side effects in two different preclinical OA rodent models involving either surgical (upon partial medial meniscectomy) or nonsurgical induction (with monoiodoacetate). The injection of Nano-PAZII blocks VEGFR1 and relieves OA pain by suppressing sensory neuronal ingrowth into the knee synovium and neuronal plasticity in the dorsal root ganglia and spinal cord. Simultaneously, the inhibition of VEGFR2 reduces cartilage degeneration. These findings provide a mechanism-based disease-modifying drug strategy that addresses both pain symptoms and cartilage loss in OA.

Repurposing Mitomycin C in Combination with Pentamidine or Gentamicin to Treat Infections with Multi-Drug-Resistant (MDR) Pseudomonas aeruginosa

The aims of this study were (i) to determine if the combination of mitomycin C with pentamidine or existing antibiotics resulted in enhanced efficacy versus infections with MDR P. aeruginosa in vivo; and (ii) to determine if the doses of mitomycin C and pentamidine in combination can be reduced to levels that are non-toxic in humans but still retain antibacterial activity. Resistant clinical isolates of P. aeruginosa, a mutant strain over-expressing the MexAB-OprM resistance nodulation division (RND) efflux pump and a strain with three RND pumps deleted, were used. MIC assays indicated that all strains were sensitive to mitomycin C, but deletion of three RND pumps resulted in hypersensitivity and over-expression of MexAB-OprM caused some resistance. These results imply that mitomycin C is a substrate of the RND efflux pumps. Mitomycin C monotherapy successfully treated infected Galleria mellonella larvae, albeit at doses too high for human administration. Checkerboard and time-kill assays showed that the combination of mitomycin C with pentamidine, or the antibiotic gentamicin, resulted in synergistic inhibition of most P. aeruginosa strains in vitro. In vivo, administration of a combination therapy of mitomycin C with pentamidine, or gentamicin, to G. mellonella larvae infected with P. aeruginosa resulted in enhanced efficacy compared with monotherapies for the majority of MDR clinical isolates. Notably, the therapeutic benefit conferred by the combination therapy occurred with doses of mitomycin C close to those used in human medicine. Thus, repurposing mitomycin C in combination therapies to target MDR P. aeruginosa infections merits further investigation.

Loss of PKCδ/Prkcd prevents cartilage degeneration in joints but exacerbates hyperalgesia in an experimental osteoarthritis mouse model

Pain is the prime symptom of osteoarthritis (OA) that directly affects the quality of life. Protein kinase Cδ (PKCδ/Prkcd) plays a critical role in OA pathogenesis; however, its significance in OA-related pain is not entirely understood. The present study investigated the functional role of PKCδ in OA pain sensation. OA was surgically induced in control (Prkcdfl/fl), global- (Prkcdfl/fl; ROSACreERT2), and sensory neuron-specific conditional knockout (cKO) mice (Prkcdfl/fl; NaV1.8/Scn10aCreERT2) followed by comprehensive analysis of longitudinal behavioral pain, histopathology and immunofluorescence studies. GlobalPrkcd cKO mice prevented cartilage deterioration by inhibiting matrix metalloproteinase-13 (MMP13) in joint tissues but significantly increased OA pain. Sensory neuron-specificdeletion of Prkcd in mice did not protect cartilage from degeneration but worsened OA-associated pain. Exacerbated pain sensitivity observed in global- and sensory neuron-specific cKO of Prkcd was corroborated with markedly increased specific pain mediators in knee synovium and dorsal root ganglia (DRG). These specific pain markers include nerve growth factor (NGF) and vascular endothelial growth factor (VEGF), and their cognate receptors, including tropomyosin receptor kinase A (TrkA) and vascular endothelial growth factor receptor-1 (VEGFR1). The increased levels of NGF/TrkA and VEGF/VEGFR1 were comparable in both global- and sensory neuron-specific cKO groups. These data suggest that the absence of Prkcd gene expression in the sensory neurons is strongly associated with OA hyperalgesia independent of cartilage protection. Thus, inhibition of PKCδ may be beneficial for cartilage homeostasis but could aggravate OA-related pain symptoms.

Targeting Vascular Endothelial Growth Factor Receptors as a Therapeutic Strategy for Osteoarthritis and Associated Pain

Pain is the major reason that patients suffering from osteoarthritis (OA) seek medical care. We found that vascular endothelial growth factors (VEGFs) mediate signaling in OA pain pathways. To determine the specific contributions of VEGFs and their receptors (VEGFRs) to joint pathology and pain transmission during OA progression, we studied intra-articular (IA) injections of VEGF ligands into murine knee joints. Only VEGF ligands specific for the activation of VEGFR1, but not VEGFR2, induced allodynia within 30 min. Interventions in OA by inhibitors of VEGFRs were done in vivo using a preclinical murine OA model by IA injections of selective inhibitors of VEGFR1/VEGFR2 kinase (pazopanib) or VEGFR2 kinase (vandetanib). OA phenotypes were evaluated using pain-associated murine behavioral tests and histopathologic analyses. Alterations in VEGF/VEGFR signaling by drugs were determined in knee joints, dorsal root ganglia, and spinal cord by immunofluorescence microscopy. Pazopanib immediately relieved OA pain by interfering with pain transmission pathways. Pain reduction by vandetanib was mainly due to the inhibition of cartilage degeneration by suppressing VEGFR2 expression. In conclusion, IA administration of pazopanib, which simultaneously inhibits VEGFR1 and VEGFR2, can be developed as an ideal OA disease-modifying drug that rapidly reduces joint pain and simultaneously inhibits cartilage degeneration.

Enzyme treatment of red blood cells: use of ficin and papain

Proteolytic enzymes are used to treat red blood cells (RBCs) to aid in complex antibody identification. Although there are many enzymes that can be used, for the purpose of this method review, enzyme-treated RBCs refers only to RBCs treated with ficin or papain. Ficin and papain can increase the sensitivity of antibody detection by modifying the RBC membrane. Enzyme treatment and test methods can be performed using one-stage or two-stage procedures. Enzyme treatment is especially useful for the differentiation of multiple antibodies, enhancement of detection of weak antibodies, and adsorption methods. In all cases, quality control is required to ensure adequate treatment of RBCs before additional testing. Ficin and papain are useful tools for both immunohematology reference laboratories and transfusion services.

Gut-microbiota modulation: The impact of thegut-microbiotaon osteoarthritis

Osteoarthritis (OA) is one of the most common medical conditions affecting > 300 million people globally which represents the formidable public health challenge. Despite its clinical and financial ramifications, there are currently no approved disease modifying OA drugs available and symptom palliation is the only alternative. Currently, the amount of data on the human intestinal microbiome is growing at a high rate, both in health and in various pathological conditions. With an increase in the amount of the accumulated data, there is an expanded understanding that the microbiome provides compelling evidence of a link between thegut microbiomeand development ofOA. The microbiota management tools of probiotics and/or prebiotics or symbiotic have been developed and indeed, commercialized over the past few decades with the expressed purpose of altering the microbiota within the gastrointestinal tract which could be a potentially novel intervention to tackle or prevent OA. However, the mechanisms how intestinal microbiota affects the OA pathogenesis are still not clear and further research targeting specific gut microbiota or its metabolites is still needed to advance OA treatment strategies from symptomatic management to individualized interventions of OA pathogenesis. This article provides an overview of the various preclinical and clinical studies using probiotics and prebiotics as plausible therapeutic options that can restore the gastrointestinal microbiota and its impact on the OA pathogenesis. May be in the near future the targeted alterations of gut microbiota may pave the way for developing new interventions to prevent and treat OA.

Short communication: Survival of replacement kids from birth to mating on commercial dairy goat farms in New Zealand

Commercial dairy goat systems rely on the successful rearing of kids for herd replacement. The objectives of this study were to (1) determine survival from birth until mating for a large cohort of commercial dairy goat kids; (2) descriptively summarize the causes of mortality and removal from the herd during this period; and (3) compare actual (determined by postmortem examination) and suspected (farmer-reported) causes of mortality. A total of 1,262 female kids were enrolled at birth on 16 commercial dairy goat farms in New Zealand. Median ages at weaning and mating were 86 d [minimum = 54, quartile (Q)1 = 78, Q3 = 97, maximum = 144] and 223 d (minimum = 183, Q1 = 208, Q3 = 237, maximum = 310), respectively. Overall, 87.1% (1,099/1,262) of kids remained on farm at mating, 10.4% (131/1,262) died or were euthanized, and 2.5% (32/1,262) were lost to follow-up or sold. Mortality risk was greatest in early life, with more than 90% of deaths occurring before weaning. Mortality from enrollment to mating varied between farms (minimum = 0%, Q1 = 5.9%, median = 8.9%, Q3 = 15.8%, maximum = 20.5%). The leading cause of death was gastrointestinal disorders (33.6%, 36/107), followed by disbudding-related injury (15.9%, 17/107), and septicemia (12.1%, 13/107). Farmers correctly identified approximately half of the deaths attributed to gastrointestinal disorders (56.0%, 14/25) and disbudding-related injury (44.4%, 4/9), but were less successful at diagnosing septicemia (0%, 0/5), starvation or dehydration (0%, 0/4), and suffocation (18.8% 3/16). This is the largest cohort of dairy goat kids to be systematically followed over time to confirm survival until mating and to determine causes of death by postmortem examination. We found that kid mortality was highest during the preweaning period and there was often a discrepancy between farmer-perceived and actual cause of death. Postmortem examinations should be more widely used to establish causes of death and inform on-farm strategies to reduce kid mortality.

A critical review of the potential impacts of marine seismic surveys on fish & invertebrates

Marine seismic surveys produce high intensity, low-frequency impulsive sounds at regular intervals, with most sound produced between 10 and 300Hz. Offshore seismic surveys have long been considered to be disruptive to fisheries, but there are few ecological studies that target commercially important species, particularly invertebrates. This review aims to summarise scientific studies investigating the impacts of low-frequency sound on marine fish and invertebrates, as well as to critically evaluate how such studies may apply to field populations exposed to seismic operations. We focus on marine seismic surveys due to their associated unique sound properties (i.e. acute, low-frequency, mobile source locations), as well as fish and invertebrates due to the commercial value of many species in these groups. The main challenges of seismic impact research are the translation of laboratory results to field populations over a range of sound exposure scenarios and the lack of sound exposure standardisation which hinders the identification of response thresholds. An integrated multidisciplinary approach to manipulative and in situ studies is the most effective way to establish impact thresholds in the context of realistic exposure levels, but if that is not practical the limitations of each approach must be carefully considered.

Segregation or aggregation? Sex-specific patterns in the seasonal occurrence of white sharks Carcharodon carcharias at the Neptune Islands, South Australia

The seasonal patterns of occurrence of male and female white sharks Carcharodon carcharias at the Neptune Islands in South Australia were reviewed. Analyses of a 14 year data series indicate that females seasonally aggregate in late autumn and winter coinciding with the maximum in-water availability of lactating female long-nose fur seals and seal pups. During this period, observed male:female sex ratios were similar; whereas during late spring and summer, males continued to visit, but females were rarely recorded. There was no evidence for segregation by sex or size at the Neptunes, but the highly focused seasonal pattern of occurrence of females compared with the year-round records of males suggests that there are likely to be differences between the sexes in overall distribution and movement patterns across southern Australia. It is suggested that foraging strategies and prey selection differ between sexes in C. carcharias across the life-history stages represented and that sex-specific foraging strategies may play an important role in structuring movement patterns and the sex ratios observed at such aggregation sites. Differences between sexes in distribution, movement patterns and foraging strategies are likely to have implications for modelling the consequences of fisheries by-catch between regions or jurisdictions and other spatially or temporally discrete anthropogenic effects on C. carcharias populations. Such differences urge for caution when estimating the size of C. carcharias populations based on observations at pinniped colonies due to the likelihood of sex-specific differences in movements and patterns of residency. These differences also suggest a need to account for sex-specific movement patterns and distribution in population and movement models as well as under conservation actions.

Salvage of contaminated osteochondral allografts: the effects of chlorhexidine on human articular chondrocyte viability

BACKGROUND

Because chondrocyte viability is imperative for successful osteochondral allograft transplantation, sterilization techniques must provide antimicrobial effects with minimal cartilage toxicity. Chlorhexidine gluconate (CHG) is an effective disinfectant; however, its use with human articular cartilage requires further investigation.

PURPOSE

To determine the maximal chlorhexidine concentration that does not affect chondrocyte viability in allografts and to determine whether this concentration effectively sterilizes contaminated osteoarticular grafts.

STUDY DESIGN

Controlled laboratory study.

METHODS

Osteochondral plugs were subjected to pulse lavage with 1-L solutions of 0.002%, 0.01%, 0.05%, and 0.25% CHG and cultured for 0, 1, 2, and 7 days in media of 10% fetal bovine serum and antibiotics. Chondrocyte viability was determined via LIVE/DEAD Viability Assay. Plugs were contaminated with Staphylococcus aureus and randomized to 4 treatment groups. One group was not contaminated; the 3 others were contaminated and received no treatment, saline pulse lavage, or saline pulse lavage with 0.002% CHG. Serial dilutions were plated and colony-forming units assessed.

RESULTS

The control group and the 0.002% CHG group showed similar cell viability, ranging from 67% ± 4% to 81% ± 22% (mean ± SD) at all time points. In the 0.01% CHG group, cell viability was reduced in comparison with control by 2-fold at day 2 and remained until day 7 (P < .01). The 0.05% and 0.25% CHG groups showed a 2-fold reduction in cell viability at day 1 (P < .01). At day 7, cell viability was reduced to 15% ± 18% (4-fold decrease) for the 0.05% CHG group and 10% ± 19% (6-fold decrease) for the 0.25% CHG group (P < .01). Contaminated grafts treated with 0.002% CHG demonstrated no colony-forming units.

CONCLUSION

Pulse lavage with 0.002% CHG does not cause significant cell death within 7 days after exposure, while CHG at concentrations >0.002% significantly decreases chondrocyte viability within 1 to 2 days after exposure and should therefore not be used for disinfection of osteochondral allograft. Pulse lavage does not affect chondrocyte viability but cannot be used in isolation to sterilize contaminated fragments. Overall, 0.002% CHG was shown to effectively decontaminate osteoarticular fragments.

CLINICAL RELEVANCE

This study offers a scientific protocol for sterilizing osteochondral fragments that does not adversely affect cartilage viability.

Subpectoral biceps tenodesis for failed type II SLAP repair

Superior labrum anterior-posterior lesions are a common cause of shoulder pain. The diagnosis, classification, and indications for surgical intervention remain controversial, and mixed outcomes are associated with primary repair. Given the increasing prevalence of primary superior labrum anterior-posterior repairs in the United States, more surgeons will need to treat patients with poor primary results. A retrospective review of prospectively collected data was performed on patients who underwent subpectoral biceps tenodesis for failed type II superior labrum anterior-posterior repair by a single surgeon between January 2008 and December 2011. Primary outcome variables included pain via the visual analog scale, American Shoulder and Elbow Surgeons score, and Short Form 12 score. Secondary outcome variables included the Simple Shoulder Test and Single Assessment Numeric Evaluation scores. Demographic and intraoperative information was recorded for each patient. A paired t test statistical analysis was performed with a P value less than .05 considered statistically significant. A total of 11 patients met the inclusion criteria. Of these patients, 9 (82%) completed postoperative surveys at a mean 26-month follow-up. Mean visual analog scale scores improved from 4.1 to 2.5 (P=.03), Simple Shoulder Test scores from 5.4 to 9.3 (P=.005), American Shoulder and Elbow Surgeons scores from 54.5 to 78.0 (P=.002), and Single Assessment Numeric Evaluation scores from 42.5 to 70.4 (P=.001). Mean SF-12 (physical component) improved from 35.5 to 47.9 (P=.018). No failures or peri- or postoperative complications occurred. No patients required additional surgery. The findings suggest that subpectoral biceps tenodesis as a salvage for failed type II superior labrum anterior-posterior repair demonstrates improved results. Larger scale comparative studies are required to justify this technique.

A review of modern management of lateral epicondylitis

Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A "watch-and-wait" approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

Disability outcomes and dose escalation with etanercept, adalimumab, and infliximab in rheumatoid arthritis patients: a US-based retrospective comparative effectiveness study

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic disease that if left untreated may substantially impair physical functioning. Etanercept, infliximab, and adalimumab are tumor necrosis factor (TNF) blockers whose FDA-approved indications in the US include moderate to severe RA. TNF-blocker dose escalation has been well documented in the literature; however, the comparative effectiveness of these agents remains uncertain.

OBJECTIVE

To compare the effectiveness and dose escalation rates of etanercept, adalimumab, and infliximab in US community settings. We hypothesized that etanercept would be equivalent to infliximab and adalimumab in patient-reported disability 9-15 months after therapy initiation, and that fewer etanercept patients would experience dose escalation.

METHODS

This is a retrospective analysis of the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS). Adult patients with no biologic use 6 months before TNF-blocker initiation (index) and with Health Assessment Questionnaire Disability Index (HAQ-DI) scores at index and 9-15 months after index were analyzed (218 etanercept, 93 infliximab, and 40 adalimumab).

RESULTS

HAQ-DI change scores at 9-15 months did not differ by treatment (-0.12, -0.10, and -0.08 points for etanercept, infliximab, and adalimumab, respectively; p = 0.52). Dose increases were observed in 1.4% of etanercept, 10.8% of infliximab (p < 0.001), and 12.5% of adalimumab patients (p = 0.004). HAQ-DI change was associated with pre-index HAQ-DI score (p < 0.0001) and disease duration (p = 0.001).

CONCLUSIONS

Fewer etanercept patients escalated dose than infliximab or adalimumab patients, but improvements in functional disability were similar. These differences may have been influenced by package labeling, mode of administration, or other factors. RA treatment with infliximab and adalimumab in community settings, characterized by dose escalation, did not yield greater disability improvements compared to etanercept, which remained at a relatively stable dose. Uncontrolled treatment selection in this observational design may have influenced outcomes, and prior methotrexate treatment may partly explain disability improvements smaller than typically observed in clinical trials.

Initial fixation strength of transosseous-equivalent suture bridge rotator cuff repair is comparable with transosseous repair

BACKGROUND

The outcome of rotator cuff repair correlates with tendon healing. Early studies of arthroscopic rotator cuff repair demonstrate lower healing rates than traditional open techniques. Transosseous-equivalent repair techniques (suture bridge) were developed to improve the initial fixation strength.

PURPOSE

To compare the initial in vitro tensile fixation strength of a transosseous-equivalent suture bridge (TOE-SB) rotator cuff repair construct to a traditional transosseous (TO) suture construct.

STUDY DESIGN

Controlled laboratory study.

METHODS

Identical simulated rotator cuff tears were created on 8 matched pairs of humeri. Each matched pair underwent repair with 4 sutures using either the TOE-SB or TO technique. Initial fixation strength was tested in a custom testing jig. Each shoulder underwent 1000 cycles each of low and then high load testing. Gap displacement was measured at anterior and posterior sites of the repair with digital video tracking of paired reflective markers and recorded at predetermined cycle intervals.

RESULTS

There were no statistically significant differences in gap formation at the repair sites under low or high load conditions between TOE-SB and TO techniques. The mean maximal gap formation of the repairs during low load testing in the TOE-SB and TO constructs was 0.93 ± 0.88 mm and 0.55 ± 0.22 mm, respectively (P = .505). The mean maximal gap formation during high load testing in the TOE-SB and TO constructs was 2.04 ± 1.10 mm and 2.28 ± 1.62 mm, respectively (P = .517). The most significant increase in gap distance occurred at the transition from low load to high load in both constructs. Most of the incremental displacement occurred within the first 100 cycles for both high and low load testing (P < .001).

CONCLUSION

The arthroscopic TOE-SB technique is comparable in initial fixation strength to the traditional TO simple suture repair technique.

CLINICAL RELEVANCE

Arthroscopic techniques can achieve initial fixation strength comparable with traditional TO techniques performed without suture anchors.

Are dropped osteoarticular bone fragments safely reimplantable in vivo?

BACKGROUND

There are limited data detailing the appropriate management of nondisposable autologous osteoarticular fragments that have been contaminated by the operating room floor. The goal of the present study was to perform a comprehensive, three-phase investigation to establish an appropriate intraoperative algorithm for the management of the acutely contaminated, but nondisposable, autologous osteoarticular bone fragment.

METHODS

Phase I of the study was performed to quantify the rate of contamination and microbial profile of human osteoarticular fragments that were dropped onto the operating room floor (n = 162). Phase II was performed to assess the feasibility and optimal means of decontaminating 340 similar fragments that underwent controlled contamination with bacteria that were identified in Phase I; decontamination was performed with use of cleansing agents that are routinely available in an operating room. Phase III was performed to assess the effect of each decontamination process on fragment chondrocyte viability through histologic evaluation.

RESULTS

The contamination rate in Phase I was 70%. Coagulase-negative Staphylococcus was the most commonly cultured organism. In Phase II, varying exposure time to the chemical agents did not make a significant difference in decontamination rates. Mechanical scrubbing was superior to mechanical saline solution lavage (zero of fifty-six cultures compared with twenty of fifty-six cultures were positive for coagulase-negative Staphylococcus; p < 0.001). As a whole, bactericidal agents were found to be more effective decontaminating agents than normal saline solution. Povidone-iodine and 4% chlorhexidine gluconate were the most effective decontaminating agents, with none of the twenty-eight specimens that were decontaminated with each agent demonstrating positive growth on culture. Phase III demonstrated that the groups that were treated with normal saline solution and povidone-iodine retained the greatest number of live cells and the least number of dead cells. Mechanical scrubbing significantly decreased chondrocyte viability as compared with a normal saline solution wash (p < 0.05).

CONCLUSIONS

The majority of osteochondral fragments that contact the operating room floor produce positive bacterial cultures. Five minutes of cleansing with a 10% povidone-iodine solution followed by a normal saline solution rinse appears to provide the optimal balance between effective decontamination and cellular toxicity for dropped autologous bone in the operative setting.

The value of DNA paternity identification in beef cattle: Examples from Nevada's free-range ranches1

The feasibility and economic value of DNA paternity identification were investigated and illustrated using Nevada beef cattle operations. A panel of 15 microsatellites was genotyped in 2,196 animals from 8 ranches with a total of 31,571 genotypes. Probabilities of exclusion for each marker within ranch and across ranches were computed. Joint probabilities of exclusion for the 15 microsatellites were also determined, resulting in values over 0.99 for any individual ranch and across ranches. Dropping 1 or 2 microsatellites with the lowest probabilities of exclusion resulted in joint probabilities greater than 0.99 and with marginal reduction compared with the probabilities with 15 microsatellites. Formulas for benefit-cost analysis for a DNA paternity identification program in beef cattle were derived. Genotyping 15 microsatellites with 20 calves per sire resulted in benefits of $1.71 and $2.44 per dollar invested at bull culling rates of 0.20 and 0.30, respectively. The breakpoints for the program to be profitable occurred when the ratio of the price of 1 kg of calf liveweight over the cost of genotyping 1 microsatellite was greater than 1.1 for a bull culling rate of 0.30. Benefit-cost analysis was also derived under incomplete DNA paternity identification using a lower number of DNA markers than necessary to achieve joint probabilities of exclusion of 0.99. Approximately a 20% increase in the benefit-cost ratio was achieved using 10 vs. 12 microsatellites with incomplete paternity identification. The greater the number of bulls in the operation, the lower the benefit-cost ratio of the paternity testing program. Low probabilities of exclusion and a high number of bulls in the beef operation reduced the benefit-cost ratio dramatically. The DNA paternity identification programs are feasible and may be profitable for free-range beef cattle operations.

More relevant, precise, and efficient items for assessment of physical function and disability: moving beyond the classic instruments

OBJECTIVES

Patient reported outcomes (PROs) have become standard study endpoints. However, little attention has been given to using item improvement to advance PRO performance which could improve precision, clarity, patient relevance, and information content of "physical function/disability" items and thus the performance of resulting instruments.

METHODS

The present study included 1860 physical function/disability items from 165 instruments. Item formulations were assessed by frequency of use, modified Delphi consensus, respondent judgement of clarity and importance, and item response theory (IRT). Data from 1100 rheumatoid arthritis, osteoarthritis, and normal ageing subjects, using qualitative item review, focus groups, cognitive interviews, and patient survey were used to achieve a unique item pool that was clear, reliable, sensitive to change, readily translatable, devoid of floor and ceiling limitations, contained unidimensional subdomains, and had maximal information content.

RESULTS

A "present tense" time frame was used most frequently, better understood, more readily translated, and more directly estimated the latent trait of disability. Items in the "past tense" had 80-90% false negatives (p<0.001). The best items were brief, clear, and contained a single construct. Responses with four to five options were preferred by both experts and respondents. The term physical function may be preferable to the term disability because of fewer floor effects. IRT analyses of "disability" suggest four independent subdomains (mobility, dexterity, axial, and compound) with factor loadings of 0.81-0.99.

CONCLUSIONS

Major improvement in performance of items and instruments is possible, and may have the effect of substantially reducing sample size requirements for clinical trials.

Expression of the cytoskeleton linker protein ezrin in human cancers

Expression of the metastasis-associated protein, ezrin, in over 5,000 human cancers and normal tissues was analyzed using tissue microarray immunohistochemistry. Ezrin staining was compared between cancers and their corresponding normal tissues, between cancers of epithelial and mesenchymal origin, in the context of the putative inhibitor protein, merlin, and against clinicopathological data available for breast, lung, prostate cancers and sarcomas. Ezrin was found in most cancers and normal tissues at varying levels of intensity. In general ezrin was expressed at higher levels in sarcomas than in carcinomas. By normalizing the expression of ezrin in each cancer using ezrin expression found in the corresponding normal tissue, significant associations between ezrin were found in advancing histological grade in sarcomas (P = 0.02) and poor outcome in breast cancer (P = 0.025). Clinicopathologic associations were not changed by simultaneous assessment of ezrin and merlin in each patient sample for the cancer types examined. These data support a role for ezrin in the biology of human cancers and the need for additional studies in breast cancer and sarcoma patients that may validate ezrin as a marker of cancer progression and as a potential target for cancer therapy.

The Health Assessment Questionnaire (HAQ)

Patient-reported outcomes (PROs) provide intrinsic knowledge about a patient's health, functional status, symptoms, treatment preferences, satisfaction, and quality of life. They have become an established approach for assessing health outcomes. The Health Assessment Questionnaire (HAQ), introduced in 1980, is among the first PRO instruments designed to represent a model of patient-oriented outcome assessment. The HAQ is based on five patient-centered dimensions: disability, pain, medication effects, costs of care, and mortality. It has been validated by mail, in the office, by telephone, and by comparison with paraprofessional and physician judgments as a reliable instrument, and has been significantly correlated with other PRO instruments. Typically, one of two HAQ versions is used: the Full HAQ, which assesses all five dimensions, and the Short or 2-page HAQ, which contains only the HAQ disability index (HAQ-DI) and the HAQ's patient global and pain visual analog scales (VAS). The HAQ-DI and the global and pain VAS (i.e., the short HAQ) have essentially retained their original content since their inception, while the Full HAQ undergoes periodic revision to address issues of contemporary scientific interest. The HAQ-DI has been translated or culturally adapted into more than 60 different languages or dialects and has become part of the National Institutes of Health "Road-map" Project, the Patient-Reported Outcomes Measurement Information System (PROMIS).

The promise of PROMIS: using item response theory to improve assessment of patient-reported outcomes

PROMIS (Patient-Reported-Outcomes Measurement Information System) is an NIH Roadmap network project intended to improve the reliability, validity, and precision of PROs and to provide definitive new instruments that will exceed the capabilities of classic instruments and enable improved outcome measurement for clinical research across all NIH institutes. Item response theory (IRT) measurement models now permit us to transition conventional health status assessment into an era of item banking and computerized adaptive testing (CAT). Item banking uses IRT measurement models and methods to develop item banks from large pools of items from many available questionnaires. IRT allows the reduction and improvement of items and assembles domains of items which are unidimensional and not excessively redundant. CAT provides a model-driven algorithm and software to iteratively select the most informative remaining item in a domain until a desired degree of precision is obtained. Through these approaches the number of patients required for a clinical trial may be reduced while holding statistical power constant. PROMIS tools, expected to improve precision and enable assessment at the individual patient level which should broaden the appeal of PROs, will begin to be available to the general medical community in 2008.

The Arthritis, Rheumatism and Aging Medical Information System (ARAMIS): still young at 30 years

Chronic diseases such as atherosclerosis, arthritis, diabetes, and cancer are among major public health concerns. To understand their cumulative risk factors and antecedents, a chronic disease databank consisting of time-oriented, multidisciplinary longitudinal data, prospectively collected on consecutive patients and describing their clinical courses, provides a systematic anthology of patient reported outcome (PRO) data. ARAMIS, which began in the mid-1970s, was the first large-scale chronic disease data bank system. Outcomes data are collected using the Health Assessment Questionnaire (HAQ), a well established PRO instrument that collects patient-centered data in the areas of disability, pain and other symptoms, adverse effects of treatment, economic impact, and mortality. More than 900 peer-reviewed studies have emanated from ARAMIS since its inception. In the earlier days, and even today, ARAMIS had to invent its own tools for the study of these new sciences. ARAMIS has made dominant contributions to the understanding of PROs and to helping improve treatment and health outcomes in rheumatoid arthritis (RA), osteoarthritis (OA), scleroderma, lupus, aging, and drug side effects. It continues to traverse terrain with participation in the NIH "Roadmap" project, the Patient Reported Outcome Measurement Information System (PROMIS). PROMIS is designed to provide improved assessment of health status across all chronic illnesses as part of an improved infrastructure for clinical research. As initiator of the rich history of chronic disease data banks with "rolling" consecutive open patient cohorts, ARAMIS has enabled the study of real-world PROs in rheumatology, with a wealth of resultant improved approaches to treatment, outcome, cost effectiveness, and quality of life.

Group interventions for the prevention of injuries in young children: a systematic review

OBJECTIVE

This systematic review examined group based injury prevention interventions that targeted young children to determine the effectiveness of such strategies in enhancing children's safety behaviors.

METHODS

A comprehensive (manual and electronic) search of the literature was performed using the following study selection criteria: (1) intervention engaged children under the age of 6 years; (2) included a control group; (3) used a group intervention approach; (4) study written in English language; (5) addressed unintentional injuries; and (6) outcomes included injuries, knowledge, or safety behaviors. Data abstraction was performed independently by two researchers using a standardized approach.

RESULTS

Nine studies met the criteria that included safety interventions of road crossing (4), car restraint (2), spinal cord safety (1), poison safety (1), and 911/stranger danger/street crossing (1). The types of interventions included videos, interactive activities, cartoons, stories, puppets, singing, coloring, games, simulation games, demonstrations, modeling/role playing, and rehearsal practice using seat belts, models, and real street crossing. The intensity and duration of interventions varied substantially and only two studies randomly assigned participants. The review revealed a positive effect (knowledge, behaviour, and/or attitude) for five of the studies, three had mixed effect, and one reported no effect.

CONCLUSIONS

Although no clear conclusions can be drawn from the limited number of studies of diverse design and rigor, researchers should attempt to minimize shortcomings occurring in community based research. Engaging community partners including teachers and parents who influence relationships and outcomes could provide opportunity for more rigorous, comprehensive, and integrated approach to longitudinal research that could identify key factors of successful strategies.

Cations reduce antimicrobial efficacy of lysozyme-chelator combinations

Reduction of the antimicrobial efficacy of lysozyme-chelator combinations against two Escherichia coli O157:H7 strains on addition of mineral salts was studied. The objective of the study was to determine the effect of type and concentration of mono-, di-, and trivalent mineral salts on the antimicrobial effectiveness of lysozyme and various chelators against E. coli O157:H7. Seven salts (Al3+, Ca2+, Fe2+, Fe3+, K+, Mg2+, and Na+) at 1 to 10 mM were added to aqueous solutions of lysozyme and disodium ethylenediamine tetraacetic acid (EDTA), disodium pyrophosphate (DSPP), or pentasodium tripolyphosphate (PSTPP) at pH 6, 7, or 8 and applied to cultures of E. coli O157:H7 strains 932 and H1730. Inhibitory activity of lysozyme chelator combinations against both strains was completely lost after addition of > or = 1 mM Ca2+ and Mg2+ at pH 7 and 8. At pH 6, antimicrobial activity of lysozyme-EDTA against both strains was retained in the presence of calcium or magnesium cations. DSPP-lysozyme inhibited strain H1730 at pH 6 despite the presence of Mg2+. Concentrations above 4 mM Fe2+ neutralized activity of all lysozyme-chelator combinations. Reversal of inhibition by lysozyme-chelator complexes by the monovalent Na+ and K+ ions depended on E. coli O157:H7 strain type. Neither monovalent cation reversed inhibition of strain 932. However, Na+ and K+ reversed lysozyme-chelator inhibition of strain H1730. The addition of > or = 1 mM Fe3+ or Al3+ was effective in reversing inhibition of both strains by lysozyme and EDTA at pH 6, 7, and 8. Isothermal titration calorimetry was used to determine the amount of ion-specific competitive binding of free cations by EDTA-lysozyme combinations. A mechanistic model for the antimicrobial functionality of chelator-lysozyme combinations is proposed.

Identifying children at risk for language impairment: screening of communication at 18 months

AIM

To investigate the possibility of identifying children at risk for language impairment based on a new screening instrument to assess communication and language skills at 18 mo of age.

METHODS

At 18 mo, 58 children were assessed with a screening instrument for communication and language consisting of a professional assessment and a parents' questionnaire. Students of speech and language pathology, well trained in child language assessment, carried out the professional assessment, which was based on observations of play behaviour, interaction and expressive and receptive language skills. Of the 58 children, 43 attended a follow-up assessment of language skills at 54 mo of age.

RESULTS

Nine children were considered to be at risk for language impairment at 18 mo and 10 children were evaluated as being at risk at 54 mo. A significant positive correlation was found between the professional evaluations at 18 mo and the language tests at 54 mo. Verbal comprehension and pretend play correlated significantly with the results on the language tests.

CONCLUSION

A professional screening of communication and language at 18 mo of age is worthwhile for predicting problems in language development. The results further show that language comprehension and pretend play rather than expressive skills should be emphasized.

Unintentional traumatic brain injury in children: the lived experience

Brain injury is a major cause of injury death and long-term neurological impairment in children often requiring long-term support. Despite the significance and frequency of such injuries, very little is known about the circumstances of these injuries, the long-term outcomes and family support needs. In this pilot study of 10 families of children with traumatic brain injury, participants described a variety of factors which contributed to their child's injury (inattentiveness, unfamiliarity, developmental level, lack of protective gear, invulnerability, peer pressure, environmental hazards and lack of supervision). As a result of their child's injury, family members described fundamental shifts in how they view life and that the roles and responsibilities of family members changed drastically. Study families experienced sustained uncertainty and described the impact on family relationships. While social support was clearly a mediating factor, families described the need for ongoing support and services to help them adapt to new roles, cope with new challenges, and manage sequellae such as post-traumatic headaches, epilepsy, learning difficulties and behavioural problems. The study findings represent an initial attempt to develop knowledge upon which focussed injury prevention interventions can be developed. Furthermore, this information will assist in the determination of appropriate health, rehabilitative, and educational support services for children with brain injuries. Involving families in this way will enhance the implementation of practical and useful support services for families of children with brain injuries.

Working toward an ethical anthropology. Where do we go from here?

This article posits an ethical anthropology for the 21st century that addresses and informs our understanding of international conflict situations and their solutions while providing methodologies for anthropologists of color to position their issues of concern at the center of social science discourse.

A diet high in whole and unrefined foods favorably alters lipids, antioxidant defenses, and colon function

OBJECTIVE

Diets rich in whole and unrefined foods, like whole grains, dark green and yellow/orange-fleshed vegetables and fruits, legumes, nuts and seeds, contain high concentrations of antioxidant phenolics, fibers and numerous other phytochemicals that may be protective against chronic diseases. This study compared the effects of a phytochemical-rich diet versus a refined-food diet on lipoproteins, antioxidant defenses and colon function.

METHODS

Twelve hyperlipidemic women followed two diets for four weeks starting with a refined-food diet. Subjects then directly crossed over to the phytochemical-rich diet. Duplicate, fasting serum lipids and single, fasting antioxidant enzymes were measured at the end of the four-week refined-food diet period (baseline) and again at the end of the phytochemical-rich diet period.

RESULTS

Total energy and total fat intake were similar during both diet periods, but there was a decrease in saturated fat (SFA) of 61% in the phytochemical-rich diet group. Dietary fiber, vitamin E, vitamin C and carotene intakes were 160%, 145%, 160% and 500% more, respectively, than during the refined-food diet period. The phytochemical-rich diet induced a drop of 13% in total cholesterol (TC) (p < 0.05) and 16% (p < 0.001) in low density lipoprotein-cholesterol (LDL-C). Erythrocyte superoxide dismutase decreased 69% (p < 0.01) and glutathione peroxidase dropped 35% (p < 0.01). Colon function was improved on the phytochemical-rich diet.

CONCLUSIONS

A diet abundant in phytochemically-rich foods beneficially affected lipoproteins, decreased need for oxidative defense mechanisms and improved colon function.

Nuts and plasma lipids: an almond-based diet lowers LDL-C while preserving HDL-C

OBJECTIVE

To compare lipid-altering effects of an almond-based diet with an olive oil-based diet, against a cheese and butter-based control diet.

METHODS

Forty-five free-living hyperlipidemic men (n = 12) and women (n = 33) with a mean plasma total cholesterol (TC) of 251 +/- 30 mg/dL followed one of three diets; almond-based, olive oil-based, or dairy-based for 4 weeks. Total fat in each diet was matched, and the study-provided sources of fat comprised the major portion of fat intake.

RESULTS

Reductions in TC and low-density lipoprotein-cholesterol (LDL-C) between the three groups were significantly different from the almond group (both p < 0.001). Within group analysis revealed that the almond-based diet induced significant reductions in TC (p < 0.05), LDL-C (p < 0.001), and the TC:HDL ratio (p < 0.001), while HDL-C levels were preserved. TC and HDL-C in the control diet were significantly increased from baseline (both p < 0.05), while the olive oil-based diet resulted in no significant changes over the study period. Weight did not change significantly.

CONCLUSION

Results suggest that the more favorable lipid-altering effects induced by the almond group may be due to interactive or additive effects of the numerous bioactive constituents found in almonds.

The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults

OBJECTIVES

This study was undertaken to test the effectiveness of the Stanford Nutrition Action Program, an experimental trial to reduce dietary fat intake among low-literacy, low-income adults.

METHODS

Twenty-four paired adult education classes (351 participants, 85% women, mean age = 31 years) were randomly assigned to receive a newly developed dietary fat curriculum (the Stanford Nutrition Action Program) or an existing general nutrition curriculum. Food frequency and nutrition-related data, body mass index, and capillary blood cholesterol were collected at baseline and at two postintervention follow-ups.

RESULTS

The Stanford Nutrition Action Program classes showed significantly greater net improvements in nutrition knowledge (+7.7), attitudes (/0.2), and self-efficacy (-0.2) than the general nutrition classes; they also showed significantly greater reductions in the percentage of calories from total (-2.3%) and saturated (-0.9%) fat. There were no significant differences in body mass index or blood cholesterol. All positive intervention effects were maintained for 3 months postintervention.

CONCLUSIONS

The Stanford Nutrition Action Program curriculum, tailored to the cultural, economic, and learning needs of low-literacy, low-income adults, was significantly more effective in achieving fat-related nutritional changes than the general nutrition curriculum.

Predicting achievement of a low-fat diet: a nutrition intervention for adults with low literacy skills

BACKGROUND

This paper identifies factors that predict achievement of a low-fat diet among 242 California adults with low literacy skills, following their participation in the Stanford Nutrition Action Program (SNAP), a randomized classroom-based nutrition intervention trial (1993-1994).

METHODS

The intervention classes received a newly developed curriculum that focuses on reducing dietary fat intake (SNAP); the control classes received an existing general nutrition (GN) curriculum. Data were collected at baseline and 3 months postintervention. This hypothesis-generating analysis uses a signal detection method to identify mutually exclusive groups that met the goal of a low fat diet, defined as < 30% of calories from total fat, at 3 months postintervention.

RESULTS

Three mutually exclusive groups were identified. Twenty-three percent of Group 1, participants with high baseline dietary fat (> 60 g) who received either the GN or the SNAP curriculum, met the postintervention goal of < 30% of calories from total fat. Thirty-four percent of Group 2, participants with moderate baseline dietary fat (< or = 60 g) who received the GN curriculum, were successful. Sixty percent of Group 3, participants with moderate baseline dietary fat who received the SNAP curriculum, were successful. Members of Group 3 also significantly increased their intake of vegetables, grains, and fiber.

CONCLUSIONS

Within this population of adults with low literacy skills, a large proportion of those with moderate baseline dietary fat who participated in the SNAP classes met the postintervention criteria for a low-fat diet. A much smaller proportion of those with high baseline dietary fat were successful, suggesting that this group may benefit from different, more intensive, or longer-term interventions.

Nurses' practices and perceptions of family-centered care

This exploratory, descriptive study examined pediatric nurses' perceptions and practices of family-centered care. Nurses (n = 124) indicated on the 55-item Family-Centered Care Questionnaire (FCCQ) whether the activity was necessary for family-centered care and was currently a part of their practice. Content validity, test-retest reliability, and internal consistency were good. The nurses perceived that they performed all elements significantly less in their current practice than they believed necessary. Their perceptions about the necessary components and their practices of family-centered care varied with their age and clinical position. Although nurses indicated knowledge of family-centered care, they reported that they did not incorporate this knowledge into their practice. Several issues, such as nurses' ability to practice family-centered care, the support of the hospital infrastructure provided for nurses to practice family-centered care, and nurses' perceptions of their role in caring for families, help to explain the findings.

Binge eating among the overweight population: a serious and prevalent problem

Obesity is a major public health problem in the United States and is now recognized as a heterogeneous condition. This suggests that treatment effectiveness may be improved with an increased understanding of the multiple factors contributing to obesity. Recent data clearly indicate that one common and serious factor among a subset of the overweight population is binge eating. Dietitians in research settings, clinical settings, or private practice are likely to treat obese patients who are seeking weight-related treatment. This article provides an overview of current knowledge about obese persons who binge eat and recommends that dietitians who treat patients for weight-related conditions take a proactive role by screening them for binge eating problems or, at a minimum, screen those who are suspected of binge eating and then refine treatment approaches accordingly.

Comparing the cost effectiveness of psychiatric treatments: bulimia nervosa

We conducted an exploratory post hoc study that compared the cost effectiveness of five treatments for bulimia nervosa: 15 weeks of cognitive behavioral therapy (CB) followed by three monthly sessions, 16 weeks (Med16) and 24 weeks (Med24) of desipramine (< or = 300 mg/day), and CB combined with desipramine for those durations (Combo16 and Combo24). We illustrate how a treatment's cost effectiveness varies according to when evaluation is done and how effectiveness and cost are defined. At 32 weeks, Med16 appears the most cost-effective treatment, and Combo16 appears the least. At 1 year, Med24 appears the most cost-effective treatment, and Combo16 appears the least. Using this post hoc analysis as an example, we discuss the pitfalls and limitations of cost-effectiveness analysis of psychiatric treatments.

One-year follow-up of psychosocial and pharmacologic treatments for bulimia nervosa

BACKGROUND

This study examined the outcome 1-year posttreatment of the use of desipramine, cognitive-behavioral therapy (CBT), and their combination in the treatment of bulimia nervosa.

METHOD

Sixty-one patients meeting DSM-III-R criteria for bulimia nervosa were randomly assigned to one of five groups--desipramine (withdrawn at 16 or 24 weeks), CBT (18 sessions), or the combined treatment (18 sessions of CBT plus desipramine withdrawn at 16 or 24 weeks)--and were followed to 1-year posttreatment.

RESULTS

At 1-year follow-up, both the combined 24-week treatment and CBT alone were significantly superior in reducing binge eating to desipramine given for 16 weeks. The combined treatment was also superior to 16 weeks of desipramine in reducing emotionally driven eating and dietary restraint. Only 18% (2 of 11) of those receiving 16 weeks of desipramine were free of binge eating and purging at follow-up compared with 78% (7 of 9) of those receiving the combined 24-week treatment. The other groups fell between these two extremes.

CONCLUSION

With the exception of the group treated for 16 weeks with desipramine alone, maintenance of improvement appeared satisfactory with all the treatments. Since the poorest results were found with 16 weeks of desipramine treatment, this study suggests that desipramine should be continued for at least 24 weeks either alone or combined with CBT. The broadest gain in reducing the psychopathology associated with bulimia nervosa was found with the combined 24-week treatment.