Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative

OBJECTIVE

To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA).

DESIGN

We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7.

RESULTS

A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics.

CONCLUSION

The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Precise localization of silicone-based intercranial planar electrodes in magnetic resonance imaging

Intercranial planar electrodes enable neural recordings with high spatial resolution in diagnosis as well as for treatments. The value of the measurements increases with the precision of localization of the electrodes related to the individual anatomy. In this context, post-implantation MRI provides excellent soft tissue contrast, but the accurate localization of electrodes is impaired by magnetic susceptibility artifacts. We have addressed this problem without adding a substantial burden to the electrode fabrication process. Simple silicone reference structures were strategically placed on the implant surface to visualize the electrodes position in MRI. These reference structures allowed high precision electrode localization independently of electrode imaging artifacts. This implant manufacturing approach could prove extremely useful in combination with existing image processing pipelines.

Prevalence, symptom patterns and management of episodic diarrhoea in the community: a population-based survey in 11 countries

BACKGROUND

The extent of episodic diarrhoea in the community is relatively unknown.

AIM

To ascertain the prevalence, symptoms and management behaviours associated with self-reported diarrhoea across 11 countries.

METHODS

Community screening surveys were conducted using quota sampling of respondents to identify a nationally representative sample of individuals suffering from 'episodic' diarrhoea (occurring once a month or more often). Second-phase in-depth surveys provided data on epidemiology, symptoms, attributed causes and management of episodic diarrhoea.

RESULTS

A total of 11 508 phase 1 and 6613 phase 2 surveys were completed. The prevalence of self-reported episodic diarrhoea ranged from 16% to 23% across the 11 countries. The majority of episodic diarrhoea sufferers were female (57%) and were not diagnosed with pre-existing irritable bowel syndrome (IBS); IBS diagnosis ranged from 9% in Mexico to 44% in Italy. Diarrhoea was frequently attributed to anxiety/stress, food-related causes, gastrointestinal 'sensitivity' and menstruation. Accompanying symptoms included 'stomach pain/cramping' (35-62%), 'stomach grumbling' (29-68%) and 'wind' (18-74%). The proportion of episodic sufferers who reported treating their symptoms with remedies or medications ranged between 46% in Belgium and Canada and 90% in Mexico.

CONCLUSIONS

A substantial proportion of the population in middle- to high-income countries report episodic diarrhoea in the absence of a pre-existing diagnosis. These symptoms are likely to be associated with substantial social and economic costs, and have implications on how best to configure and guide self-led, pharmacist-led and primary care management.

Steroid hormone measurements from different types of assays in relation to body mass index and breast cancer risk in postmenopausal women: Reanalysis of eighteen prospective studies

Epidemiological studies have examined breast cancer risk in relation to sex hormone concentrations measured by different methods: "extraction" immunoassays (with prior purification by organic solvent extraction, with or without column chromatography), "direct" immunoassays (no prior extraction or column chromatography), and more recently with mass spectrometry-based assays. We describe the associations of estradiol, estrone and testosterone with both body mass index and breast cancer risk in postmenopausal women according to assay method, using data from a collaborative pooled analysis of 18 prospective studies. In general, hormone concentrations were highest in studies that used direct assays and lowest in studies that used mass spectrometry-based assays. Estradiol and estrone were strongly positively associated with body mass index, regardless of the assay method; testosterone was positively associated with body mass index for direct assays, but less clearly for extraction assays, and there were few data for mass spectrometry assays. The correlations of estradiol with body mass index, estrone and testosterone were lower for direct assays than for extraction and mass spectrometry assays, suggesting that the estimates from the direct assays were less precise. For breast cancer risk, all three hormones were strongly positively associated with risk regardless of assay method (except for testosterone by mass spectrometry where there were few data), with no statistically significant differences in the trends, but differences may emerge as new data accumulate. Future epidemiological and clinical research studies should continue to use the most accurate assays that are feasible within the design characteristics of each study.

Inhibition of the phosphoinositide 3-kinase pathway for the treatment of patients with metastatic metaplastic breast cancer

BACKGROUND

Mesenchymal/metaplastic breast cancers (MpBCs) are often triple-negative (TNBC), and chemo-refractory, and can harbor phosphoinositide 3-kinase (PI3kinase) alterations; thus, therapy with mTor inhibitors may demonstrate activity.

PATIENTS AND METHODS

Patients with mesenchymal/MpBC treated with temsirolimus-based regimens were evaluated. Mutational analyses [polymerase chain reaction (PCR)-based DNA sequencing method, mass spectrometric detection (Sequenom MassARRAY), or next-generation sequencing] as well as loss of phosphatase and tensin homolog (PTEN) (immunohistochemistry) were performed (archived tissue when available).

RESULTS

Twenty-three patients (one of whom was on two separate trials) were treated using temsirolimus-containing regimens: temsirolimus alone (n = 1 patient) or combined with the following: liposomal doxorubicin and bevacizumab (DAT, n = 18); liposomal doxorubicin (DT, n = 1); paclitaxel and bevacizumab (TAT, n = 2); paclitaxel (TT, n = 1); carboplatin and bevacizumab (CAT, n = 1). Response rate [complete response (CR) + partial response (PR)] was 25% across all regimens; 32% in the anthracycline-based regimens [DAT and DT (CR = 2, PR = 4; N = 19)]. An additional two patients achieved stable disease (SD) ≥6 months [total SD ≥6 months/CR/PR = 8 (33%)]. Molecular aberrations in the PI3K pathway were common: PIK3CA mutation = 6/15 (40%), PTEN mutation = 3/11 (27%), and PTEN loss = 2/11 (18%). A point mutation in the NF2 gene (K159fs*16; NF2 alterations can activate mTor) was found in one patient who attained CR (3+ years). Of the eight patients who achieved SD ≥6 months/CR/PR, all 4 patients with available tissue had a molecular aberration that activate the PIK3CA/Akt/mTOR axis: PIK3CA mutation = 2; PTEN loss = 1; NF2 aberration = 1.

CONCLUSIONS

DAT has activity in MpBCs including complete CRs. Molecular aberrations that can activate the PI3 K/Akt/mTOR axis are common in MpBC.

Why hyperoxia matters during acute anemia

BACKGROUND

Given the low physical solubility of oxygen (O2) in plasma, little value is attached to hyperoxic ventilation (FiO2 1.0) as a modality for improving O2 transport and tissue oxygen supply when hypoxemia (i.e., O2 partial pressure (paO2) <60 mmHg) is absent. Because recent experimental and clinical data conflict with this notion, we used mathematical modeling to reevaluate efficacy of hyperoxic ventilation in improving tissue oxygenation in the absence of hypoxemia by specifying its theoretical efficacy in terms of hemoglobin (Hb) equivalents.

METHODS

A mathematical approach was used based on the assumption that efficacy of hyperoxic ventilation depends on the additional amount of O2 dissolved in plasma and is influenced by the high biological availability of the additional O2 provided at high paO2. This approach was used to calculate the amount of additional Hb necessary to increase the amount of utilizable O2 to the same extent as hyperoxic ventilation (the so-called "Hb equivalent").

RESULTS

Although former estimations strongly underestimated efficacy of hyperoxic ventilation (Hb equivalent, 1-2 g/dL), our more exact mathematical approach revealed a theoretical Hb equivalent of hyperoxic ventilation in the range of 3-7 g/dL, which depended on basic physiological conditions like pulmonary function, Hb concentration, and peripheral shunt perfusion.

CONCLUSION

Hyperoxic ventilation establishes a highly available source of O2 that can be utilized effectively for tissue oxygenation. Although further experimental studies are required to quantify this theoretically calculated amount of utilizable O2, these results suggest that the tissue oxygenation efficacy of hyperoxic ventilation, even in absence of hypoxemia, is grossly underestimated in daily clinical practice.

P1-07-09: Estrogen Receptor (ER) mRNA and ER-Related Gene Expression in Breast Cancers That Are 1%-10% ER-Positive by Immunohistochemistry

Purpose: Our goal was to examine whether borderline estrogen receptor (ER)-positive cancers, defined as 1–10% positivity by immunohistochemistry (IHC), show the same global gene expression pattern and high ESR1 mRNA expression as ER-positive cancers or are more similar to ER-negative cancers.

Patients and methods: ER status was determined by IHC in 465 primary breast cancers and with Affymetrix U133A gene chip (ESR1 mRNA gene expression: Probe set = 205225_at). We compared expressions of ESR1 mRNA and a 106-probe set ER-associated gene signature score between ER-negative (n=183), 1–9% (n=25), exactly 10% (n=6), and &gt; 10% ER-positive (n=251) cancers. We also assessed the molecular class of the borderline ER-positive cases using the PAM-50 classifier.

Results: Among the 1–9%, 10% and &gt; 10% IHC positive cases, 24%, 67% and 92% were also ER-positive by ESR1 mRNA expression. The average ESR1 expression was significantly higher in the &gt; 10% IHC-positive cohorts compared to the 1–9% or completely negative cases but in these latter two cohorts ER expression was similarly low. The average ER gene signature scores were similar for the ER-negative and 1–9% IHC-positive cases, but significantly lower than in &gt; 10% ER-positive cases. None of the 1–9% ER-positive cases were classified as Luminal A, 2 were Luminal B and 12 were Basal-like. Among the 10% ER-positive cases, 2 were Luminal A and 1 was Luminal B. Conclusion: Overall, 24% of the 1–9% and 67% of the 10% ER-positive cancers show ESR1 mRNA levels and gene signatures that are consistent with ER-positive, potentially endocrine sensitive tumors.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-09.

Circulating sex hormones and breast cancer risk factors in postmenopausal women: reanalysis of 13 studies

Background:

Breast cancer risk for postmenopausal women is positively associated with circulating concentrations of oestrogens and androgens, but the determinants of these hormones are not well understood.

Methods:

Cross-sectional analyses of breast cancer risk factors and circulating hormone concentrations in more than 6000 postmenopausal women controls in 13 prospective studies.

Results:

Concentrations of all hormones were lower in older than younger women, with the largest difference for dehydroepiandrosterone sulphate (DHEAS), whereas sex hormone-binding globulin (SHBG) was higher in the older women. Androgens were lower in women with bilateral ovariectomy than in naturally postmenopausal women, with the largest difference for free testosterone. All hormones were higher in obese than lean women, with the largest difference for free oestradiol, whereas SHBG was lower in obese women. Smokers of 15+ cigarettes per day had higher levels of all hormones than non-smokers, with the largest difference for testosterone. Drinkers of 20+ g alcohol per day had higher levels of all hormones, but lower SHBG, than non-drinkers, with the largest difference for DHEAS. Hormone concentrations were not strongly related to age at menarche, parity, age at first full-term pregnancy or family history of breast cancer.

Conclusion:

Sex hormone concentrations were strongly associated with several established or suspected risk factors for breast cancer, and may mediate the effects of these factors on breast cancer risk.

Molybdenum Involvement in Aerobic Degradation of 2-Furoic Acid by Pseudomonas putida Fu1

An organism identified as Pseudomonas putida was isolated from an enrichment culture with 2-furoic acid as its sole source of carbon and energy. The organism contained a 2-furoyl-coenzyme A (CoA) synthetase to form 2-furoyl-CoA and a 2-furoyl-CoA dehydrogenase to form 5-hydroxy-2-furoyl-CoA as the first two enzymes involved in the degradation. Tungstate, the specific antagonist of molybdate, decreased growth rate and consumption of 2-furoic acid but had no influence on growth with succinate. Correspondingly, the 2-furoyl-CoA dehydrogenase activity decreased when the organism was grown on 2-furoic acid in the presence of increasing amounts of tungstate. The addition of molybdate reversed the negative effect on 2-furoyl-CoA dehydrogenase activity, which points to the involvement of a molybdoenzyme in this reaction. Both enzymes studied were inducible. No plasmid was detected in this organism.

Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain

BACKGROUND

Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians.

AIM

To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients.

METHODS

Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks.

RESULTS

A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.).

CONCLUSION

This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care.

Thrombin-thrombomodulin inhibits prourokinase-mediated pleural mesothelial cell-dependent fibrinolysis

Fibrin deposition is a hallmark of pleural inflammation and loculation but understanding of mechanisms by which mesothelial cells regulate intrapleural fibrinolysins remains incomplete. We speculated that pleural mesothelial cells regulate local fibrinolytic capacity via processing of single chain urokinase type plasminogen activator (scuPA). Pretreatment of human pleural mesothelial (MeT-5A) cells with TGF-beta or thrombin, either alone or in combination, inhibited urokinase (uPA)-mediated fibrinolysis by MeT-5A. Thrombin, unlike TGF-beta, inhibited fibrinolysis without induction of PAI-1, suggesting that thrombin-mediated cleavage of scuPA inhibits the fibrinolytic capacity of MeT-5A cells. Thrombin cleaves both purified scuPA as well as that secreted by MeT-5A cells and cell surface thrombomodulin accelerates thrombin-mediated cleavage of scuPA to inhibit cellular fibrinolytic activity. Molecular dynamics analyses demonstrated that thrombin-cleaved scuPA (uPAt) do not acquire a catalytically active conformation and that secondary plasminogen binding sites of uPA implicated in plasminogen activation are distorted in uPAt, explaining, at least in part, why uPAt is a poor enzyme. uPAt was detectable in transudative and exudative pleural effusions from patients. Intrapleural administration of scuPA generated increased levels of uPAt in PF of rabbits with pleural injury and loculation induced by tetracycline in vivo. This pathway is operative in diverse forms of pleural injury, restricts the urokinase-dependent fibrinolytic capacity of pleural mesothelial cells and contributes to local control of fibrinolytic activity via processing of endogenous or exogenous scuPA within the pleural compartment.

Breakable stent for interventions in infants and neonates: an animal study and histopathological findings

OBJECTIVE

To test in a neonatal animal model the feasibility and biocompatibility of a new breakable stent that can be broken open by balloon dilatation during reintervention for use in neonates and infants.

MATERIALS AND METHODS

Medical grade stainless steel breakable stents (n = 16) were interventionally implanted in systemic arteries in neonatal piglets (n = 7). Patency of the stented segments was shown by repeated angiography. Stents were redilated up to three times. After a follow up of 18-165 days the animals were killed and the tissue block containing the stent was excised. Besides standard histological examination, scanning electron microscopy was used for biocompatibility screening.

RESULTS

The stents were broken by redilatation with a conventional angioplasty balloon catheter. During follow up, patency of all stented segments was shown angiographically. One stent became dislocated during implantation. One vessel ruptured during redilatation when an inadequately large balloon catheter was used for dilatation. No other complications were observed. Scanning electron microscopy showed complete cellular coverage of the stent struts. Histological examination showed thinning of the vessel wall and partial rupture of the media at the site of stent breakage. An only mild inflammatory reaction was detected.

CONCLUSION

The new breakable stent can be broken open by simple angioplasty. Feasibility, effectiveness, and biocompatibility were shown in an animal model. Surgery to remove stents from paediatric patients due to disproportion between a previously implanted stent and the growing vessel may be avoided by the use of a breakable stent.

Dead but Highly Dynamic – The Stratum corneum Is Divided into Three Hydration Zones

Topically applied water exerts mechanical stress on individual corneocytes as well as on the whole stratum corneum (SC), resulting in an alteration of barrier function. In this study we used complete skin biopsies and showed that the SC reacts to water stress as a highly optimized and well-regulated structure against osmotic changes. Following a relatively new cryo-processing protocol for cryo-SEM, it is possible to reliably maintain and investigate the hydrated state of the SC and individual corneocytes after treatment with solutions of different ionic strength. Treatment with distilled water results in swelling of SC cells together with formation of massive water inclusions between adjacent cell layers. Treatment with 5-20% NaCl reveals three different hydration zones within the SC: Corneocytes near the live-dead transition zone can swell to nearly double their thickness. The second zone is the most compact, as the corneocytes here show the smallest thickness variation with all treatments. Within the outermost zone, again a massive swelling and loosening of intracellular filament packing can be observed. We therefore conclude that the SC itself is subdivided into three functional zones with individual water penetration and binding potentials. Since the second zone remains nearly unaffected by water stress, we propose that this zone hosts the functional SC barrier.

Body mass index, serum sex hormones, and breast cancer risk in postmenopausal women

BACKGROUND

Obesity is associated with increased breast cancer risk among postmenopausal women. We examined whether this association could be explained by the relationship of body mass index (BMI) with serum sex hormone concentrations.

METHODS

We analyzed individual data from eight prospective studies of postmenopausal women. Data on BMI and prediagnostic estradiol levels were available for 624 case subjects and 1669 control subjects; data on the other sex hormones were available for fewer subjects. The relative risks (RRs) with 95% confidence intervals (CIs) of breast cancer associated with increasing BMI were estimated by conditional logistic regression on case-control sets, matched within each study for age and recruitment date, and adjusted for parity. All statistical tests were two-sided.

RESULTS

Breast cancer risk increased with increasing BMI (P(trend) =.002), and this increase in RR was substantially reduced by adjustment for serum estrogen concentrations. Adjusting for free estradiol reduced the RR for breast cancer associated with a 5 kg/m2 increase in BMI from 1.19 (95% CI = 1.05 to 1.34) to 1.02 (95% CI = 0.89 to 1.17). The increased risk was also substantially reduced after adjusting for other estrogens (total estradiol, non-sex hormone-binding globulin-bound estradiol, estrone, and estrone sulfate), and moderately reduced after adjusting for sex hormone-binding globulin, whereas adjustment for the androgens (androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and testosterone) had little effect on the excess risk.

CONCLUSION

The results are compatible with the hypothesis that the increase in breast cancer risk with increasing BMI among postmenopausal women is largely the result of the associated increase in estrogens, particularly bioavailable estradiol.

Methodological issues in designing a multisite trial of risperidone in children and adolescents with autism

OBJECTIVE

To describe the methodological challenges and decisions made in developing a multisite, controlled study of risperidone in children and adolescents with autism.

METHODS

Review the design considerations for clinical trials in children with autistic disorder accompanied by severe tantrums, aggressive and/or self-injurious behaviors. These design considerations include the definition of inclusion criteria that are relevant to clinical practice and matching study design to the goal of evaluating short- and long-term effects. Additional ethical and scientific issues concern the length of trial and sample size.

RESULTS

We undertook a short-term, placebo-controlled study to evaluate the efficacy and safety of risperidone in children and adolescents with autistic disorder. This trial design was followed by an extended open-label maintenance on risperidone to confirm durability of treatment effects and to monitor safety. Finally, a placebo-controlled discontinuation study tested the need for continuous treatment.

CONCLUSIONS

In the absence of standard pharmacological treatment for children with autistic disorder, a placebo-controlled study remains the most appropriate method of testing efficacy and safety. The clinical relevance of this study is enhanced by the addition of an extended maintenance phase followed by a placebo discontinuation.

Assessment of children with pervasive developmental disorders

TOPIC

Pervasive developmental disorders, a group of conditions marked by impaired social reciprocity, communication deficits, and restricted, repetitive behaviors.

PURPOSE

Advanced practice nurses (APNs) are in a unique position to assess these children, make appropriate diagnoses, and refer parents for further consultation and intervention.

SOURCES

Current literature, formal training on diagnostic instruments, and clinical experience.

CONCLUSIONS

Diagnosis of pervasive developmental disorders requires knowledge of normal growth and development and other childhood psychiatric disorders. The role of the APN includes counseling parents regarding their child's legal right to intervention and guiding parents to make empirically based choices for intervention.

The effect of pharmacological doses of different antioxidants on oxidation parameters and atherogenesis in hyperlipidaemic rabbits

The oxidation hypothesis of atherosclerosis implies that antioxidants are able to inhibit lipoprotein oxidation in the arterial wall and thereby retard atherogenesis. Since most of the animal studies performed have used very high doses of antioxidants, it is to date unknown whether antioxidants are effective antiatherosclerotic agents when given in pharmacological doses. Here we addressed this question using homozygous Watanabe heritable hyperlipidaemic (WHHL) rabbits as an animal model of atherosclerosis. The rabbits were divided into four groups, each consisting of ten animals. They received either a standard diet or a diet containing 4.3 mg ubiquinone-10, or 4.3 mg vitamin E or 15 mg probucol/kg body weight daily. After 12 months, the extent of aortic atherosclerosis was assessed as the intima thickness, media thickness and intima-to-media ratio in 14 cross sections equally distributed over the whole aorta. To evaluate the antioxidant effects of the diet, lipophilic and hydrophilic antioxidants, lipids, fatty acids and plasma oxidizability were measured after 0, 3 and 6 months of feeding. We found that supplementation with probucol significantly decreased aortic intima-to-media ratio compared to controls. The antiatherosclerotic action of probucol was accompanied by its beneficial action on plasma oxidizability and some plasma antioxidants. No decrease in aortic atherosclerosis was measured in ubiquinone-10- and vitamin E-supplemented rabbits, despite the fact that both antioxidants decreased plasma oxidizability and ubiquinone-10 increased the plasma levels of antioxidants. Taken together, these data suggest that pharmacological doses of probucol retard atherogenesis in WHHL rabbits by an antioxidant mechanism, while ubiquinone-10 and vitamin E at these dosages are ineffective in this highly hyperlipidaemic model. The measurement of some oxidation-related parameters in plasma, such as lipophilic antioxidants, polyunsaturated fatty acids and lipoprotein oxidizability, may be useful in assessing the risk of atherogenesis in humans.

Vitronectin adsorption to chrysotile asbestos increases fiber phagocytosis and toxicity for mesothelial cells

Biological modification of asbestos fibers can alter their interaction with target cells. We have shown that vitronectin (VN), a major adhesive protein in serum, adsorbs to crocidolite asbestos and increases fiber phagocytosis by mesothelial cells via integrins. Because chrysotile asbestos differs significantly from crocidolite in charge and shape, we asked whether VN would also adsorb to chrysotile asbestos and increase its toxicity for mesothelial cells. We found that VN, either from purified solutions or from serum, adsorbed to chrysotile but at a lower amount per surface area than to crocidolite. Nevertheless, VN coating increased the phagocytosis of chrysotile as well as of crocidolite asbestos. VN coating of both chrysotile and crocidolite, but not of glass beads, increased intracellular oxidation and apoptosis of mesothelial cells. The additional apoptosis could be blocked by integrin-ligand blockade with arginine-glycine-aspartic acid peptides, confirming a role for integrins in the fiber-induced toxicity. We conclude that VN increases the phagocytosis of chrysotile as well as of crocidolite asbestos and that phagocytosis is important in fiber-induced toxicity for mesothelial cells.

Tissue factor pathway inhibitor expression by human pleural mesothelial and mesothelioma cells

The mesothelial lining of the pleura and malignant mesothelioma promote fibrin deposition in pleural injury or neoplasia via expression of tissue factor (TF). It was hypothesized that these cells might also regulate intrapleural coagulation by elaborating TF pathway inhibitor (TFPI). TFPI activity and antigen in pleural fluids were assayed from patients with congestive heart failure (CHF), pneumonia, empyema, metastatic pleural cancer and malignant mesothelioma. The authors also assessed expression of TF and TFPI messenger ribonucleic acid (mRNA) as well as TFPI activity and antigen by human pleural mesothelial cells, malignant mesothelioma cells (MS-1 cell line) and human lung fibroblasts. Immunohistochemical analyses of normal, fibrotic, and neoplastic pleura were performed to determine whether TFPI antigen was expressed in vivo. The study revealed that TFPI was present in transudates from patients with CHF and exudative pleural effusions from patients with pneumonia, empyema or pleural carcinoma. TFPI mRNA, activity and antigen were expressed by pleural mesothelial cells, MS-1 cells and lung fibroblasts. Cytokines and serum stimulated a significant early increase in TF mRNA levels with minimal enhancement of TFPI mRNA, activity and antigen levels. TFPI antigen was found in normal, fibrotic and neoplastic pleural tissues. The current observations indicate that tissue factor pathway inhibitor is locally expressed in pleural disease, but that it does not prevent the development of a prothrombotic environment favouring local fibrin deposition in pleural inflammation or cancer.

Psychotropic medication use and risk of hormone-related cancers: the New York University Women's Health Study

BACKGROUND

The use of psychotropic medications may increase the risk of hormone-related cancers in females through increased gonadotropin secretion, but the data from epidemiologic studies are limited to evaluate the hypothesis.

METHODS

The association between the use of psychotropic medications and cancer incidence was studied in a prospective cohort study that involves 15,270 women who participated in mammographic screening. The relative risks (RR) and 95 per cent confidence intervals (CIs) for cancer associated with the use of psychotropic medications were estimated by the Cox's proportional hazard model.

RESULTS

During an average of 7.3 years of follow-up, 1,130 incident cases of cancer were identified, including 566 breast, 67 endometrial and 47 ovarian cancers. The use of any type of psychotropic medication at baseline was associated with increased risks of breast [relative risk (RR) = 1.39, 95 per cent CI 1.11-1.74], endometrial (RR=1.71; 95 per cent CI 0.93-3.14) and ovarian (RR= 1.48, 95 per cent CI 0.69-3.16) cancers, whereas no increase in risk was observed for other cancers (RR = 1.06). When the subjects were divided by menopausal status at baseline, premenopausal women tended to have higher risk of all hormone-related cancers (RR = 1.73, 95 per cent CI 1.27-2.35) than postmenopausal women (RR=1.23, 95 per cent CI 0.94-1.62). The magnitude of the RR associated with the use of these medications did not change by length of follow-up. Analysis by type of medication did not find that the association was limited to specific types.

CONCLUSION

The observed association needs to be confirmed in further studies based on more detailed medication history.

Risk of iron overload among middle-aged women

Iron overload, expressed as increased body iron stores, has been recognized as a potential hazard because it promotes the generation of oxygen radicals. We analyzed factors associated with serum ferritin levels (an indicator of body iron stores) among middle-aged women with a high prevalence of nutrient supplement use. Serum ferritin concentrations were determined on automated immunoassay for 487 healthy women with the mean age of 57 years who participated in the New York University Women's Health Study. The mean serum ferritin concentration in postmenopausal women was more than twice that in premenopausal women. Serum ferritin concentrations progressively increased with advancing age, but adjustment for menopausal status considerably weakened this association. Among non-dietary factors, nonwhite ethnicity, obesity and cigarette smoking were positively associated with serum ferritin concentrations. After adjustment for these factors and for menopausal status, serum ferritin levels were positively associated with meat intake and multivitamin use and inversely associated with breakfast cereal consumption. However, none of these lifestyle factors positively associated with serum ferritin levels had a significant impact on serum ferritin levels above 100 ng/ml (approximately equal to median concentration). Our results suggest that iron overload seems unlikely among middle aged women through their diet and nutritional supplements.

Breslow thickness and clark level in melanoma: support for including level in pathology reports and in American Joint Committee on Cancer Staging

BACKGROUND

Thickness is known to be an important survival prognosticator for cutaneous melanoma, but controversy exists as to whether Clark level of invasion retains prognostic significance once thickness has been accounted for. A recent proposal to eliminate Clark level from the staging system for melanoma of the American Joint Committee on Cancer (AJCC) prompted the authors to investigate whether level adds useful prognostic information to Breslow thickness. They used the data base of the New York University Melanoma Cooperative Group (NYU-MCG) Registry.

METHODS

The analysis was based on 919 patients with AJCC Stage I or II melanomas diagnosed between 1972 and 1982 and followed for an average of 10.9 years. Melanoma thicknesses were divided into 4 categories (< or = 0.75, 0.76-1.50, 1.51-4.00, and >4.00 mm). Patients were cross-classified according to tumor thickness and Clark level (II-V). For each combination of thickness and level, the Kaplan-Meier survival curve and 10-year survival proportion were computed, using death from melanoma as the outcome. The impact of Clark level on survival was evaluated for each of the thickness categories. The Cox proportional hazards model was used to assess the simultaneous effect of thickness and level on survival while controlling for other important prognostic factors, i.e., age, tumor location, and presence or absence of ulceration.

RESULTS

Level of invasion was a significant predictor of death from melanoma in each of the four thickness categories. Likewise, in the Cox analyses, level was a significant prognostic variable, even after thickness was included in the model and regardless of whether thickness was treated as a categoric or a continuous variable.

CONCLUSIONS

These results confirm that both tumor thickness and level of invasion are important independent prognostic factors in AJCC Stage I and II melanomas. The authors recommend that Clark levels be kept as criteria in the AJCC staging system and be included in pathology reports. [See editorial on pages 491-6, this issue.]

Epidemiologic correlates of serum folate and homocysteine levels among users and non-users of vitamin supplement

Lower serum folate and higher serum homocysteine levels are known risk factors for various conditions. Thus, epidemiologic correlates with these measurements were studied for 256 multivitamin users and 230 non-users who were middle-aged women. Both serum folate and homocysteine levels increased with advancing age in both multivitamin users (P < 0.01 and P < 0.01) and non-users (P = 0.08 and P < 0.01). Among non-users, higher intake of vegetables, fruits, cold cereals and total protein were associated positively with serum folate and inversely with homocysteine levels. There were 25-74% increases in serum folate and 10-15% decreases in serum homocysteine between 1st and 4th quartiles of intake of these food/nutrients. In addition, 26% lower serum folate and 18% higher serum homocysteine were observed for those smoking 20 or more cigarettes per day compared with non-smokers. Among multivitamin users, body weight was correlated inversely with serum folate (P < 0.01) and positively with serum homocysteine levels (P = 0.04), while no correlates were found among lifestyle factors. Regular use of multivitamins increased serum folate about fourfold and decreased homocysteine twofold. These results suggest that multivitamin use can offset the effects of an unhealthy lifestyle on these serum markers, and that levels of serum folate and homocysteine can also be favorably influenced by healthier diet and abstinence from smoking.

Open-label quetiapine in the treatment of children and adolescents with autistic disorder

OBJECTIVE

The purpose of this trial was to investigate the short-term safety and efficacy of quetiapine fumarate in the treatment of children and adolescents with autistic disorder (AD).

METHOD

This was a 16-week, open-label trial that included 6 male subjects with a mean age of 10.9 +/- 3.3 years. All subjects met the DSM-IV criteria for AD and functioned in the mentally retarded range (mild, n = 2; moderate, n = 3; severe, n = 1). Behavioral ratings were obtained at baseline and every four weeks thereafter.

RESULTS

Overall, there was no statistically significant improvement between baseline and endpoint for the group as a whole. Only two subjects completed 16 weeks of treatment and were considered "responders" by the global improvement item of the Clinical Global Impression Scale (CGIS). Dosages ranged from 100 to 350 mg/day (1.6-5.2 mg/kg/day). Subjects dropped out prematurely because of lack of response and sedation, limiting further dose increases (n = 3), and because of a possible seizure during the fourth week of treatment (n = 1). Other significant side effects included behavioral activation, increased appetite and weight gain (range, 0.9 to 8.2 kg).

CONCLUSIONS

Quetiapine was poorly tolerated and associated with serious side effects in this clinical population.

Serum folate, homocysteine and colorectal cancer risk in women: a nested case-control study

Accumulating evidence suggests that folate, which is plentiful in vegetables and fruits, may be protective against colorectal cancer. The authors have studied the relationship of baseline levels of serum folate and homocysteine to the subsequent risk of colorectal cancer in a nested case-control study including 105 cases and 523 matched controls from the New York University Women's Health Study cohort. In univariate analyses, the cases had lower serum folate and higher serum homocysteine levels than controls. The difference was more significant for folate (P < 0.001) than for homocysteine (P = 0.04). After adjusting for potential confounders, the risk of colorectal cancer in the subjects in the highest quartile of serum folate was half that of those in the lowest quartile (odds ratio, OR = 0.52, 95% confidence interval, CI = 0.27-0.97, P-value for trend = 0.04). The OR for the highest quartile of homocysteine, relative to the lowest quartile, was 1.72 (95% CI = 0.83-3.65, P-value for trend = 0.09). In addition, the risk of colorectal cancer was almost twice as high in subjects with below-median serum folate and above-median total alcohol intake compared with those with above-median serum folate and below-median alcohol consumption (OR = 1.99, 95% CI = 0.92-4.29). The potentially protective effects of folate need to be confirmed in clinical trials.

Iron intake, body iron stores and colorectal cancer risk in women: a nested case-control study

Accumulated evidence suggests that increased body iron stores may increase the risk of colorectal cancer, possibly via catalyzing oxidation reactions. We examined the relationship between iron status and colorectal cancer in a case-control study nested within the New York University Women's Health Study cohort. For 105 incident cases of colorectal cancer with an average follow-up of 4.7 years and 523 individually matched controls, baseline levels of serum iron, ferritin, total iron binding capacity (TIBC) and transferrin saturation were determined as indicators of body iron stores, and total iron intake was assessed based on their diet and supplement intake. Overall, there were no associations between the risk of colorectal cancer and any of these indices except for serum ferritin, which showed a significant inverse association. When analyzed by subsite, there was an increasing trend in risk of cancer of the proximal colon with increasing total iron intake (p-value for trend = 0.04). In addition, a significantly increased risk of colorectal cancer associated with higher total iron intake [odds ratio (OR) = 2.50; 95% confidence interval (CI): 1.06-5.87] was observed among subjects with higher intake of total fat. Our results do not support a role of increased body iron stores in the development of colorectal cancer, but suggest that luminal exposure to excessive iron may possibly increase the risk in combination with a high fat diet.

Iron intake, body iron stores and colorectal cancer risk in women: a nested case-control study

Accumulated evidence suggests that increased body iron stores may increase the risk of colorectal cancer, possibly via catalyzing oxidation reactions. We examined the relationship between iron status and colorectal cancer in a case-control study nested within the New York University Women's Health Study cohort. For 105 incident cases of colorectal cancer with an average follow-up of 4.7 years and 523 individually matched controls, baseline levels of serum iron, ferritin, total iron binding capacity (TIBC) and transferrin saturation were determined as indicators of body iron stores, and total iron intake was assessed based on their diet and supplement intake. Overall, there were no associations between the risk of colorectal cancer and any of these indices except for serum ferritin, which showed a significant inverse association. When analyzed by subsite, there was an increasing trend in risk of cancer of the proximal colon with increasing total iron intake (p-value for trend = 0.04). In addition, a significantly increased risk of colorectal cancer associated with higher total iron intake [odds ratio (OR) = 2.50; 95% confidence interval (CI): 1.06-5.87] was observed among subjects with higher intake of total fat. Our results do not support a role of increased body iron stores in the development of colorectal cancer, but suggest that luminal exposure to excessive iron may possibly increase the risk in combination with a high fat diet.

Pharmacotherapy in children and adolescents with pervasive developmental disorders

Children with autism and the related PDDs may benefit from serotonin reuptake inhibitors such as clomipramine, fluoxetine, fluvoxamine, and sertraline for targeting repetitive thoughts and behaviors, anxiety, and depressed mood. To date, however, there are few controlled studies of these agents in children with PDD, so definitive evidence is lacking. Despite preliminary results in favor of naltrexone, neuroleptic medication appears to be effective for reducing aggression, self-injurious behavior, agitation, and stereotypies. The primary drawback with traditional neuroleptics is risk of short- and long-term side effects. The newer atypical neuroleptics have the potential for benefit with fewer extrapyramidal side effects, but more study is needed to establish their efficacy and safety. Children on neuroleptic medications should be started at the lowest possible dose, with gradual increases until clinical benefit is observed. The likelihood of untoward side effects is increased if the medication dose is increased rapidly. Baseline measurement of target behaviors can be aided by using standardized scales. The presence of abnormal movements should be assessed before initiating treatment and at regular intervals during the course of treatment--including after medication withdrawal. Weight gain is emerging as a recurrent side effect with the atypical neuroleptics. Thus, weight should be monitored, and the family should be advised about a diet baseline. As with all treatments of children with severe behavioral difficulties, pharmacotherapy should be instituted in the context of an integrated treatment plan.

Risk of melanoma in medium-sized congenital melanocytic nevi: a follow-up study

BACKGROUND

The risk of the occurrence of malignant melanoma (MM) in medium-sized (1.5 to 19.9 cm in diameter) congenital melanocytic nevi (CMN) is the subject of controversy. Universally accepted recommendations regarding the management of such lesions have not been made.

OBJECTIVE

Our purpose was to assess the risk of MM arising in medium-sized CMN.

METHODS

The study included 230 medium-sized CMN in 227 patients, first seen in a private dermatology practice from 1955 to 1996, who were followed up for MM arising within their CMNs. Criteria for entry into the study included (1) a clinically diagnosed medium-sized CMN, (2) minimum follow-up period of 1 year, and (3) a photograph of the lesion in the patient's medical record.

RESULTS

No MM occurred in a medium-sized CMN during an average follow-up of 6.7 years (median, 5.8 years) to an average age of 25.5 years (median, 19.1 years).

CONCLUSION

The results of this short-term follow-up study do not support the view that there is a clinically significantly increased risk for MM arising in banal-appearing medium-sized CMN or that prophylactic excision of all such lesions is mandatory. Lifelong medical observation seems a reasonable alternative for many medium-sized CMN.

Buffering capacity of coal and its acid-soluble Fe2+ content: possible role in coal workers' pneumoconiosis

Epidemiological studies have shown that the prevalence of coal workers' pneumoconiosis (CWP) differed remarkably between different coal mine regions despite comparable exposures to respirable dust. In the United States, CWP was found to be most common in Pennsylvania coal miners and least common in miners from Utah. The active component(s) responsible for the regional differences in CWP has not yet been identified. In the present study, we found that coals from Pennsylvania, compared with Utah coals, showed a much lower buffering capacity as determined by the amount of acid consumed in order to reach pH 4.5, which is the pH of the phagolysosomes of macrophages. Moreover, the coals from Pennsylvania released large amounts of Fe2+ in the acidified extract, whereas the coals from Utah released little Fe2+. Using electron spin resonance (ESR), we found that the coals from Pennsylvania, but not from Utah, were effective in oxidizing formate by a radical pathway. Two coals, one from Utah with high buffering capacity and low acid-soluble Fe2+ and the other from Pennsylvania with low buffering capacity and high acid-soluble Fe2+, were then selected for cell treatment. We found that human tracheal epithelial (HTE) cells treated with the coal from Pennsylvania (10 microg/cm2) showed a 36% increase in oxidant formation over the control as detected by dichlorofluorescein assay, whereas the coal from Utah had no effect. An electrophoretic mobility shift assay was used to test the binding affinity of nuclear proteins extracted from the coal-treated HTE cells to an oxidative stress-responsive transcription factor activator protein-1 (AP-1) element. The coal from Pennsylvania with high acid-soluble Fe2+ (1 microg/cm2) activated AP-1 to the same extent as 10 microM H2O2, while the coal from Utah without acid-soluble Fe2+ had no effect. These results support our hypothesis that the prevalence of CWP may be higher in coal workers exposed to coal with high acid-soluble Fe2+ and low buffering capacity than in workers exposed to coal with low acid-soluble Fe2+ and high buffering capacity.

Tissue factor pathway inhibitor in tetracycline-induced pleuritis in rabbits

Pleural fibrin deposition that promotes loculation and fibrosis after pleural injury is initiated by tissue factor (TF). In this study, we sought to determine if tissue factor pathway inhibitor (TFPI), an inhibitor of the TF-factor VIIa complex, was likewise expressed in tetracycline (TCN)-induced pleural injury and, if so, whether TFPI was locally elaborated. Pleural fluid TFPI activity approximated that of plasma by 24 h and doubled by 3 days after intrapleural TCN. By contrast, pleural fluid coagulation factors VII and V remained below plasma concentrations at these intervals. Immunohistochemical studies demonstrated TF, TFPI and fibrin localized in pleural and subpleural tissues and within intrapleural adhesions. TFPI activity and mRNA were also elaborated by rabbit pleural mesothelial cells and lung fibroblasts. TFPI is locally expressed and pleural fluid TFPI exceeds plasma levels during TCN-induced pleural injury. Resident cells as well as extravasation likely contribute to intrapleural TFPI. TFPI expression temporally and anatomically approximates that of TF and may limit TF-induced fibrin deposition in evolving TCN-induced pleuritis.

Tube collapse and valve closure in ambulatory venous pressure regulation: studies with a mechanical model

PURPOSE

To determine the role of valve closure and column segmentation in ambulatory venous pressure regulation.

METHODS

Using a mechanical model consisting of a graduated adjustable valve and a collapsible tube, we studied the differential effects of valve closure and tube collapse on venous pressure regulation. By utilizing materials with differing wall properties for the infravalvular tube, the influence of wall property changes on tube function and pressure regulation was explored.

RESULTS

Valve closure, per se, does not cause venous pressure reduction. Collapse of the tube below the valve is the primary pressure regulatory mechanism. The nonlinear volume-pressure relationship that exists in infravalvular tubes confers significant buffering properties to the collapsible tube, which tends to retain a near-constant pressure for a wide range of ejection fractions, residual tube volumes, and valve leaks. Changes in tube wall property affect this buffering action, at both the low and high ends of the physiological venous pressure range.

CONCLUSIONS

The valve and the infravalvular venous segment should be considered together in venous pressure regulation. Tube collapse of the segment below the valve is the primary pressure regulatory mechanism. An understanding of the hydrodynamic principles involved in pressure regulation derived from this model will provide the basis for construction of more complex models to explore clinical physiology and dysfunction.

Prospective study of diet and female colorectal cancer: the New York University Women's Health Study

The relation between diet and female colorectal cancer was analyzed in a prospective study of 14,727 women aged 34-65 years, who were enrolled at mammographic screening clinics in New York and Florida from 1985 to 1991. They were followed through the end of 1994 (average 7.1 yrs) by a combination of direct contact through mail and telephone and record linkages with regional tumor registries, resulting in 100 incident cases of colorectal cancer. There was no overall positive or inverse association of colorectal cancer risk with intakes of total calories, total or subclasses of fat, carbohydrate, or dietary fiber, whereas there was an inverse association with total protein. Among major food groups, there was a progressive decline in risk of colorectal cancer with increasing intake of fish and shellfish (relative risk for 4th vs. 1st quartile = 0.49, 95% confidence interval = 0.27-0.89). A similar inverse association was also observed for consumption of dairy products, and this association was explained mainly by calcium, not by other nutrients, such as fat or protein. The results of the present study indicated that certain dietary components of fish or dairy products may protect against colorectal cancer, whereas the relations with red meat or total fat remained unclear.

Convenient isolation and kinetic mechanism of glutathionylspermidine synthetase from Crithidia fasciculata

Trypanothione, the essential metabolite in the oxidant defense system of trypanosomatids, is synthesized by two distinct proteins, glutathionylspermidine synthetase and trypanothione synthetase. Glutathionylspermidine synthetase was purified to homogeneity from the trypanosomatid Crithidia fasciculata by aqueous two-phase systems and chromatography. The enzyme showed a specific activity of 38 micromol of glutathionylspermidine formed per min per mg of protein. Its molecular mass was 78 kDa in SDS-polyacrylamide gel electrophoresis, and it appeared predominantly monomeric in native polyacrylamide gel electrophoresis and gel filtration. The isoelectric point was at pH 4.6, and the pH optimum was near 7.6. Partial amino acid sequencing revealed homology with, but low similarity to, the glutathionylspermidine synthetase/amidase of Escherichia coli, and amidase activity was not detected in glutathionylspermidine synthetase of C. fasciculata. The kinetics of trypanosomatid glutathionylspermidine synthetase revealed a rapid equilibrium random mechanism with limiting Km values for Mg2+-ATP, GSH, and spermidine of 0.25 +/- 0.02, 2.51 +/- 0.33, and 0.47 +/- 0. 09 mM, respectively, and a kcat of 415 +/- 78 min-1. Partial reactions at restricted cosubstrate supply were not detected by 31P NMR, supporting the necessity of a quarternary complex formation for catalysis. ADP inhibited competitively with respect to ATP (Ki = 0. 08 mM) and trypanothione exerted a feedback inhibition competitive with GSH (Ki = 0.48 mM).

Disposition and bioavailability of ceftazidime after intraperitoneal administration in patients receiving continuous ambulatory peritoneal dialysis

This study investigated the disposition and bioavailability of ceftazidime when it was given intraperitoneally. Seven patients were given 1 gm of ceftazidime intravenously, and 1 wk later, the same dose was given intraperitoneally. After both intravenous and intraperitoneal dosing, serum and peritoneal dialysate samples were obtained at set time intervals over a 24-h period. High-performance liquid chromatography was used to determine the ceftazidime concentrations in the serum and dialysate samples. Inspection of the concentration versus time data after intraperitoneal dosing demonstrated that serum ceftazidime concentrations reached therapeutic (> 8 micrograms/mL) levels within 30 min and remained in the therapeutic range for the entire 24-h period. Simulation of a variety of ceftazidime dosing regimens using the mean pharmacokinetic parameters from this population of patients suggests that a regimen of 1.5 gm administered intraperitoneally every 24 h produces trough serum drug concentrations (approximately 40 micrograms/mL) similar to those achieved with a standard regimen of 1.0 gm given intravenously every 24 h in patients undergoing continuous ambulatory peritoneal dialysis. It was concluded that the intraperitoneal dosing of ceftazidime in these patients is an equally effective and a more convenient alternative to its administration.

A clinical and histologic evaluation of two medium-depth peels. Glycolic acid versus Jessner's trichloroacetic acid

BACKGROUND

Chemical peels using alpha hydroxy acids have become one of the most frequently requested dermatologic procedures. The use of glycolic acid in superficial chemical peels is now well established. However, the role of glycolic acid in medium-depth chemical peels has yet to be elucidated.

OBJECTIVE

We performed a clinical and histologic comparison of 70% glycolic acid versus Jessner's solution as part of a medium-depth chemical peel using 35% trichloroacetic acid (TCA).

METHODS

Thirteen patients with actinic keratoses, solar lentigines and fine wrinkling were evaluated prospectively. Each patient was treated with 70% glycolic acid plus 35% TCA (GA-TCA) to the right face and Jessner's solution plus 35% TCA (JS-TCA) to the left face. Clinical and histologic changes were evaluated at 7, 30, and 60 days postoperatively.

RESULTS

Clinically, the GA-TCA peel was effective in treating photodamaged skin. The GA-TCA peel was slightly more efficacious in removing actinic keratoses (clinical response score = 1.5) than the JS-TCA peel (clinical response score = 1.0). Histologically, the GA-TCA peel caused the formation of a slightly thicker Grenz zone (mean = 0.053 mm) 60 days postpeel than the JS-TCA peel (mean = 0.048 mm) (not statistically significant). The GA-TCA peel caused more neoelastogenesis than the JS-TCA peel, while the JS-TCA peel resulted in more papillary dermal fibrosis and neovascularization than the GA-TCA peel.

CONCLUSION

The GA-TCA peel is a new medium-depth chemical peel that is effective in treating photodamaged skin.