Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action

OBJECTIVE (STUDY QUESTION)

To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States.

DATA SOURCES/STUDY SETTING

Data were collected from six groups of system actors via online focus groups.

STUDY DESIGN

This is a qualitative multilevel study using the iceberg systems thinking framework.

DATA COLLECTION/EXTRACTION METHODS

Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas.

PRINCIPAL FINDINGS

Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders.

CONCLUSIONS

By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Perinatal morbidity and health utilization among mothers of medically fragile infants

OBJECTIVE

To determine the burden of perinatal morbidity among mothers of medically fragile infants.

STUDY DESIGN

We conducted a retrospective cohort study of 6849 mothers who delivered liveborn infants at a quaternary care hospital during a two-year period. We compared mothers of well babies with mothers of infants admitted to the Neonatal Intensive Care Unit (NICU), and we used logistic regression to model predictors of postpartum acute care utilization among NICU mothers.

RESULTS

Rates of obstetric morbidity were highest for mothers of infants staying ≥72 h in the NICU; 54.2% underwent cesarean birth, 7.5% experienced severe maternal morbidity, and 6.6% required a blood transfusion. Factors independently associated with postpartum acute care use included gestational age <28 weeks, ever smoking, non-Hispanic Black race, temperature >38 °C and receiving psychiatric medication during the birth hospitalization.

CONCLUSION

Focused support for mothers of NICU infants has the potential to reduce maternal morbidity and improve health.

Postpartum Health Experiences of Women with Newborns in Intensive Care: The Desire to Be by the Infant Bedside as a Driver of Postpartum Health

INTRODUCTION

Women with infants in a neonatal intensive care unit (NICU) encounter multiple challenges following childbirth, including greater burden of chronic disease and increased risk for depression, compared with women with well infants. At the same time, they are confronted with the trauma of a hospitalized infant while also managing their postpartum recovery. Limited research exists describing the health needs of these women, despite the many numbers living this experience daily. This study aimed to better understand postpartum health needs of women with infants in the NICU in the 90 days following birth and to propose actionable system improvements to address identified needs.

METHODS

The authors conducted in-depth individual interviews with 50 postpartum women of infants admitted to the NICU at a quaternary care hospital. Eligible women were aged at least 18 years, spoke English or Spanish, and had infants in the NICU longer than 3 days. Interview topics included NICU experience, recommended and desired health care, and suggestions for improvement. Interviews were audiotaped and transcribed verbatim. The authors used qualitative description techniques including memo-writing, coding, matrices, diagramming, and team discussion to analyze the data.

RESULTS

Women reported significant intrapartum health conditions and concerns (eg, preeclampsia, emergency cesarean birth, anxiety) and described unmet social, emotional, mental, and physical health needs. Unmet practical needs while in the NICU (eg, a place to rest, affordable parking, access to food, childcare) caused considerable burden. Despite disease burden and emergent health needs, few women reported regular monitoring of their postpartum health by maternal health care providers. Women frequently minimized and delayed care for their health needs so as to remain by the infant bedside.

DISCUSSION

Women with infants in the NICU would benefit from patient-centered care that provides greater attention to their postpartum health and recovery while also supporting their drive to remain close to their hospitalized infant.

Targeting the eicosanoid pathway in hepatocellular carcinoma

Liver cancer has variable incidence worldwide and high mortality. Histologically, the most common subtype of liver cancer is hepatocellular carcinoma (HCC). Approximately 30-40% of HCC patients are diagnosed at an advanced stage, and at present, there are limited treatment options for such patients. The current first-line therapy with tyrosine kinase inhibitors, sorafenib or lenvatinib, prolongs survival by a median of about 2.5-3 months after which the disease normally progresses. Additionally, many patients discontinue the use of tyrosine kinase inhibitors due to toxicity or may not be suitable candidates due to co-morbidity or frailty. It is, therefore, imperative to identify novel therapeutic targets for advanced HCC patients. Persistent injury to the liver as a result of insults such as hepatitis B or C viral (HBV or HCV) infections, alcohol abuse, and non-alcoholic fatty liver disease (NAFLD), results in chronic inflammation, which progresses to hepatic fibrosis and later, cirrhosis, provides the conditions for initiation of HCC. One of the key pathways studied for its role in inflammation and carcinogenesis is the eicosanoid pathway. In this review, we briefly outline the eicosanoid pathway, describe the mechanisms by which some pathway members either facilitate or counter the development of liver diseases, with the focus on NAFLD/hepatic fibrosis/cirrhosis, and HCC. We describe the link between the eicosanoid pathway, inflammation and these liver diseases, and identify components of the eicosanoid pathway that may be used as potential therapeutic targets in HCC.

Nuclear Leukocyte Immunoglobulin-like Receptor A3 Is Monomeric and Is Involved in Multiple Layers of Regulated Gene Expression and Translation

The leukocyte immunoglobulin-like receptor A3 (LILRA3) is a soluble protein primarily expressed by peripheral blood monocytes and is abundant in sera of healthy donors. Extracellular LILRA3 is anti-inflammatory and displays neuro-regenerative functions in vitro. However, its intracellular expression, distribution, and function(s) remain unknown. Using a combination of high-resolution confocal and super-resolution microscopy, we identified intracellular expression of native LILRA3 in the nucleus of peripheral blood monocytes and in vitro-derived macrophages. This unexpected nuclear localization of LILRA3 was confirmed in LILRA3-GFP-transfected HEK293T cells. Western blot of proteins fractionated from primary macrophages and the transfected HEK293T cells confirmed nuclear localization of the native and expressed LILRA3 proteins. Interestingly, most of the LILRA3 in the nucleus was in a monomeric form like the biologically active secreted protein, while that in the other cellular compartments was in mixed monomeric, dimeric, and oligomeric forms. The predominant presence of monomeric LILRA3 in the nucleus was independently corroborated in transfected live HEK293T cells using the number and molecular brightness (N&B) analysis method. Immunoprecipitation and mass spectrometric peptide sequencing studies revealed that nuclear LILRA3 co-immunoprecipitated with several nuclear proteins involved in host protein synthesis machinery via direct interactions to a key multifunctional RNA-binding protein, the Ewing sarcoma breakpoint region 1 protein (EWS) (data are available via ProteomeXchange with identifier PXD024602). The biological significance of the nuclear expression of LILRA3 and its interaction with these key proteins remain to be elucidated.

Identifying co-morbid fibromyalgia in patients with systemic lupus erythematosus using the Multi-Dimensional Health Assessment Questionnaire

Objective

Fibromyalgia (FM) is prevalent but often under-recognized in patients with systemic lupus erythematosus (SLE). Patient-reported outcomes (PROs) from the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) can identify co-morbid FM in patients with rheumatic diseases. The present study examined the utility of the MDHAQ in recognizing FM in patients with SLE during routine consultations.

Methods

Patients with SLE completed an MDHAQ. FM status was determined by the validated 2016 revision of the ACR 2010/2011 preliminary FM criteria. Individual PROs from the MDHAQ and composite Fibromyalgia Assessment Tool (FAST) indices of the discriminatory PROs were compared between patients with and without FM using Student’s unpaired t-test and receiver operating characteristic curve analysis to determine the area under the curve (AUC). The physician’s clinical impression of FM was recorded, and the SLE Disease Activity Index was used to assess disease activity.

Results

Of 88 patients with SLE, 23 (26%) satisfied the 2016 FM criteria. The FAST3 composite measure of two out of three of pain (≥6/10), joint count (≥16/48) and symptom checklist (≥16/60) correctly classified 89% of patients (AUC=0.90, kappa=0.71). Physician diagnosis demonstrated moderate agreement with the 2016 FM criteria (kappa=0.43) but missed 43% of patients with FM. In the presence of active disease, the FAST3 correctly classified 91% of patients.

Conclusions

Co-morbid FM is prevalent in SLE yet often underdiagnosed by physicians. The simple FAST3 index of the MDHAQ provides an easy-to-use self-reported tool to improve identification of FM in patients with SLE.

Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management

OBJECTIVE

To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth.

METHODS

We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0-24 and 25-48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit.

RESULTS

A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4-9.5; P<.05). Results at 25-48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0-24 hours postpartum (adjusted mean 5.1-7.5 oxycodone tablet equivalents; P<.001-.05), as well as at 25-28 hours postpartum.

CONCLUSION

Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.

Red cell distribution width correlates with fatigue levels in a diverse group of patients with systemic lupus erythematosus irrespective of anaemia status

OBJECTIVES

Fatigue remains a debilitating feature of systemic lupus erythematosus (SLE). Although in some cases this may be the result of intercurrent fibromyalgia, mood disorder or untreated metabolic syndrome, in many cases the cause is unclear. The aim of this study was to investigate the relationship between fatigue and red cell distribution width (RDW), a measure of variability in erythrocyte size and volume.

METHODS

A total of 225 patients were recruited from three clinics in England and Australia. Patients completed the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Score or 12-item Short Form survey (SF-12) to measure fatigue, which was compared with RDW and haemoglobin. In a subgroup of 72 patients, markers of disease activity were also assessed for correlation with fatigue using univariate and multivariate analysis with fatigue as the dependent variable.

RESULTS

In all three groups, significant correlations between fatigue and RDW were observed (p<0.001; p=0.02; p<0.001 respectively) and this was preserved in multivariate analysis. There was no correlation between fatigue and haemoglobin in two groups (with the correlation between RDW and fatigue remaining significant in non-anaemic patients in the third group). In subgroup analysis, fatigue was not associated with any measures of disease activity.

CONCLUSIONS

We report a reproducible, statistically significant association between RDW and fatigue levels in a diverse population of patients with SLE. The findings of this study raise the possibility of a potential novel biological basis for fatigue in those in whom there is a lack of an alternate explanation.

Differential expression and regulation of the non-integrin 37/67-kDa laminin receptor on peripheral blood leukocytes of healthy individuals and patients with rheumatoid arthritis

The non-integrin 37/67-kDa laminin receptor (LAMR1) is a complex protein with diverse functions. LAMR1 is widely expressed in epithelial cells and recently it was reported on neutrophils and a subset of activated T cells. Ligation of LAMR1 on peripheral blood mononuclear cells (PBMC) downregulated LPS-induced TNFα production, suggesting immune functions. However, its expression on primary monocytes remain unknown. Interestingly, LAMR1 mRNA is downregulated in PBMC of patients with early rheumatoid arthritis (RA), and low gene expression is an independent predictor of poor response to anti-TNFα treatment, suggesting a role in RA pathogenesis. We found LAMR1 was constitutively expressed on all peripheral blood monocytes and a subset of B cells from healthy individuals and patients with RA and it was abundantly present in synovial tissue of patients with RA. On monocytes and synovial tissue lower levels of LAMR1 expression tended to correlate with increased disease activity scores. In vitro treatment of monocytes with IFNγ or IL-10 up-regulated surface LAMR1 in healthy individuals and patients with RA with greater effects observed in healthy individuals. Importantly, treatment with IFNγ significantly increased specific binding of monocytes to laminin-1. TNFα and IL-1β caused marginal downregulation of LAMR1 in patients but effects in controls were variable. Taken together, constitutively expressed LAMR1 on monocytes is differentially regulated by pro-inflammatory and immune-regulatory cytokines suggesting LAMR1 may regulate the threshold and amplitude of their activation and migration. Decreased levels in patients with RA may indicate loss of this potentially critical homeostatic regulation thereby contributing to the excessive inflammation.

Search for K_{L}→π^{0}νν[over ¯] and K_{L}→π^{0}X^{0} Decays at the J-PARC KOTO Experiment

A search for the rare decay K_{L}→π^{0}νν[over ¯] was performed. With the data collected in 2015, corresponding to 2.2×10^{19} protons on target, a single event sensitivity of (1.30±0.01_{stat}±0.14_{syst})×10^{-9} was achieved and no candidate events were observed. We set an upper limit of 3.0×10^{-9} for the branching fraction of K_{L}→π^{0}νν[over ¯] at the 90% confidence level (C.L.), which improved the previous limit by almost an order of magnitude. An upper limit for K_{L}→π^{0}X^{0} was also set as 2.4×10^{-9} at the 90% C.L., where X^{0} is an invisible boson with a mass of 135  MeV/c^{2}.

Vitamin D in SLE: a role in pathogenesis and fatigue? A review of the literature

Fatigue is a common, disabling problem that is highly prevalent in patients with systemic lupus erythematous (SLE). More recently, vitamin D status has been established as a potential contributor to SLE pathogenesis and manifestations, in particular fatigue. This review summarizes the literature regarding the role of vitamin D in SLE, and provides an overview of the recent literature examining the association between vitamin D and fatigue in patients with SLE. Finally, the role of vitamin D supplementation in the treatment of SLE-related fatigue is considered.

Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study

Background

Alcohol consumption has been associated with poor antiretroviral therapy (ART) adherence but less is known about its relationship to HIV viral suppression, or whether certain drinking patterns have a stronger association than others. The objectives of this study were to determine the association of different patterns of alcohol consumption to HIV viral suppression and ART adherence, and to determine whether any associations of alcohol with HIV viral suppression were mediated by poor ART adherence.

Methods

This observational study used baseline data from 619 HIV+ participants, recruited across 8 clinical and community settings across Florida as part of the Florida Cohort from 2014 to 2016. Alcohol consumption was measured by self-report, and grouped into four categories: heavy drinking (>7/week for women or >14 drinks/week for men); binge, but not heavy drinking (≥4 or >5 drinks/occasion for women and men, respectively), low level drinking (neither heavy nor binge), and abstinence. Serum HIV RNA measurements were obtained from statewide HIV surveillance data, and durable viral suppression was defined as achieving HIV viral suppression (<200 copies/ml) at every assessment in the past 12 months.

Results

The majority of the 619 participants were male (63%) and aged 45 or greater (65%). The proportion of participants with heavy, binge, low-level drinking and abstinence was 9, 25, 37 and 30%, respectively. Optimal ART adherence (≥95%) was reported by 68%, and 60% achieved durable viral suppression. In multivariable analysis controlling for demographic factors, drug use, and homelessness, heavy drinking (compared to abstinence) was associated with increased odds of failing to achieve durable viral suppression (OR 2.16, 95% CI 1.08–4.32) whereas binge drinking alone was not significantly associated with this outcome (OR 1.04, 95% CI 0.64–1.70). Both heavy drinking and binge drinking were significantly associated with suboptimal ART adherence. Mediation analyses suggested that only a small proportion of the relationship between heavy drinking and suboptimal viral suppression was due to poor ART adherence.

Conclusions

Exceeding weekly recommended levels of alcohol consumption (heavy drinking) was significantly associated with poor HIV viral suppression and ART non-adherence, while binge drinking was associated with suboptimal ART adherence in this sample. Clinicians should attempt to address heavy drinking in their patients with HIV.

The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy

OBJECTIVES

Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied.

METHODS

Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties).

RESULTS

Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged.

CONCLUSIONS

Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.

Leukocyte immunoglobulin-like receptor A3 (LILRA3) displays anti-inflammatory and neuro-regenerative functions through interaction with multiple ligands

LILRA3 belongs to a family of highly homologous surface activating and inhibitory receptors that are emerging as critical regulators of immune cell activation by transducing opposing signals. Uniquely, LILRA3 is soluble and so cannot transduce intracellular signals, hence its functions are unknown, despite its ubiquitous presence in sera and its strong clinical association with various inflammatory diseases. This is primarily due lack of knowledge of its ligands, absence of a LILRA3 homolog in rodents and difficulties in producing functional protein. We produced full-length rLILRA3 protein typical of the native protein and used it in a proteomic approach to concurrently identify two novel ligands; LAMR1 and Nogo 66, and one known MHC I ligand, HLA-B2705 that were validated by expression cloning. Importantly, LAMR1 and Nogo 66 independently interacted with LILRA3 with high affinities of 9.1 pmol and 22 pmol respectively. LAMR1 is a multifunctional protein involved in LPS-induced inflammation and HLA-B2705 is strongly associated with seronegative arthritis (SpA). Nogo 66 is potent inhibitors of neurite outgrowth in the central nervous system. We discovered that LILRA3 promoted neurite outgrowth and synapse formation in central nervous system by blocking Nogo 66; strongly suppressed LPS-mediated inflammation in vivo via interaction with LAMR1, and inhibited activation of peripheral blood T cell by competitively blocking interaction of HLA-B2705 with a closely related activating receptor (LILRA1) which is highly expressed on a subset of T cells in HLA-B27 +ve patients with SpA. These results led to a new concept that LILRA3 may bind multiple ligands with varying affinities and display clinically relevant tissue-specific functions.

Leukocyte immunoglobulin-like receptor B4 regulates key signalling molecules involved in FcγRI-mediated clathrin-dependent endocytosis and phagocytosis

FcγRI cross-linking on monocytes may trigger clathrin-mediated endocytosis, likely through interaction of multiple intracellular molecules that are controlled by phosphorylation and dephosphorylation events. However, the identity of phospho-proteins and their regulation are unknown. We proposed the leukocyte immunoglobulin-like receptor B4 (LILRB4) that inhibits FcγRI-mediated cytokine production via Tyr dephosphorylation of multiple kinases, may also regulate endocytosis/phagocytosis through similar mechanisms. FcγRI and/or LILRB4 were antibody-ligated on THP-1 cells, lysates immunoprecipitated using anti-pTyr antibody and peptides sequenced by mass spectrometry. Mascot Search identified 25 Tyr phosphorylated peptides with high confidence. Ingenuity Pathway Analysis revealed that the most significantly affected pathways were clathrin-mediated endocytosis and Fc-receptor dependent phagocytosis. Tyr phosphorylation of key candidate proteins in these pathways included common γ-chain of the Fc receptors, Syk, clathrin, E3 ubiquitin protein ligase Cbl, hepatocyte growth factor-regulated tyrosine kinase substrate, tripartite motif-containing 21 and heat shock protein 70. Importantly, co-ligation of LILRB4 with FcγRI caused significant dephosphorylation of these proteins and was associated with suppression of Fc receptor-dependent uptake of antibody-opsonised bacterial particles, indicating that LILRB4. These results suggest that Tyr phosphorylation may be critical in FcγRI-dependent endocytosis/phagocytosis that may be regulated by LILRB4 by triggering dephosphorylation of key signalling proteins.

Exhaled breath markers of alveolar macrophage activity in sarcoidosis

OBJECTIVE

Granuloma formation in sarcoidosis is dependent upon the interaction between alveolar macrophages (AMs) and a CD4+-driven TH1 response. This study aimed to measure TNF-α and calcium ion concentrations as markers of AM activity, in addition to total protein as a non-specific inflammatory marker in the exhaled breath condensate (EBC) of patients with sarcoidosis as well as control subjects.

METHODS

EBC was collected from 17 sarcoidosis patients and 23 healthy volunteers. Protein was measured by the bicinchoninic acid assay, TNF-α concentration was measured by ELISA and Ca(2+) concentration was measured by inductively coupled plasma-mass spectrometry. Conductivity of EBC was assessed using a conductivity probe.

RESULTS

Total protein concentration was significantly elevated in EBC from patients with sarcoidosis compared to control subjects (19.51 ± 4.52 vs. 10.60 ± 1.31 µg/ml, p = 0.020), as was TNF-α (3.37 ± 0.38 vs. 2.59 ± 0.40 pg/ml, p = 0.037) and conductivity (66.68 ± 16.73 vs. 36.85 ± 3.070 µS/cm, p = 0.044). EBC Ca(2+) concentration was significantly higher in healthy controls compared to patients with sarcoidosis (116.50 ± 12.19 vs. 73.88 ± 13.35 µmol/l, p = 0.018), although this was in the context of normal serum Ca(2+) in the sarcoidosis cohort.

CONCLUSIONS

Total protein and TNF-α concentrations were elevated in EBC from patients with sarcoidosis and could indicate disease activity. The reduction in EBC Ca(2+) concentrations could represent granulomatous activity in the lung.

Cetuximab plus platinum-based chemotherapy in head and neck squamous cell carcinoma: a randomized, double-blind safety study comparing cetuximab produced from two manufacturing processes using the EXTREME study regimen

BACKGROUND

Cetuximab, in combination with platinum chemotherapy plus 5-fluoruracil (5-FU), is approved for the first-line treatment of recurrent/metastatic squamous cell carcinoma of the head and neck (SCCHN). Cetuximab manufactured by ImClone (US commercial cetuximab) potentially results in higher systemic exposures than cetuximab manufactured by Boehringer Ingelheim (BI-manufactured cetuximab). This prospective, randomized, double-blind study compared the safety profiles of the two cetuximab formulations.

METHODS

Patients with previously untreated locoregionally recurrent and/or metastatic SCCHN were randomly assigned to receive the same dose of US commercial cetuximab (Arm A) or BI-manufactured cetuximab (Arm B), each in combination with cisplatin or carboplatin plus 5-FU. The primary outcome was all-grade, all-cause treatment-emergent adverse events (TEAEs).

RESULTS

The majority of patients experienced ≥ 1 TEAE, regardless of causality (Arm A: 75/77 patients, 97.4%; Arm B: 68/71 patients, 95.8%). TEAEs with the highest incidence included nausea, fatigue, and hypomagnesemia in both arms. The absolute risk difference between the two arms for patients experiencing at least one adverse event (AE) was 0.029 (p = 0.281, 95% confidence interval [CI]: -0.024, 0.082) for AEs regardless of causality and 0.005 (p = 0.915, 95% CI: -0.092, 0.103) for AEs possibly related to study drug. There were no significant differences between the two arms in the incidence of acneiform rash, cardiac events, infusion reactions, or hypomagnesemia. Overall survival, progression-free survival, and overall response rates were similar in the two arms.

CONCLUSIONS

There were no clinically meaningful differences in safety between US commercial cetuximab and BI-manufactured cetuximab in combination with platinum-based therapy with 5-FU in patients with locoregionally recurrent and/or metastatic SCCHN. The use of US commercial cetuximab in this combination chemotherapy regimen did not result in any unexpected safety signals. The efficacy results of this study are consistent with the efficacy results of the cetuximab arm of the EXTREME study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01081041 ; date of registration: March 3, 2010).

Soluble LILRA3 promotes neurite outgrowth and synapses formation through high affinity interaction with Nogo 66

Inhibitory proteins, particularly Nogo 66, a highly conserved 66 amino acid loop of Nogo A, play key roles in limiting the intrinsic capacity of the central nervous system to regenerate after injury. Ligation of surface Nogo receptors (NgRs) and/or leukocyte immunoglobulin like receptor B2 (LILRB2) and its mouse orthologue the paired-immunoglobulin-like receptor B (PIRB) by Nogo 66 transduces inhibitory signals that potently inhibit neurite outgrowth. Here we show that soluble leukocyte immunoglobulin-like receptor A3 (LILRA3) is a high affinity receptor for Nogo 66, suggesting that LILRA3 might be a competitive antagonist to these cell surface inhibitory receptors. Consistent with this, LILRA3 significantly reversed Nogo 66-mediated inhibition of neurite outgrowth and promoted synapse formation in primary cortical neurons via regulation of the MEK/ERK pathway. LILRA3 represents a new antagonist to Nogo 66-mediated inhibition of neurite outgrowth in the CNS, a function distinct from its immune-regulatory role in leukocytes. This report is also the first to demonstrate that a member of LILR family normally not expressed in rodents exerts functions on mouse neurons through the highly homologous Nogo 66 ligand.

Sexual partner notification of HIV infection among a National United States-based sample of HIV-infected men

Limited data exist on whether sexual partner notification practices among HIV-infected men, particularly those who have sex with men (MSM), vary by HIV viral load. We examined factors associated with complete (all partners) versus incomplete partner notification in 760 HIV-infected individuals across the United States, 49 % of whom were MSM. Thirty-four percent reported incomplete partner notification. Incomplete partner notification was more likely among black men, MSM, and those reporting casual partners and non-condom use. Partner notification practices did not vary by HIV viral load except among those with casual partners in whom a detectable viral load was associated with incomplete partner notification. Increased sexual partner notification among HIV-infected men, especially MSM, is needed.

Glycosylation in a mammalian expression system is critical for the production of functionally active leukocyte immunoglobulin-like receptor A3 protein

The leukocyte immunoglobulin-like receptor (LILR) A3 is a member of the highly homologous activating and inhibitory receptors expressed on leukocytes. LILRA3 is a soluble receptor of unknown functions but is predicted to act as a broad antagonist to other membrane-bound LILRs. Functions of LILRA3 are unclear primarily because of the lack of high quality functional recombinant protein and insufficient knowledge regarding its ligand(s). Here, we expressed and characterized recombinant LILRA3 (rLILRA3) proteins produced in 293T cells, Escherichia coli, and Pichia pastoris. We found that the purified rLILRA3 produced in the mammalian system was the same size as a 70-kDa native macrophage LILRA3. This is 20 kDa larger than the calculated size, suggesting significant post-translational modifications. In contrast, rLILRA3 produced in E. coli was similar in size to the unprocessed protein, but yeast-produced protein was 2-4 times larger than the unprocessed protein. Treatment with peptide-N-glycosidase F reduced the size of the mammalian cell- and yeast-produced rLILRA3 to 50 kDa, suggesting that most modifications are due to glycosylation. Consistent with this, mass spectrometric analysis of the mammalian rLILRA3 revealed canonical N-glycosylation at the predicted Asn(140), Asn(281), Asn(302), Asn(341), and Asn(431) sites. Functionally, only mammalian cell-expressed rLILRA3 bound onto the surface of monocytes with high affinity, and importantly, only this significantly abrogated LPS-induced TNFα production by monocytes. Binding to monocytes was partially blocked by β-lactose, indicating that optimally glycosylated LILRA3 might be critical for ligand binding and function. Overall, our data demonstrated for the first time that LILRA3 is a potential new anti-inflammatory protein, and optimal glycosylation is required for its functions.

Incidence of respiratory viruses in patients with community-acquired pneumonia admitted to the intensive care unit: results from the Severe Influenza Pneumonia Surveillance (SIPS) project

Few patients with community-acquired pneumonia (CAP) require admission to the intensive care unit (ICU-CAP). However, they represent the most severe form of the disease. An understanding of the etiologic agents of ICU-CAP may lead to better treatment decisions and patient outcomes. The objective of this study was to determine the incidence of respiratory viruses in patients with ICU-CAP. This was an observational study conducted in six Kentucky hospitals from December 2008 through October 2011. A case of ICU-CAP was defined as a patient admitted to an ICU with the diagnosis of CAP. The Luminex xTAG multiplex polymerase chain reaction (PCR) assay was used for viral identification. A total of 468 adult and pediatric patients with ICU-CAP were enrolled in the study. A total of 92 adult patients (23 %) and 14 pediatric patients (19 %) had a respiratory virus identified. Influenza was the most common virus identified in adults and the second most common in pediatric patients. This study suggests that respiratory viruses may be common etiologic agents of pneumonia in patients with ICU-CAP. The Centers for Disease Control and Prevention (CDC) recommend empiric anti-influenza therapy during the winter for hospitalized patients with CAP. This study supports this recommendation in patients with ICU-CAP.

Expression of activating and inhibitory leukocyte immunoglobulin-like receptors in rheumatoid synovium: correlations to disease activity

Rheumatoid arthritis (RA) is a heterogeneous chronic inflammatory joint disease characterized by excessive activation of inflammatory cells of which the underlying mechanisms are not fully elucidated. Perturbed expression and function of immune regulatory molecules called leukocyte immunoglobulin-like receptors (LILRs) may contribute to uncontrolled inflammation. LILRs primarily expressed on the surface of leukocytes are emerging as critical regulators of the threshold and amplitude of leukocyte activation. Inhibitory LILRs (LILRBs) contain cytoplasmic tails with immunoreceptor tyrosine-based inhibitory motifs that provide negative signals. Activating LILRs (LILRAs) have short cytoplasmic domains lacking signaling motifs but transmit activating signals by linking to immunoreceptor tyrosine-based activation motifs of the FcR γ-chain. Here we show that activating LILRA2, A5 and inhibitory LILRB2, B3 were abundantly expressed in synovial tissue of > 75% RA patients. Expression of LILRA2, A5, and B3 significantly correlated to disease activity. In contrast, LILRA1 and B4 were expressed in a subset of patients and no B1 or B5 expression was detected. LILRA2 and A5 were mainly expressed by synovial macrophages and endothelial cells but not lymphocytes, whereas B2 and B3 were expressed by macrophages and lymphocytes. Increase in the number of macrophages expressing activating LILRs and macrophages and lymphocytes expressing inhibitory LILRs suggest a crosstalk between these cells that may regulate the levels of cellular activation and disease severity, while differences in expression pattern may contribute to disease heterogeneity.

EPOCH-F: a novel salvage regimen for multiple myeloma before reduced-intensity allogeneic hematopoietic SCT

There exists a need for effective salvage regimens for multiple myeloma patients being considered for reduced-intensity allogeneic hematopoietic SCT (RI-alloHSCT). We developed EPOCH-F, a regimen consisting of infusional etoposide, VCR and adriamycin with prednisone, CY and fludarabine to achieve both tumor control and host lymphocyte depletion to facilitate engraftment before RI-alloHSCT. In all, 22 multiple myeloma patients were treated with EPOCH-F before RI-alloHSCT. The median age was 53 years (range 36-65), and the median number of previous therapies was 2 (range 1-8). Patients received a median of three cycles (range 1-5) of EPOCH-F. Toxicities were primarily hematologic and manageable. Median lymphocyte counts decreased from 1423/μL (range 335-2788) to 519/μL (range 102-1420; P=0.0002). The overall response (≥PR) to EPOCH-F was 22 with 13% achieving a CR/near-complete response (nCR); only 1 patient progressed while on therapy. A total of 20 patients underwent RI-alloHSCT. Median day +100 donor chimerism was 100% (range 60-100). In all, 70% of patients achieved very good partial response or better response after transplant; 40% of patients achieved CR/nCR. TRM at 100 days and 5 years was 5 and 30%, respectively. Median OS after RI-alloHSCT was 46.1 months. EPOCH-F provides disease control and host lymphocyte depletion with consistent full donor engraftment in multiple myeloma patients undergoing RI-alloHSCT.

Predicting outpatient treatment entry following detoxification for injection drug use: the impact of patient and program factors

This article examines variables that predicted outpatient treatment entry within 6 months of residential detoxification. Patient data were collected from 632 injection drug users enrolled in a randomized trial conducted at eight detoxification programs within the National Drug Abuse Treatment Clinical Trials Network (CTN) with follow-up assessments conducted at 2, 8, 16, and 24 weeks. Detoxification program characteristics were collected during this study and from a survey of CTN treatment organizations. Survival analysis found that estimated proportions of reported outpatient treatment entry varied across sites from .06 to .72. A model-building approach determined variables significantly associated with outpatient treatment entry. The best predictive model contained five program-level variables: accreditation, fewer beds, longer stays, shorter distance between detoxification and outpatient unit, and larger city population. Results suggest the importance of detoxification program characteristics in facilitating further treatment and the need for systems modifications to improve continuity of care.

Decreased adherence and spontaneous separation of fetal membrane layers--amnion and choriodecidua--a possible part of the normal weakening process

INTRODUCTION

The fetal membrane (FM) layers, amnion and choriodecidua, are frequently noted to have varying degrees of separation following delivery. FM layers normally separate prior to rupture during in vitro biomechanical testing. We hypothesized that the adherence between amnion and choriodecidua decreases prior to delivery resulting in separation of the FM layers and facilitating FM rupture.

METHODS

FM from 232 consecutively delivered patients were examined to determine the extent of spontaneous separation of the FM layers at delivery. Percent separation was determined by the weight of separated FM tissue divided by the total FM weight. Separately, the adherence between intact FM layers was determined. FM adherence was tested following term vaginal delivery (13), term unlabored cesarean section (10), and preterm delivery (6).

RESULTS

Subjects enrolled in the two studies had similar demographic and clinical characteristics. FM separation was present in 92.1% of membranes. Only 4.3% of FM delivered following spontaneous rupture of the fetal membranes (SROM) had no detectable separation. 64.7% of FM had greater than 10% separation. FM from term vaginal deliveries had significantly more separation and were less adherent than FM of term unlabored, elective cesarean section (39.0+/-34.4% vs 22.5+/-30.9%, p=.046 and 0.041+/-0.018N/cm vs 0.048+/-0.019N/cm, p<.005). Preterm FM had less separation and were more adherent than term FM (9.95+/-17.7% vs 37.5+/-34.4% and 0.070+/-0.040N/cm vs 0.044+/-0.020N/cm; both p<.001).

CONCLUSIONS

Separation of the amnion from choriodecidua at delivery is almost universal. Increased separation is associated with decreased adherence as measured in vitro. Increased separation and decreased adherence are seen both with increasing gestation and with labor suggesting both biochemical and mechanical etiologies. The data are consistent with the hypothesis that FM layer separation is part of the FM weakening process during normal parturition.

Leukocyte Ig-like receptor B4 (LILRB4) is a potent inhibitor of FcgammaRI-mediated monocyte activation via dephosphorylation of multiple kinases

The leukocyte immunoglobulin-like receptor (LILR) B4 belongs to a family of cell surface receptors that possesses cytoplasmic immunoreceptor tyrosine-based inhibitory motifs (ITIMs). LILRB4 is believed to down-regulate activation signals mediated by non-receptor tyrosine kinase cascades through the recruitment of SHP-1. However, the exact mechanisms of LILRB4-mediated inhibition are not fully elucidated. In this study, we demonstrate high level surface expression of LILRB4 on THP-1 cells and primary peripheral blood monocytes, which profoundly inhibited production of a key pro-inflammatory cytokine (TNFalpha) induced by FcgammaRI (CD64). We also report that LILRB4 aggregated to sites of activation upon co-ligation with CD64 and that this may enhance its inhibitory effects. Cross-linking of CD64 on THP-1 cells markedly increased phosphorylation of multiple proteins including tyrosine kinases and signaling molecules (Lck, Syk, LAT, and Erk), an adaptor protein that targets protein-tyrosine kinases for degradation (c-Cbl) and a protein involved in the formation of actin cytoskeletal rearrangement (alpha-actinin-4). Co-ligation of LILRB4 considerably reduced CD64-mediated phosphorylation of Lck, Syk, LAT, Erk, and c-Cbl but not alpha-actinin-4, suggesting selective inhibition of signaling molecules. Treatment of cells with a broad-spectrum phosphatase inhibitor, sodium pervanadate (SP), significantly reversed LILRB4-mediated inhibition of TNFalpha production and protein tyrosine phosphorylation. In comparison, treatment with an SHP-1 specific inhibitor, sodium stibogluconate (SS) has no effects indicating involvement of phosphatase(s) other than SHP-1 in LILRB4 signaling. Collectively, our data show LILRB4 is a potent inhibitor of monocytes activation. This may provide a new potential therapeutic strategy for inflammatory conditions characterized by excessive TNFalpha production.

Sibling donor immunization with patient-derived Id-KLH vaccine prior to reduced-intensity allogeneic hematopoietic cell transplantation for multiple myeloma

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Background: Relapse is the most common cause of treatment failure after reduced-intensity allogeneic hematopoietic cell transplantation (RI-alloHCT) for multiple myeloma (MM). To enhance graft-versus-myeloma effects, we investigated the use of patient-specific idiotype (Id) vaccine in both donors and recipients. Methods: Id protein was obtained by plasmapheresis and conjugated to keyhole limpet hemocyanin (Id-KLH) to generate vaccine. Donors received 3 SQ injections of Id-KLH + GM-CSF at 10, 8, and 4 weeks before stem cell donation. MM pts received a reduced-intensity conditioning regimen (Flu/Cy) and GVHD prophylaxis consisted of cyclosporine plus methotrexate. MM pts were vaccinated with the Id-KLH+GM-CSF at 3, 4, and 6 months post-transplant. Humoral responses were determined by ELISA and Th1 (IL-2, IFN-γ, TNF-α, and GM-CSF) and Th2 (IL-4, IL-5, IL-10, and IL-13) cellular immune responses against Id and KLH were determined by multiplex cytokine assay. Results: Ten MM pts (median age: 54 years; IgG = 8, IgA = 2) and their respective donors were enrolled onto study. All 10 donors completed vaccinations without significant complications. Following vaccination, KLH-specific antibody and Th1/Th2 responses were noted in all 10 donors. Id-specific antibody responses were noted in 6 donors; Th1 and Th2 responses were noted in 5 and 6 donors, respectively. All 10 MM pts underwent RI-alloHCT; the median potential follow-up post-transplant is 43.8 months. Id-specific Th1 and Th2 responses were noted in 5 and 3 pts, respectively, prior to post-transplant immunization; antibody response was noted in 1 patient. Nine evaluable MM pts completed their post-transplant vaccinations. KLH-specific antibody and Th1/Th2 responses were detectable in all 9 pts post-transplant. Id and KLH immune responses were further enhanced by post-transplant vaccinations. Median progression-free survival is 27.3 months; median survival has not been reached. Conclusions: The data suggest Id-specific immunity can be safely induced in normal stem cell donors and passively transferred to recipients of RI-alloHCT. Donor vaccination with tumor-specific antigen represents a tactic to potentially reduce relapse after RI-alloHCT.

No significant financial relationships to disclose.

LILRA3 protein is constitutively expressed in normal serum and increased in patients with active rheumatoid arthritis (49.11)

Leukocyte immunoglobulin-like receptor A3 (LILRA3) belongs to a family of cell surface receptors that have activating or inhibiting functions in leukocytes through their intracytoplasmic immunoreceptor tyrosine-based activating motifs (ITAMs) and inhibitory motifs (ITIMs). LILRA3 lacks transmembrane and cytoplasmic domains, suggesting that it may be secreted. Although LILRA3 function is unknown, its high structural homology to activating LILRA1 and A2 indicate that it may act as antagonist or agonist to these receptors. Clinically, LILRA3 may have a role in a number of immune-related diseases. A recent finding showed that individuals who lack the LILRA3 gene have a higher incidence of multiple sclerosis, suggesting that LILRA3 may regulate inflammatory responses. However to date, expression studies of LILRA3 have been limited to mRNA. Here we developed an ELISA to detect LILRA3 protein in serum. To investigate whether LILRA3 plays a role in chronic inflammation, we examined its expression in serum and synovial fluid of patients with rheumatoid arthritis (RA). For the first time, we demonstrate LILRA3 protein expression in serum with increased levels in serum and synovial fluid of patients with RA compared to osteoarthritis or normal subjects. The level of LILRA3 in RA correlated with disease activity score. These findings indicate that LILRA3 may play a role in the pathogenesis of RA.

Alterations in immune function and CYP450 activity in adult male deer mice (Peromyscus maniculatus) following exposure to benzo[a]pyrene, pyrene, or chrysene

Polycyclic aromatic hydrocarbons (PAHs) are among the most common classes of chemical contaminants found at hazardous waste sites. Deer mice (Peromyscus maniculatus) exhibit a wide geographic distribution throughout North America and have been suggested as a terrestrial biomonitoring species to facilitate comparisons between superfund sites. Chemicals tested were benzo[a]pyrene (BaP; CAS number 50-32-8), pyrene (Pyr; CAS number 129-00-0), and chrysene (Chr; CAS number 218-01-9). Adult male deer mice were exposed via intraperitoneal (i.p.) injection every other day for 11 d to the PAHs (0.3, 1, 3, 10, or 30 mg/kg) or a corn oil carrier control. Both BaP and Chr suppressed the plaque-forming cell (PFC) response at all treatment levels. Pyr exposure (1-30 mg/kg) also resulted in suppression of this response. Macrophage pinocytosis was suppressed only by Chr (3, 10, and 30 mg/kg). Concanavalin A-induced proliferation was stimulated by BaP at all dose levels, by Pyr at 1-30 mg/kg, and by Chr at 30 mg/kg. Chr did not affect pokeweed mitogen (PWM)-induced proliferation; however, BaP (1-30 mg/kg) and Pyr (0.3-30 mg/kg) produced stimulation of this response as compared to respective controls. BaP and Chr stimulated cytochrome P-450 1A1 (CYP1A1) activity (3, 10, or 30 mg/kg) as measured by ethoxyresorufin O-deethylase (EROD) activity, but Pyr did not. These results indicate that immune function endpoints appear to be more sensitive to these PAHs than measured hepatic CYP450 activity.

Estimating the impact of alcohol consumption on survival for HIV+ individuals

Alcohol consumption is associated with decreased antiretroviral adherence, and decreased adherence results in poorer outcomes. However the magnitude of alcohol's impact on survival is unknown. Our objective was to use a calibrated and validated simulation of HIV disease to estimate the impact of alcohol on survival. We incorporated clinical data describing the temporal and dose-response relationships between alcohol consumption and adherence in a large observational cohort (N=2,702). Individuals were categorized as nondrinkers (no alcohol consumption), hazardous drinkers (consume > or =5 standard drinks on drinking days), and nonhazardous drinkers (consume <5 standard drinks on drinking days). Our results showed that nonhazardous alcohol consumption decreased survival by more than 1 year if the frequency of consumption was once per week or greater, and by 3.3 years (from 21.7 years to 18.4 years) with daily consumption. Hazardous alcohol consumption decreased overall survival by more than 3 years if frequency of consumption was once per week or greater, and by 6.4 years (From 16.1 years to 9.7 years) with daily consumption. Our results suggest that alcohol is an underappreciated yet modifiable risk factor for poor survival among individuals with HIV.

The onset of HIV infection in the Leningrad region of Russia: a focus on drug and alcohol dependence

OBJECTIVES

Within 5 years, 5 million Russians may be infected with HIV. Currently, injection drug use is the major risk factor for HIV. As Russia's alcohol consumption per capita is among the highest in the world, alcohol-associated behaviours may be an important contributor to the HIV epidemic. Our objective was to examine the prevalence of HIV infection among drug- and alcohol-dependent patients in a regional narcology hospital and in the general population in Leningrad.

METHODS

All patients in the Narcology Hospital, Leningrad Regional Center of Addictions (LRCA), were tested for HIV antibody between 1997 and 2001. We reviewed these clinical records (i.e. serostatus, gender, age, and addiction) and data from the HIV/AIDS Center in the Leningrad Region (1997-2001).

RESULTS

From 1997 to 2001, HIV prevalence at the LRCA increased from 0 to 12.7% overall, 33.4% among drug-dependent patients and 1.2% among alcohol-dependent patients. During the same 5-year period (1997-2001), 2826 persons were registered at the HIV/AIDS Center: 6, 6, 51, 780, and 1983 persons in 1997, 1998, 1999, 2000 and 2001, respectively.

CONCLUSIONS

HIV infection is exploding in the Leningrad Region, currently in injection drug users (IDUs) but potentially more broadly. The known high per capita alcohol intake in Russia heightens concern regarding the sexual transmission of HIV. Interventions to prevent such a development should include use, and assessment of the effectiveness, of known HIV prevention measures for at-risk and infected individuals.

The Role of Selective Estrogen Receptor Modulators in the Prevention of Breast Cancer: Comparison of the Clinical Trials

The role of estrogen in the development of breast cancer is well recognized, and the use of selective estrogen receptor modulators (SERMs) to reduce breast cancer risk continues to be evaluated. Tamoxifen is the only SERM approved for the reduction of breast cancer incidence in women at high risk. This approval was based on results from the Breast Cancer Prevention Trial. Although initial results from the Royal Marsden Hospital tamoxifen trial and Italian Tamoxifen Prevention Study did not show a similar overall effect of tamoxifen, recent updates from these two trials and initial results from the International Breast Cancer Intervention Study are consistent with a risk reduction effect of tamoxifen for estrogen-receptor-positive breast cancer. Raloxifene, approved for the prevention and treatment of postmenopausal osteoporosis, is another SERM being evaluated for breast cancer risk reduction. The recently completed Continuing Outcomes Relevant to Evista trial and the Raloxifene Use for The Heart trial, have breast cancer risk reduction as a primary end point. A third, ongoing trial, the Study of Tamoxifen and Raloxifene trial, is evaluating the relative efficacy and adverse event profile of these two agents in a population at high risk. The study populations of these raloxifene breast cancer prevention trials and the four tamoxifen prevention trials are quite diverse in terms of breast cancer risk. Completion of these trials will provide important information about the occurrence of invasive breast cancer in postmenopausal women and the efficacy of raloxifene for breast cancer risk reduction.

Hepatosplenic cat scratch disease treated with corticosteroids

A 3 year old girl with hepatosplenic cat scratch disease developed prolonged fever unresponsive to treatment with multiple antibiotics, including gentamicin, azithromycin, rifampin, and ciprofloxacin. Fever resolved with corticosteroid treatment.

Gender differences in the association of alcohol intoxication and illicit drug abuse among persons arrested for violent and property offenses

PURPOSE

To explore the associations between violent and other crimes, and alcohol intoxication and recent use of cocaine, marijuana, and other drugs among men and women arrestees and examine gender differences in these relationships.

METHODS

We conducted a secondary analysis of 1998 using Arrestee Drug Abuse Monitoring (ADAM) system data using a sample of 9242 male and 2594 women arrested for violent and property offenses in 35 cities. Logistic regression was used to predict arrest for a violent offense (rather than a property crime) from drug- and alcohol-related, and other variables.

RESULTS

Both gender and alcohol intoxication are significantly related to arrest for a violent offense. However, the intoxication effects (in the absence of cocaine) are more than three times as great for female (Exp(beta) = 5.59) as male arrestees (Exp(beta) = 1.74), while the combined effects of alcohol and cocaine predict a property offense for women but are insignificant for men.

IMPLICATIONS

To achieve further reductions in violent crime, intervention strategies need to focus on reducing alcohol intoxication as well as illicit drug use. Research on the role of alcohol on women's aggression and violence also is suggested.

Strain characterization and 16S-23S probe development for differentiating geographically dispersed isolates of the phytopathogen Ralstonia solanacearum

The causative agent of potato brown rot and bacterial wilt, Ralstonia solanacearum, results in serious world-wide economic losses, particularly in the tropics. In the last decade, however, the incidence of bacterial wilt in potatoes grown in Northern Europe has increased, presenting an interesting epidemiological puzzle. Its occurrence may be as a result of changes in agricultural practice or the emergence of a novel bacterial variety, better adapted to cooler conditions. To understand the distribution and genetic diversity of this phytopathogen, we have analysed a collection of 82 isolates from Europe and tropical regions. Both phenotypic [SDS-PAGE (sodium dodecyl sulphate polyacrylamide gel electrophoresis) profiling, FAME (fatty acid methyl esters) analysis, growth profiles and EPS (exopolysaccharide) production] and genotypic [16S rRNA RFLP (restriction fragment length polymorphism), ARDRA (amplified ribosomal DNA restriction analysis) and sequence analysis of 16S-23S rRNA ITS and flanking regions] methods were compared. Principal component analysis of FAME profiles clustered isolates into three groups and ARDRA of a 0.85 kb amplified fragment from the 16S-23S ITS region differentiated isolates into four groups. Using sequence analysis, specific primers were designed within the variable region 147-170 of the 23S rRNA. These primers, RsolT2 and RsolT3, respectively, differentiated isolates into two distinct clusters as described previously by Wullings and colleagues (Wullings et al., 1998). The European strains (Biovar 2, race 3) analysed in this study specifically hybridized with RsolT3, and showed considerable genetic homogeneity when compared with strains of other races from 'the rest of the world'. These data indicate the possible selection and proliferation of a 'European'-adapted variant.

Self-reported alcohol use and abuse by arrestees in the 1998 Arrestee Drug Abuse Monitoring Program

Data collected in the Arrestee Drug Abuse Monitoring (ADAM) program on alcohol and other drug use among arrestees provide a valuable opportunity to examine the relationship between alcohol use and violence. The data are used to explore the combined use of alcohol and other drugs among offenders and the relationships between substance use and the offenders' demographic characteristics and offenses. These findings are used to identify changes in the offenders' alcohol and other drug use over time.

Renal candidiasis in neonates with candiduria

BACKGROUND

Candida species commonly cause urinary tract infection in infants admitted to neonatal intensive care units. The purpose of this study was to describe the natural history of renal candidiasis as evidenced by sonography in infants with candiduria.

METHODS

The medical records of all infants who developed candiduria during their neonatal intensive care hospitalization between 1982 and 1993 were reviewed. Candiduria was defined as the isolation of Candida from (1) one or more specimens obtained by bladder catheterization or suprapubic aspiration, (2) one or more voided specimens and concurrent positive cultures from another sterile body site or (3) one or more voided specimens and changes on renal ultrasound consistent with renal candidiasis. Renal ultrasounds were retrospectively reviewed by one pediatric radiologist. Nonshadowing echogenic foci were considered evidence of renal fungus balls.

RESULTS

Forty-one infants with candiduria were identified. Thirty-six infants underwent 1 or more renal imaging studies (ultrasonography, 35; computerized tomography, 1). The incidence of renal candidiasis in neonates with candiduria, defined as renal fungus balls or renal fungal abscess, was 42%. Of the 13 patients who had sonographic abnormalities suggestive of renal fungus balls, 7 had abnormalities on the first ultrasound obtained after the discovery of candiduria, whereas 6 patients developed abnormalities between 8 and 39 days later.

CONCLUSIONS

Serial renal ultrasounds are required to reliably detect late appearing renal fungus balls in neonates with candiduria. Complications requiring surgical intervention, like urinary tract obstruction, were uncommon.