EVALUATING AN INNOVATIVE USE OF CIVIL MONETARY PENALTY FUNDS: THE MA SUPPORTIVE PLANNING AND OPERATIONS TEAM (SPOT)

The Office of the Inspector General reported in 2014, that one in three NH residents experienced an adverse event within 35 days of admissions causing lasting or temporary harm. Thus, state departments of public health (DPH) were implored to invest in improving NH quality and safety. Using Civil Monetary Penalty funds, the Massachusetts DPH, developed the SPOT Initiative to innovatively provide NH teams with technical assistance and training to enhance their federally required Quality Assurance & Performance Improvement (QAPI) programs. Selection criteria included NH Compare 5-Star and MA scorecard ratings and geographic spread. To assess program effectiveness, the SPOT Team collected a range of data in each of the three SPOT years (e.g., QAPI assessments, leadership interviews and surveys, and training evaluations). Results demonstrated the success of the Initiative. Assessment data indicated an increase in QAPI readiness in each subsequent year overall and within of the each QAPI assessment domains (Design and Scope; Governance and Leadership; Feedback, Data Systems, and Monitoring/Systematic Analysis; Performance Improvement Projects and Systematic Analysis/Systemic Action). In Year 1, the overall data collected from the assessments demonstrated that 78% of the NHs that engaged with SPOT had “Not Started” or “Just Started” (1.8/5) implementation of the key QAPI measures. By Year 3, only 13% of NH teams rated themselves in these initial categories, whereas, 57% rated themselves as “Almost There” or “Doing Great” (3.92/5). Further, feedback from most SPOT NH teams was extremely positive as evidenced by high evaluation rankings following initiative learning sessions.

Cluster-Randomized Trial of a Behavioral Intervention to Incorporate a Treat-to-Target Approach to Care of US Patients With Rheumatoid Arthritis

Objective

To assess the feasibility and efficacy of implementing a treat‐to‐target approach versus usual care in a US‐based cohort of rheumatoid arthritis patients.

Methods

In this behavioral intervention trial, rheumatology practices were cluster‐randomized to provide treat‐to‐target care or usual care. Eligible patients with moderate/high disease activity (Clinical Disease Activity Index [CDAI] score >10) were followed for 12 months. Both treat‐to‐target and usual care patients were seen every 3 months. Treat‐to‐target providers were to have monthly visits with treatment acceleration at a minimum of every 3 months in patients with CDAI score >10; additional visits and treatment acceleration were at the discretion of usual care providers and patients. Coprimary end points were feasibility, assessed by rate of treatment acceleration conditional on CDAI score >10, and achievement of low disease activity (LDA; CDAI score ≤10) by an intent‐to‐treat analysis.

Results

A total of 14 practice sites per study arm were included (246 patients receiving treat‐to‐target and 286 receiving usual care). The groups had similar baseline demographic and clinical characteristics. Rates of treatment acceleration (treat‐to‐target 47% versus usual care 50%; odds ratio [OR] 0.92 [95% confidence interval (95% CI) 0.64, 1.34]) and achievement of LDA (treat‐to‐target 57% versus usual care 55%; OR 1.05 [95% CI 0.60, 1.84]) were similar between groups. Treat‐to‐target providers reported patient reluctance and medication lag time as common barriers to treatment acceleration.

Conclusion

This study is the first to examine the feasibility and efficacy of a treat‐to‐target approach in typical US rheumatology practice. Treat‐to‐target care was not associated with increased likelihood of treatment acceleration or achievement of LDA, and barriers to treatment acceleration were identified.

One-year risk of serious infection in patients treated with certolizumab pegol as compared with other TNF inhibitors in a real-world setting: data from a national U.S. rheumatoid arthritis registry

Background

Registry studies provide a valuable source of comparative safety data for tumor necrosis factor inhibitors (TNFi) used in rheumatoid arthritis (RA), but they are subject to channeling bias. Comparing safety outcomes without accounting for channeling bias can lead to inaccurate comparisons between TNFi prescribed at different stages of the disease. In the present study, we examined the incidence of serious infection and other adverse events during certolizumab pegol (CZP) use vs other TNFi in a U.S. RA cohort before and after using a methodological approach to minimize channeling bias.

Methods

Patients with RA enrolled in the Corrona registry, aged ≥ 18 years, initiating CZP or other TNFi (etanercept, adalimumab, golimumab, or infliximab) after May 1, 2009 (n = 6215 initiations), were followed for ≤ 12 months. A propensity score (PS) model was used to control for baseline characteristics associated with the probability of receiving CZP vs other TNFi. Incidence rate ratios (IRRs) of serious infectious events (SIEs), malignancies, and cardiovascular events (CVEs) in the CZP group vs other TNFi group were calculated with 95% CIs, before and after PS matching.

Results

Patients were more likely to initiate CZP later in the course of therapy than those initiating other TNFi. CZP initiators (n = 975) were older and had longer disease duration, more active disease, and greater disability than other TNFi initiators (n = 5240). After PS matching, there were no clinically important differences between CZP (n = 952) and other TNFi (n = 952). Before PS matching, CZP was associated with a greater incidence of SIEs (IRR 1.53 [95% CI 1.13, 2.05]). The risk of SIEs was not different between groups after PS matching (IRR 1.26 [95% CI 0.84, 1.90]). The 95% CI of the IRRs for malignancies or CVEs included unity, regardless of PS matching, suggesting no difference in risk between CZP and other TNFi.

Conclusions

After using PS matching to minimize channeling bias and compare patients with a similar likelihood of receiving CZP or other TNFi, the 1-year risk of SIEs, malignancies, and CVEs was not distinguishable between the two groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1496-5) contains supplementary material, which is available to authorized users.

Benefit of biologics initiation in moderate versus severe rheumatoid arthritis: evidence from a United States registry

Objectives

To compare clinical outcomes and treatment patterns among patients with moderate vs severe RA following biologic DMARD initiation.

Methods

Biologics-naive patients with moderate to severe RA [Clinical Disease Activity Index (CDAI) >10] who initiated a biologic DMARD were selected from the Corrona registry (2001-13). CDAI, functional status [modified HAQ (mHAQ)] and patterns of drug use were compared at 1 and 2 years post-initiation between patients with moderate (CDAI >10⩽22) vs severe (CDAI >22) baseline disease activity.

Results

A total of 1596 patients (817 severe, 779 moderate) had ⩾1 year of follow-up and 1269 (635 severe, 634 moderate) had ⩾2 years of follow-up. Patients with severe vs moderate baseline disease activity experienced greater improvements in disease activity [mean change in CDAI -18.9 vs -6.0 at year 1; -21.0 vs -7.1 at year 2 ( P < 0.0001)] and physical function [mean change in mHAQ -0.2 vs -0.1 ( P < 0.0001) at year 1; -0.2 vs -0.1 ( P = 0.0013) at year 2]. Greater proportions of patients with moderate vs severe disease activity achieved remission (CDAI ⩽2.8) [22.7 vs 15.8% ( P = 0.0003) at year 1; 25.9 vs 20.9% ( P = 0.0396) at year 2] or low disease activity (CDAI <10) [60.1 vs 41.2% at year 1; 66.7 vs 49.4% at year 2 ( P < 0.0001)]. Most patients remained on the original biologic drug (>70% at year 1; >62% at year 2).

Conclusion

With biologic therapy, RA patients with higher baseline disease activity achieved greater improvements in measures of disease activity than those with lower levels of disease, but less often achieved the common targets of remission or low disease activity.

Clinical and demographic factors associated with change and maintenance of disease severity in a large registry of patients with rheumatoid arthritis

Background

We examined models to predict disease activity transitions from moderate to low or severe and associated factors in patients with rheumatoid arthritis (RA).

Methods

Data from RA patients enrolled in the Corrona registry (October 2001 to August 2014) were analyzed. Clinical Disease Activity Index (CDAI) definitions were used for low (≤10), moderate (>10 and ≤22), and severe (>22) disease activity states. A Markov model for repeated measures allowing for covariate dependence was used to model transitions between three (low, moderate, severe) states and estimate population transition probabilities. Mean sojourn times were calculated to compare length of time in particular states. Logistic regression models were used to examine impacts of covariates (time between visits, chronological year, disease duration, age) on disease states.

Results

Data from 29,853 patients (251,375 visits) and a sub-cohort of 9812 patients (46,534 visits) with regular visits (every 3–9 months) were analyzed. The probability of moving from moderate to low or severe disease by next visit was 47% and 18%, respectively. Patients stayed in moderate disease for mean 4.25 months (95% confidence interval: 4.18–4.32). Transition probabilities showed 20% of patients with low disease activity moved to moderate or severe disease within 6 months; >35% of patients with moderate disease remained in moderate disease after 6 months. Results were similar for the regular-visit sub-cohort. Significant interactions with prior disease state were seen with chronological year and disease duration.

Conclusion

A substantial proportion of patients remain in moderate disease, emphasizing the need for treat-to-target strategies for RA patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1289-x) contains supplementary material, which is available to authorized users.

Identifying factors associated with concordance with the American College of Rheumatology rheumatoid arthritis treatment recommendations

Background

Factors associated with care concordant with the American College of Rheumatology (ACR) recommendations for the use of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) are unknown.

Methods

We identified a national cohort of biologic-naive patients with RA with visits between December 2008 and February 2013. Treatment acceleration (initiation or dose escalation of biologic and nonbiologic DMARDs) in response to moderate to high disease activity (using the Clinical Disease Activity Index) was assessed. The population was divided into two subcohorts: (1) methotrexate (MTX)-only users and (2) multiple nonbiologic DMARD users. In both subcohorts, we compared the characteristics of patients who received care consistent with the ACR recommendations (e.g., prescriptions for treatment acceleration) and their providers with the characteristics of those who did not at the conclusion of one visit and over two visits, using logistic regression and adjusting for clustering of patients by rheumatologist.

Results

Our study included 741 MTX monotherapy and 995 multiple nonbiologic DMARD users cared for by 139 providers. Only 36.2 % of MTX monotherapy users and 39.6 % of multiple nonbiologic DMARD users received care consistent with the recommendations after one visit, which increased over two visits to 78.3 % and 76.2 %, respectively (25–30 % achieved low disease activity by the second visit without DMARD acceleration). Increasing time since the ACR publication on RA treatment recommendations was not associated with improved adherence.

Conclusions

Allowing two encounters for treatment acceleration was associated with an increase in care concordant with the recommendations; however, time since publication was not.

Comparative effectiveness of biologic monotherapy versus combination therapy for patients with psoriatic arthritis: results from the Corrona registry

Objectives

To characterise the comparative effectiveness of combination therapy (a tumour necrosis factor inhibitor (TNFi) and a conventional synthetic disease-modifying antirheumatic drug (csDMARD) such as methotrexate) and monotherapy (TNFi only) for psoriatic arthritis (PsA) from a large US registry.

Methods

The analysis included adult patients with PsA who were enrolled in the Corrona database (ClinicalTrials.gov, NCT01402661), had initiated a TNFi, were biologic naïve, and had a follow-up visit ≥90 days after drug initiation. The endpoints of the analysis were TNFi persistence (drug survival) and time to Clinical Disease Activity Index (CDAI) remission. All analyses were performed using propensity scoring, which were estimated using CDAI and patient sex, to control for channelling bias.

Results

Of 519 patients meeting the inclusion criteria (318 with combination therapy and 201 with monotherapy), the analysis population was 497 for TNFi persistence and 380 for time to remission. The difference between combination therapy (TNFi+methotrexate, 91% of patients; TNFi+other csDMARD, 9%) and monotherapy was not statistically significant for TNFi persistence (32 and 31 months, p=0.73) and time to remission (21 and 25 months, p=0.56). Predictors of TNFi persistence included Hispanic ethnicity (longer persistence), PsA duration (longer persistence), history of methotrexate use (shorter persistence), body mass index (shorter persistence) and disease activity (shorter persistence).

Conclusions

Patients with PsA from a large US registry experienced similar TNFi persistence on combination therapy and monotherapy. Prospective, randomised clinical trials evaluating the efficacy of combination therapy versus monotherapy would provide much-needed clarity on treatment options for patients with PsA.

Trial registration number

NCT01402661.

Impact of Treatment With Biologic Agents on the Use of Mechanical Devices Among Rheumatoid Arthritis Patients in a Large US Patient Registry

OBJECTIVE

To assess trends and predictors of mechanical devices/aids use by rheumatoid arthritis (RA) patients since the introduction of biologic disease-modifying antirheumatic drugs (DMARDs).

METHODS

Sociodemographic characteristics, disease characteristics, and mechanical aid use (assessed using the Health Assessment Questionnaire) were compared among RA patients ages >17 years at diagnosis, enrolled in the Consortium of Rheumatology Researchers of North America (CORRONA) registry during January 2001 to December 2003 and January 2010 to December 2012. Univariate and multivariate logistic regression analyses were used to identify predictors of mechanical aid use among patients in both cohorts.

RESULTS

Sociodemographic characteristics were similar between 1,096 patients in the 2001-2003 cohort and 11,140 patients in the 2010-2012 cohort. Disease activity was significantly lower among patients in the 2010-2012 cohort (mean ± SD Clinical Disease Activity Index score 10.1 ± 11.1 versus 17.0 ± 13.8; P < 0.001). A greater proportion of patients in the 2010-2012 cohort received biologic DMARDs (50.7% versus 32.5%; P < 0.001) and fewer were biologic-naive (39.1% versus 61.6%; P < 0.001). Fewer patients in the 2010-2012 cohort used any mechanical devices/aids (31.1% versus 40.8%; P < 0.001). In multivariate analysis, patients in the 2010-2012 cohort and those with a history of biologic agent use were less likely to use devices/aids (odds ratio [OR] 0.77 [95% confidence interval (95% CI) 0.66-0.90] and OR 0.68 [95% CI 0.62-0.75], respectively). Predictors of greater devices/aids usage included older age, female sex, higher disease activity, and less employment. Effect sizes were greatest for disease activity and employment.

CONCLUSION

Mechanical devices/aids use among patients with RA was significantly lower during 2010-2012 versus 2001-2003 and among biologic-experienced patients, suggesting reduced disability.

Effectiveness of Rituximab for the Treatment of Rheumatoid Arthritis in Patients with Prior Exposure to Anti-TNF: Results from the CORRONA Registry

Objective.

To characterize the real-world effectiveness of rituximab (RTX) in patients with rheumatoid arthritis.

Methods.

Clinical effectiveness at 12 months was assessed in patients who were prescribed RTX based on the Clinical Disease Activity Index (CDAI). Change in CDAI was calculated (CDAI at 12 mos minus at initiation). Achievement of remission or low disease activity (LDA; CDAI ≤ 10) among those with moderate/high disease activity at the time of RTX initiation was compared based on prior anti-tumor necrosis factor agent (anti-TNF) use (1 vs ≥ 2) using logistic regression models.

Results.

Patients (n = 265) were followed for 12 months with a mean change in CDAI of −8.1 (95% CI −9.8 – −6.4). Of the 218 patients with moderate/high disease activity at baseline, patients with 1 prior anti-TNF (baseline CDAI 25.0) demonstrated a mean change in CDAI of −10.1 (95% CI −13.2 – −7.0); patients with ≥ 2 prior anti-TNF (baseline CDAI 30.0) demonstrated a mean change of −10.5 (95% CI −12.9 – −8.0). The unadjusted OR for achieving LDA/remission in patients with moderate/high disease activity at baseline exposed to ≥ 2 versus 1 prior anti-TNF was 0.40 (95% CI 0.22–0.73), which was robust to 4 different adjusted models (OR range 0.38–0.44).

Conclusion.

A good clinical response was observed in all patients; however, patients previously treated with 1 anti-TNF, who had lower baseline CDAI and a greater opportunity for clinical improvement compared with patients previously treated with ≥ 2 anti-TNF, were more likely to achieve LDA/remission.

The rheumatoid arthritis treat-to-target trial: a cluster randomized trial within the Corrona rheumatology network

Background

The treat-to-target (T2T) approach to the care of patients with rheumatoid arthritis involves using validated metrics to measure disease activity, frequent follow-up visits for patients with moderate to high disease activity, and escalation of therapy when patients have inadequate therapeutic response as assessed by standard disease activity scores. The study described is a newly launched cluster-randomized behavioral intervention to assess the feasibility and effectiveness of the T2T approach in US rheumatology practices. It is designed to identify patient and provider barriers to implementing T2T management. This initial paper focuses on the novel study design and methods created to provide these insights.

Methods/Design

This trial cluster-randomizes rheumatology practices from the existing Corrona network of private and academic sites rather than patients within sites or individual investigators to provide either T2T or usual care (UC) for qualified patients who meet the 2010 revised American College of Rheumatology criteria for the diagnosis of rheumatoid arthritis and have moderate to high disease activity. Specific medication choices are left to the investigator and patient, rather than being specified in the protocol. Enrollment is expected to be completed by the end of 2013, with 30 practices randomized and enrolling a minimum of 530 patients. During the 12-month follow-up, visits are mandated as frequently as monthly in patients with active disease in the T2T group and every 3 months for the UC group. Safety data are collected at each visit. The coprimary endpoints include a comparison of the proportion of patients achieving low disease activity in the T2T and UC groups and assessment of the feasibility of implementing T2T in rheumatology practices, specifically assessment of the rates of treatment acceleration, frequency of visits, time to next visit conditional on disease activity, and probability of acceleration conditional on disease activity in the 2 groups.

Discussion

This cluster-randomized behavioral intervention study will provide valuable insights on the outcomes and feasibility of employing a T2T treatment approach in clinical practice in the United States.

Trial registration

NCT01407419

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-389) contains supplementary material, which is available to authorized users.

A comparison of the malignancy incidence among patients with psoriatic arthritis and patients with rheumatoid arthritis in a large US cohort

OBJECTIVE

To compare the incidence rates of malignancy among patients with psoriatic arthritis (PsA) and patients with rheumatoid arthritis (RA) in the Consortium of Rheumatology Researchers of North America (CORRONA) registry.

METHODS

We analyzed 2,970 patients with PsA (7,133 patient-years of followup) and 19,260 patients with RA (53,864 patient-years of followup). Using a standardized adjudication process, we identified 40 confirmed malignancies in the patients with PsA and 307 confirmed malignancies in those with RA. Incidence rates were calculated per 100 patient-years. Incidence rate ratios were estimated, with adjustment for age, sex, disease duration, body mass index, disease activity, year of enrollment, and medication use.

RESULTS

The overall malignancy incidence per 100 patient-years was similar between patients with PsA and patients with RA (0.56 [95% confidence interval (95% CI) 0.40-0.76] and 0.56 [95% CI 0.50-0.63], respectively). Nonmelanoma skin cancer was the most common type of cancer in the overall cohort, with an incidence rate of 0.21 (95% CI 0.12-0.35) in PsA, and 0.20 (95% CI 0.17-0.24) in RA, with a calculated incidence rate ratio of 1.05 (95% CI 0.61-1.80; P = 0.85). Lymphoma rates were similar in PsA and RA (0.04 [95% CI 0.01-0.12] and 0.04 [95% CI 0.02-0.06], respectively; incidence rate ratio 1.00 [95% CI 0.17-3.11]; P = 0.67). The adjusted incidence rate ratio of malignancy in PsA versus RA was 1.17 (95% CI 0.82-1.69; P = 0.37).

CONCLUSION

The incidence rates across malignancy subtypes were similar in the PsA and RA cohorts from a US registry.

Birthplace, years of residence in the United States, and obesity among Mexican-American adults

OBJECTIVE

To evaluate the association between birthplace (Mexico or U.S.) and obesity in men and women and to analyze the relationship between duration of U.S. residency and prevalence of obesity in Mexican immigrants.

RESEARCH METHODS AND PROCEDURES

We used cross-sectional data from 7503 adults of Mexican descent residing in Harris County, TX, to evaluate the relationships among BMI, birthplace, and years of residency in the U.S., controlling for demographic characteristics, physical activity level, and acculturation level.

RESULTS

U.S.-born adults had an increased risk (between 34% and 65%) of obesity compared with their Mexican-born counterparts. After controlling for recognized confounders and risk factors, this association was maintained in the highly acculturated only. Among highly acculturated obese U.S.-born men, 6% of the cases were attributable to the joint effect of birthplace and acculturation; in women, this proportion was 25%. Among Mexican-born women, there was an increasing trend in mean BMI with increasing duration of residency in the U.S.. Compared with immigrants who had lived in the U.S. for <5 years, Mexican-born women who had resided in the U.S. for >or=15 years had an adjusted BMI mean difference of 2.12 kg/m2 (95% confidence interval, 1.53-2.72).

DISCUSSION

Mexican-born men and women have a lower risk of obesity than their U.S.-born counterparts, but length of U.S. residency among immigrants, especially in women, is directly associated with risk of obesity. Development of culturally specific interventions to prevent obesity in recent immigrants may have an important public health effect in this population.

Effects of nativity, age at migration, and acculturation on smoking among adult Houston residents of Mexican descent

OBJECTIVES

We investigated differences in smoking behaviors between US-and Mexican-born ever smokers and examined the influence of US culture on smoking initiation.

METHODS

Participants were 5030 adults of Mexican descent enrolled in an ongoing population-based cohort in Houston, Tex.

RESULTS

More men than women reported current smoking; rates among US-born women were higher than those among Mexican-born women. Smoking rates among US-born men were higher than earlier published rates among Hispanics and non-Hispanic Whites but similar to rates among African Americans. Current smoking rates among Mexican-born women were lower than published rates for Hispanics, non-Hispanic Whites, and African Americans. Older age, male gender, a higher level of acculturation, more than a high school education, and residing in a census tract with a higher median age predicted history of smoking among US-born participants. Among Mexican-born participants, older age, male gender, a higher level of acculturation, and younger age at migration predicted history of smoking.

CONCLUSIONS

Smoking interventions for people of Mexican descent should be tailored according to gender, nativity, and acculturation level and should target all ages, not just young people.

Training future pharmacists at a minority educational institution: evaluation of the Rx for change tobacco cessation training program

OBJECTIVES

To estimate the impact of Rx for Change, an 8-h tobacco cessation training program on pharmacy students' perceived counseling skills, confidence for counseling, and future counseling of patients for tobacco cessation.

METHODS

Unlinked, pre- and post-training surveys were administered to 142 pharmacy students enrolled at Texas Southern University, a primarily minority and historically black educational institution.

RESULTS

Post-training counseling abilities were significantly improved over pretraining values for each of the five key components of tobacco cessation counseling (Ask, Advise, Assess, Assist, and Arrange), overall counseling abilities, and confidence for counseling (P < 0.001). Racial/ethnic differences in self-reported overall counseling was observed (P = 0.01). Ninety-one percent of participants believed that the training would increase the number of patients whom they counsel for cessation, and 95% believed that it would improve the quality of counseling that they provide. At least 95% of participants believed that the pharmacy profession should be more active in preventing patients from starting smoking and helping patients to stop smoking.

CONCLUSIONS

The Rx for Change program had a positive impact on perceived abilities and confidence for providing tobacco cessation counseling to patients. While it is important that all current and future health care providers receive specialized tobacco cessation training, it is particularly important for clinicians of racial/ethnic minority backgrounds, who are more likely to practice in geographic areas with a high density of population subgroups at an elevated risk for tobacco-related mortality. In particular, pharmacists, who are uniquely positioned within the community to provide care to all patients, including the medically underserved, must be equipped with the necessary skills to assist patients with quitting.

Training Future Pharmacists at a Minority Educational Institution: Evaluation of the Rx for Change Tobacco Cessation Training Program

Objective: To estimate the impact of Rx for Change, an 8-h tobacco cessation training program on pharmacy students' perceived counseling skills, confidence for counseling, and future counseling of patients for tobacco cessation. Methods: Unlinked, pre- and post-training surveys were administered to 142 pharmacy students enrolled at Texas Southern University, a primarily minority and historically black educational institution. Results: Post-training counseling abilities were significantly improved over pretraining values for each of the five key components of tobacco cessation counseling (Ask, Advise, Assess, Assist, and Arrange), overall counseling abilities, and confidence for counseling (P &lt; 0.001). Racial/ethnic differences in self-reported overall counseling was observed (P = 0.01). Ninety-one percent of participants believed that the training would increase the number of patients whom they counsel for cessation, and 95% believed that it would improve the quality of counseling that they provide. At least 95% of participants believed that the pharmacy profession should be more active in preventing patients from starting smoking and helping patients to stop smoking. Conclusion: The Rx for Change program had a positive impact on perceived abilities and confidence for providing tobacco cessation counseling to patients. While it is important that all current and future health care providers receive specialized tobacco cessation training, it is particularly important for clinicians of racial/ethnic minority backgrounds, who are more likely to practice in geographic areas with a high density of population subgroups at an elevated risk for tobacco-related mortality. In particular, pharmacists, who are uniquely positioned within the community to provide care to all patients, including the medically underserved, must be equipped with the necessary skills to assist patients with quitting.

Reduced expression of hMLH1 and hGTBP/hMSH6: a risk factor for head and neck cancer

Head and neck cancer, like lung cancer, is considered a paradigm of an environmentally induced disease. Genetically determined variation in DNA repair capacity is thought to contribute to susceptibility to tobacco-related cancers. In this molecular epidemiology study, we investigated the association between DNA mismatch-repair (MMR) gene expression and the risk of head and neck cancer. Using our newly developed multiplex reverse transcription-PCR assay, we simultaneously evaluated the relative expression levels of five MMR genes (hMSH2, hMLH1, hPMS1, hPMS2, and hGTBP/hMSH6) in the peripheral blood lymphocytes of 78 patients (mean age = 59.6 +/- 12.4 years) with newly diagnosed head and neck cancer and 86 healthy controls (mean age = 58.2 +/- 12.9 years). The relative MMR gene expression was not correlated with disease stage or tumor site in the cases or with smoking and alcohol use in the controls. The expression levels increased with age in both cases and controls, but the mean expression of hMLH1, hPMS1, and hGTBP/hMSH6 was significantly lower in the cases than in the controls (P < 0.05). Using the median expression level in controls as the cutoff value, significantly increased odds ratios (ORs) were associated only with low expression of hMLH1 (OR = 4.4; 95% confidence interval = 2.1-9.1) and hGTBP/hMSH6 (OR = 2.1; 95% confidence interval = 1.1-4.1) after adjustment for age, sex, ethnicity, smoking status, and alcohol use. The results suggest that low hMLH1 and hGTBP/hMSH6 expression is associated with an increased risk of head and neck cancer. Additional studies with a larger number of subjects are warranted to confirm these findings.

Clinical analysis of sampatrilat, a combined renal endopeptidase and angiotensin-converting enzyme inhibitor II: assay in the plasma and urine of human volunteers by dissociation enhanced lanthanide fluorescence immunoassay (DELFIA)

Sampatrilat is a dual inhibitor of angiotensin converting enzyme (ACE) and neutral endopeptidase (NEP) under development for the treatment of hypertension and congestive heart failure. In order to support the early clinical development (with oral administration and an expected low bioavailability), a sensitive and selective assay was required. An HPLC-atmospheric-pressure chemical ionisation mass-spectrometric (HPLC-APCI-MS-MS) assay had been already validated (R.F. Venn et al., J. Pharm. Biomed. Anal., in press), but due to its low throughput an alternative method was sought. As the molecule is peptide-like and not metabolised, we believed the immunoassay approach was appropriate. Thus we developed an immunoassay for the compound using time-resolved fluorescence as an end-point (DELFIA) with lower limits of quantification of 0.2 ng ml(-1) for the plasma assay and 5 ng ml(-1) for the assay in urine. This assay is a 96-well plate based competitive immunoassay; the end-point is the determination of a (non-radioactive) europium label by time-resolved fluorimetry. Sampatrilat is labelled with chelated europium via isothiocyanate chemistry. The advantage of this assay is its extremely high throughput, allowing rapid analysis of many thousands of samples. The DELFIA method was successfully cross-validated with the HPLC-APCI-MS-MS method.

Clinical analysis of sampatrilat, a combined renal endopeptidase and angiotensin-converting enzyme inhibitor I: assay in plasma of human volunteers by atmospheric-pressure ionisation mass-spectrometry following derivatisation with BF3-methanol

Sampatrilat is a dual inhibitor of angiotensin converting enzyme (ACE) and neutral endopeptidase (NEP) under development for the treatment of hypertension and congestive heart failure. In order to support the early clinical development (with oral administration and an expected low bioavailability), a sensitive and selective assay was required. A method for plasma was developed and validated employing HPLC APCI MS-MS. The plasma samples were extracted on solid-phase extraction cartridges, derivatised with BF3-methanol, diluted, extracted again and then subjected to HPLC APCI-MS-MS. Derivatisation was necessary because the two carboxyl group in the molecule prevented efficient ionisation in the heated nebuliser source. The calibration range was from 0.5 to 20 ng ml(-1) and the lower limit of quantification was 0.5 ng ml(-1). Imprecision and inaccuracy were determined on three separate occasions at three concentrations (0.5, 5 and 20 ng ml[-1]) and shown to be lower than 10% in every case.

Hackethal stacked nailing of humeral shaft fractures. Experience with 30 patients

The Hackethal technique of using stacked medullary pins for fixation of humeral shaft fractures is usually associated with relatively little blood loss; in addition, exposure of the fracture site and possible associated muscular trauma are avoided, and the risk of contusion of the radial nerve that may occur in fixation by plate and screws is eliminated. The technique has the additional advantage of accomplishing stable fixation of the fracture, thus allowing early motion of both the shoulder and the elbow. The rate of union in 25 patients with adequate follow-up evaluation was 92%, with a reoperation rate of 14%. This high rate may be decreased further by increased experience. The method proves effective in the stabilization of pathologic fractures.

Pyoderma gangrenosum: clinical and laboratory findings in 15 patients with special reference to polyarthritis

Fifteen consecutive patients with PG have been studied during the period 1971-78. Systemic disease was found in 13 of the patients and preceded the skin disease in 10 patients by 1-25 years. Only two patients had ulcerative colitis. One patient had paroxysmal nocturnal hemoglobinuria and three patients had an IgA myeloma. Eight patients had polyarthritis; this was classical seropositive rheumatoid arthritis in two patients, and a seronegative inflammatory polyarthritis in six patients. Four patients had an unusual progressive erosive seronegative polyarthritis without evidence of granulomatous bowel disease, psoriasis, genital, urinary tract or eye disease. In three of these four patients the arthritis preceded the PG. Synovial fluid analysis showed depressed complement levels and in one patient deposits of immunoglobulins and complement were demonstrated in the synovial membrane. The course of the arthritis was progressive with development of disabling joint deformities and erosive destruction of joints, despite treatment with penicillamine, corticosteroids and nonsteroidal anti-inflammatory drugs. One other patient had severe degenerative joint disease and chondrocalcinosis in association with a seronegative inflammatory polyarthritis, and another patient had ulcerative proctitis and severe degenerative joint disease secondary to chronic seronegative inflammatory polyarthritis. None of the patients had colitic arthritis, but in view of the association between PG and ulcerative colitis, some patients previously reported with PG and joint disease may have been suffering from the arthritis of ulcerative colitis. PG developed at the site of skin trauma in six patients. The natural history of the skin disease ran one of two courses: an acute, progressive course in which the ulcers rapidly enlarged until arrested by treatment; and a chronic course in which the lesions extended slowly and which after a period of weeks began to show signs of spontaneous healing. In only the patients with ulcerative colitis was there any correlation between the activity of the associated disease and the onset and progression of the skin disease. Serum complement levels were normal and no circulating cryoprecipitable immune complexes were found. Skin histology showed no evidence of vasculitis and direct immunofluorescence examination of involved skin was negative for IgG, IgM, IgA and C3. No consistent abnormality of cell-mediated immunity or neutrophil function was found and no significantly increased prevalence of any HLA antigen type was noted. Twelve patients have been treated with systemic corticosteroids. Six of these patients developed serious steroid complications and four patients have died, all from complications of steroid therapy.

Effect of tourniquet time on postoperative quadriceps function

Postoperative weakness of quadriceps function following knee arthrotomy has often been attributed to pain inhibition or lack of motivation. However, the delayed recovery may be the result of a slowly resolving axonal compression syndrome caused by the pneumatic tourniquet. Forty-eight patients who underwent knee arthrotomy were evaluated including postoperative electromyographic testing and clinical follow-up. Thirty of these patients (62.5%) developed postoperative EMG changes. Abnormalities were noted in various muscle groups but most commonly involved the quadriceps alone or quadriceps and gastrocnemius. An effort was made in 20 patients to substantially decrease the duration of tourniquet compression by limiting tourniquet inflation to intracapsular portions of the procedures. Fewer EMG changes and more rapid clinical recovery were noted in patients with decreased tourniquet times, suggesting that it is beneficial to minimize the duration of tourniquet compression. In all patients who returned for serial testing, the EMG abnormalities eventually resolved.

Autoimmune haemolytic anaemic complicating methyldopa therapy

Ten out of fifty-seven patients on methyldopa therapy were found to have a positive direct Coombs' test, the antibody being in all cases of the IgG type. Four of these had an autoimmune haemolytic anaemia and in spite of associated diseases all four showed rapid haematological improvement when the drug was stopped.

The incidence of autoimmune haemolytic anaemia due to methyldopa may be higher than has previously been suggested, but since the haemolytic process is reversible it seems reasonable at present, in view of its effectiveness as a hypotensive drug, to continue its use under adequate haematological control.