How Medication Adherence Affects Disease Management in Veterans with Glaucoma: Lessons Learned from a Clinical Trial

INTRODUCTION

We conducted a secondary, real-world clinical assessment of a randomized controlled trial to determine how a glaucoma medication adherence intervention impacted the clinical outcomes of participants at 12 months post-randomization. Participants included veterans at a VA eye clinic with medically treated glaucoma who reported poor adherence and their companions, if applicable.

METHODS

The treatment group received a glaucoma education session with drop administration instruction and virtual reminders from a "smart bottle" (AdhereTech) for their eye drops. The control group received a general eye health class and the smart bottle with the reminder function turned off. Medical chart extraction determined if participants in each group experienced visual field progression, additional glaucoma medications, or a recommendation for surgery or laser due to inadequate intraocular pressure control over the 12 months following randomization. The main outcome measure was disease progression, defined as visual field progression or escalation of glaucoma therapy, in the 12 months following randomization.

RESULTS

Thirty-six versus 32% of the intervention (n = 100) versus control (n = 100) groups, respectively, experienced disease intensification. There was no difference between the intervention and control groups in terms of intensification (intervention vs. control group odds ratio: 1.20; 95% confidence interval: [0.67, 2.15]), including when age, race, and disease severity were accounted for in the logistic regression model. Those whose study dates included time during the COVID-19 pandemic were evenly distributed between groups.

CONCLUSIONS

A multifaceted intervention that improved medication adherence for glaucoma for 6 months did not affect the clinical outcomes measured at 12 months post-randomization. Twelve months may not be long enough to see the clinical effect of this intervention or more than 6 months of intervention are needed.

Improved Glaucoma Medication Adherence in a Randomized Controlled Trial

PURPOSE

To test the effectiveness of an intervention designed to improve glaucoma medication adherence.

DESIGN

Randomized, controlled trial at a Veterans Affairs (VA) eye clinic.

PARTICIPANTS

Veterans with medically treated glaucoma who reported poor adherence and their companions if applicable.

METHODS

Participants, and their companions if applicable, were randomized to receive an intervention to improve medication adherence that included glaucoma education, personalized disease management suggestions, and a reminder aid, or the control arm that received education regarding general eye health.

MAIN OUTCOME MEASURES

The average proportion of prescribed glaucoma medication doses taken on schedule over the 6 months after randomization according to an electronic monitor between participants in the 2 arms.

RESULTS

The mean proportion of prescribed doses taken on schedule was higher in the intervention group compared with controls (0.85 vs. 0.62, P < 0.0001). The difference in proportions between the 2 groups did not vary in regressions models adjusted for companion status, frequency of dosing, and race. The longitudinal model indicated that the intervention group had significantly higher adherence during the first month after randomization and continued to stay higher through 6 months (month by treatment interaction, P = 0.003).

CONCLUSIONS

A multifaceted intervention can help improve glaucoma medication adherence.

Health Literacy and Success with Glaucoma Drop Administration

PURPOSE

To assess the relationship between health literacy and successful glaucoma drop administration.

DESIGN

Substudy of a single-site interventional randomized controlled trial.

PARTICIPANTS

Veterans receiving care at the Durham Veterans Affairs Eye Clinic who had a diagnosis of open-angle glaucoma were recruited if they endorsed poor drop adherence.

METHODS

Participants underwent a health literacy evaluation using the Rapid Estimate of Adult Literacy in Medicine (REALM) as well as a qualitative assessment of eye drop administration technique using 3 different criteria: (1) the drop was instilled in the eye, (2) only 1 drop was dispensed, and (3) the bottle was not potentially contaminated. A multivariate logistic regression model was used to assess the association of REALM score and successful drop administration, adjusting for age, disease severity, and Veterans Administration Care Assessment Needs (CAN) score.

MAIN OUTCOME MEASURES

Successful drop administration.

RESULTS

Of the 179 participants with REALM scores and observed drop administration, 78% read at a high school level (HSL) or more and 22% read at less than HSL. Of the 179 participants, 87% (n = 156) successfully instilled the drop into the eye (criterion 1). A greater proportion of participants who read at HSL or more successfully instilled the drop in the eye compared with those reading at less than HSL (90.6% vs. 75.0%; P = 0.02). Rates of success with criterion 1 were similar across different levels of visual field severity. Care Assessment Needs scores were not statistically significant between those who did and those did not have successful overall drop technique.

CONCLUSIONS

Poor health literacy may be associated with decreased successful drop instillation in the eye in patients with glaucoma. Screening for and considering health literacy in developing interventions to improve glaucoma self-management may improve treatment adherence in a vulnerable population.

Improving the improvisational pelvic circumferential compression technique for open-book pelvic fractures using a simulation model and a sphygmomanometer

BACKGROUND

Open-book pelvic fractures are associated with significant mortality. Emergency management may require a commercial pelvic circumferential compression device to reduce the fracture and compress haemorrhaging pelvic vasculature. Standard, commercial, twin-sized bedsheets are acceptable should commercial devices be unavailable. However, obese victims or personnel with insufficient body strength may impede successful reduction.

OBJECTIVE

To demonstrate the value of an improvisational windlass (intravenous pole) in improving the ability to reduce an open-book pelvic fracture.

METHODS

The Institutional Review Board-approved study involved 28 diverse healthcare students and emergency medicine residents. Each participant's demographic information and physical characteristics were recorded. A METIman was prepared with knee and ankle binding and a sphygmomanometer set at 40 mm Hg placed over the symphysis pubis. Two-person teams were randomly selected to place a bedsheet at greater trochanter level and atop the sphygmomanometer. The bedsheet was secured with maximum effort by the pairs and the pressure recorded. Following this, the pairs inserted an intravenous pole in the knot and torqued the pole to maximum effort and a repeat pressure recorded.

RESULTS

The mean increase in pressure using only the bedsheet was 106.43 mm Hg per team. With bedsheet and intravenous pole, the mean pressure increase was 351.79 mm Hg per team. The difference was statistically significant (independent samples t-test: t = 17.177, p < 0.001, 95% CI (216.65 to 274.07 mm Hg). There was no correlation between pressure increases and the individual physical characteristics of the subjects (r = - 0.183, p = 0.352).

CONCLUSIONS

Regardless of personnel's physical attributes, the addition of an improvisational windlass to a pelvic circumferential compression bedsheet can improve the ability to reduce an open-book fracture, especially in obese victims.

Effects of egg shell quality and washing on Salmonella Infantis penetration

The vast majority of eggs in Australia are washed prior to packing to remove dirt and fecal material and to reduce the microbial contamination of the egg shell. The egg contents can be an ideal growth medium for microorganisms which can result in human illness if eggs are stored improperly and eaten raw or undercooked, and it is estimated that egg-related salmonellosis is costing Australia $44 million per year. Egg shell characteristics such as shell thickness, amount of cuticle present, and thickness of individual egg shell layers can affect the ease with which bacteria can penetrate the egg shell and washing could partially or completely remove the cuticle layer. The current study was conducted to investigate the effects of egg washing on cuticle cover and effects of egg shell quality and cuticle cover on Salmonella Infantis penetration of the egg shell. A higher incidence of unfavorable ultrastructural variables of the mammillary layer such as late fusion, type B bodies, type A bodies, poor cap quality, alignment, depression, erosion and cubics were recorded in Salmonella penetrated areas of egg shells. The influence of egg washing on the ability of Salmonella Infantis on the egg shell surface to enter the egg internal contents was also investigated using culture-based agar egg penetration and real-time qPCR based experiments. The results from the current study indicate that washing affected cuticle cover. There were no significant differences in Salmonella Infantis penetration of washed or unwashed eggs. Egg shell translucency may have effects on Salmonella Infantis penetration of the egg shell. The qPCR assay was more sensitive for detection of Salmonella Infantis from egg shell wash and internal contents than traditional microbiological methods. The agar egg and whole egg inoculation experiments indicated that Salmonella Infantis penetrated the egg shells. Egg washing not only can be highly effective at removing Salmonella Infantis from the egg shell surface, but also allows subsequent trans-shell and trans-membrane penetration into the egg. Consequently, it is important to prevent recontamination of the egg after washing.

A review of potential contaminants in Australian livestock feeds and proposed guidance levels for feed

Contaminants of man-made and natural origin need to be managed in livestock feeds to protect the health of livestock and that of human consumers of livestock products. This requires access to information on the transfer from feed to food to inform risk profiles and assessments, and to guide management interventions such as regulation or Hazard Analysis Critical Control Point approaches. This paper reviews contaminants of known and potential concern in the production of livestock feeds in Australia and compares existing but differing state and national regulatory standards with international standards. The contaminants considered include man-made organic chemical contaminants (e.g. legacy pesticides), elemental contaminants (e.g. arsenic, cadmium, lead), phytotoxins (e.g. gossypol) and mycotoxins (e.g. aflatoxins). Reference is made to scientific literature and evaluations by regulators to propose maximum levels that can be used for guidance by those involved in managing contamination incidents or developing feed safety programs.

Antimicrobial susceptibilities and resistance genes in Campylobacter strains isolated from poultry and pigs in Australia

AIMS

To evaluate the phenotypic and genotypic profiles of Campylobacter spp. from poultry faecal samples from free range or intensively raised meat chickens and free range egg layers. In addition, a case-comparison study of antibiotic resistance genes from different groups of poultry and some pig strains previously collected was carried out.

METHODS

Resistance to different antibiotics was assessed using the agar dilution method. In addition, all the strains were tested for ampicillin (bla(OXA-61) ), erythromycin (aph-3-1), tetracycline tet(O), streptomycin (aadE), and the energy-dependent multi-drug efflux pump (cmeB) resistance genes using multiplex polymerase chain reaction.

RESULTS

The evaluation of phenotypic resistance revealed all of the strains from poultry were sensitive to ciprofloxacin, gentamicin, erythromycin or tylosin. But, widespread resistance to lincomycin (51-100%), extensive resistance to ampicillin (33·3-60·2%) and less resistance to tetracycline (5·6-40·7%) were observed in the different groups of chickens. Antibiotic resistance genes bla(OXA-61,) cmeB and tet(O) were found in 82·6-92·7%, 80·3-89% and 22·3-30·9% Camp. coli isolates from pigs, whilst 59-65·4% and 19·2-40·7% Camp. jejuni from chickens were found to encode bla(OXA-61) and tet(O), respectively.

CONCLUSION

No significant difference between isolates from free range egg layers and meat chickens (P < 0·05) was found. However, there were significant differences between the pig strains and all the groups of poultry strains (P < 0·05) with regard to carriage of resistance genes. In addition, pulsed field gel electrophoresis of selected resistant isolates from the poultry and pig revealed closely related clonal groups.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results suggest the resistant strains are persisting environmental isolates that have been acquired by the different livestock species. Furthermore, the different treatment practices in poultry and pigs have resulted in differences in resistance profiles in Campylobacter isolates.

A baseline survey of the microbiological quality of chicken portions and carcasses at retail in two Australian states (2005 to 2006)

Raw poultry products were purchased from the retail market place in two Australian states, New South Wales (n = 549) and South Australia (n = 310). The products sampled on a proportional volume basis were chicken portions with the skin off or skin on, in bulk or tray packs, and whole carcasses. They were collected from butcher shops, supermarkets, and specialty stores from urban areas during the winter (2005) and summer (2006) months. The samples were analyzed to determine the prevalence and concentration of Escherichia coli, Salmonella, and Campylobacter spp. in addition to total viable counts. Salmonella was found in 47.7 and 35.5% of retail chicken samples (35.3 and 21.9% were the less virulent Salmonella Sofia), at mean counts of -1.42 and -1.6 log MPN/cm2 in New South Wales and South Australia, respectively. Campylobacter was found in 87.8 and 93.2% of samples at mean counts of 0.87 and 0.78 log CFU/cm2, respectively. In both states in both seasons, the mean total viable count was 5 log CFU/cm2. On whole birds, E. coli was detected in all winter samples and on 92.9 and 85.7% of summer samples in New South Wales and South Australia, respectively; the log of the geometric mean per square centimeter was 0.5 in winter and slightly lower in summer. On chicken portions, E. coli was detected in around 90% of winter samples in both states, and in summer on 75.1 and 59.6% of samples in New South Wales and South Australia, respectively. The log of the geometric mean CFU per square centimeter for E. coli was 0.75 and 0.91 in winter, and 0.66 and 0.5 in summer in New South Wales and South Australia, respectively.

Music therapy as a non-pharmacological anxiolytic for paediatric radiotherapy patients

Outpatient radiotherapy treatment in the paediatric cancer patient can be a traumatic and an anxiety-provoking experience for both the patient and the family. Music therapy has been widely reported to have psychosocial, educational and physical benefits for the paediatric cancer patient. Using individual case reports, this paper shows the successful use of music therapy as a non-pharmacological anxiolytic in the paediatric radiotherapy, outpatient waiting room setting, by providing the patient and the family with a means of communication, self-expression and creativity.

Importance of radiation time and dose factors on outcome for childhood medulloblastoma*

The purpose of this study was to investigate the relationship of posterior fossa radiation therapy duration (PFRTD) and relapse-free survival (RFS) following adjuvant craniospinal RT for childhood medulloblastoma. A retrospective audit was performed assessing all children aged <18 years managed with adjuvant craniospinal RT for medulloblastoma in Australia and New Zealand in 1980-1993. Children receiving prolonged (>180 days) pre-RT chemotherapy were excluded. Data were obtained for potential prognostic factors in domains of patient, tumour and treatment factors. Radiation therapy time factors assessed were PFRTD and time interval from surgery to commencement of RT (SRTD). The end-point assessed was RFS and analysis was performed using Cox regression and Kaplan-Meier survival. One hundred and eighty-nine children were identified from 10 oncology units, with data available from 182 children for analysis. Median follow up was 5.3 years. Seventy-three per cent of children presented with disease confined to the cerebellum; 13% had initial neuraxis disease. Macroscopic resection was described in 54%; 42% received adjuvant chemotherapy. Median RT dose and RT duration to PF was 55 Gy and 45 days, respectively. Seventy-eight relapses occurred with a 10-year actuarial RFS of 58.2% (standard error +/- 4%). On univariate analysis, increasing PF dose (P = 0.002), age >5 years (P = 0.006), and more thorough extent of surgical resection (P = 0.043) were associated with improved RFS; PFRTD (P = 0.20) and SRTD (P = 0.51) were not associated with RFS. On multivariate analysis, although both PF dose (P = 0.004) and extent of surgery (P = 0.045) remained strongly significant, RT duration was now associated with RFS (P = 0.049). Other factors assessed that did not reach significance were patient age, local tumour extent, presence of internal shunt and use of chemotherapy. The importance of local treatment factors was confirmed in this audit with established prognostic factors such as primary tumour macroscopic resection and adequate PF RT dose being associated with RFS. A treatment time effect is weakly suggested, although less significant than RT dose delivered.

Laryngo-pharyngeal carcinoma in childhood

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.

Phase I trial of concurrent tirapazamine, cisplatin, and radiotherapy in patients with advanced head and neck cancer

PURPOSE

To determine the maximum-tolerated dose of tirapazamine when combined with cisplatin and radiation in patients with T3/4 and/or N2/3 squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

The starting schedule was conventionally fractionated radiotherapy (70 Gy in 7 weeks) with concomitant cisplatin 75 mg/m2 and tirapazamine 290 mg/m2 (before cisplatin) in weeks 1, 4, and 7 and tirapazamine alone 160 mg/m2 three times a week in weeks 2, 3, 5, and 6. Positron emission tomography scans for tumor hypoxia (18F misonidazole) were performed before and during radiotherapy.

RESULTS

We treated 16 patients with predominantly oropharyngeal primary tumors, including 10 patients with T4 or N3 disease. Febrile neutropenia occurred toward the end of radiotherapy in three out of six patients treated on the initial dose level. Two of these patients also developed grade 4 acute radiation reactions. Another 10 patients were treated with the same doses, but the week 5 and week 6 tirapazamine doses were omitted. This resulted in less neutropenia and only one dose-limiting toxicity (DLT) (febrile neutropenia), and eight out of 10 patients completed treatment without any dose omissions. In these 10 patients, the acute radiation toxicities were not obviously enhanced compared with chemoradiotherapy regimens using concurrent platinum and fluorouracil. 18F misonidazole scans detected hypoxia in 14 of 15 patients at baseline, with only one patient having detectable hypoxia at the end of treatment. With a median follow-up of 2.7 years, the 3-year failure-free survival rate was 69% (SE, 12%), the 3-year local progression-free rate was 88% (SE, 8%), and the 3-year overall survival rate was 69% (SE, 12%).

CONCLUSION

DLT was due unexpectedly to febrile neutropenia, which could be overcome by omitting tirapazamine in weeks 5 and 6. The combination of tirapazamine, cisplatin, and radiotherapy resulted in remarkably good and durable clinical responses in patients with very advanced head and neck cancers. It warrants further investigation.

Surveillance for uterine abnormalities in tamoxifen-treated breast carcinoma survivors: a community based study

BACKGROUND

Tamoxifen-treated breast carcinoma survivors are at elevated risk of endometrial carcinoma. Whether to recommend annual surveillance for uterine abnormalities in this population is currently under debate.

METHODS

This study was a cross-sectional, community-based investigation of tamoxifen use and the frequency of surveillance for endometrial carcinomas in 541 women with breast carcinoma. Study participants whose breast carcinoma was diagnosed in 1994 were interviewed in 1998. Data were collected from a telephone interview and from a cancer registry record. Tests for uterine abnormalities, based on participant reports of endometrial biopsy and transvaginal ultrasound, were categorized according to frequency. Testing for uterine abnormalities was defined as irregular if women reported tests once every 3 years, on average, and as regular, if they reported annual tests.

RESULTS

Forty-nine percent of respondents were current tamoxifen users, 12% were former tamoxifen users, and 39% reported never taking tamoxifen. Of respondents with a uterus (n = 385), 19% reported irregular and 30% regular testing for uterine abnormalities after their breast carcinoma diagnosis. Respondents more frequently reported transvaginal ultrasound (37%) than endometrial biopsy (29%). Women 65 years of age and older were significantly less likely to report regular surveillance for uterine abnormalities (16%) than those younger than 65 years (35%). Current tamoxifen users more frequently reported regular surveillance (43%) than either former (35%) or never tamoxifen users (15%). Multivariable analyses showed tamoxifen users were more likely to have regular (odds ratio [OR], 9.8; 95% confidence interval [CI], 4.4-21.8) or to have irregular testing for uterine abnormalities (OR, 3.9; 95% CI, 1.9-8.1) compared with women who never used tamoxifen, after adjustment for age, number of recent gynecologic visits, and gynecologic symptoms.

CONCLUSIONS

The results of the current study indicate that half of the breast carcinoma survivors in this population were tested for uterine abnormalities. Although at increased risk, 38% of tamoxifen users never had a test. Clear guidelines need to be established for the type and frequency of testing for uterine abnormalities among tamoxifen-treated breast carcinoma patients.

Adherence to asthma guidelines in general practices

Adherence to asthma practice guidelines is low. Improved compliance could potentially improve care of patients with asthma. The purpose of this study was to determine if patients managed in a general practice with an associated asthma clinic are more likely to use asthma medications according to clinical practice guidelines than patients managed in the general surgery of the practice. A cross-sectional study of adult asthmatics, aged 18-55 years, was conducted in six British general practices. Prescription data on all asthma medication was collected for a 6-month period. Information on asthma clinic attendance, age, sex, employment status, other medical illness, and how patients used their inhaled beta2-agonist was collected through questionnaire. The prescription data for asthma medication and patient use of inhaled beta2-agonist were compared to the British Thoracic Society's (BTS) Guidelines for Management of Asthma in Adults to determine if the patient's asthma medication regimen was appropriate. There was no significant association found between appropriate asthma medication and asthma clinic attendance or other patient characteristics. Adherence to the BTS guidelines was low. Fifty-eight percent of the asthma patients used asthma medication regimens that were not consistent with the BTS guidelines published 1 year earlier. Adherence to the BTS guidelines was low regardless of patient characteristics, including asthma clinic attendance, age, sex, employment status, other medical illness, or individual practice. These findings underscore the need to document the utility of clinical practice guidelines which may improve physician compliance.

Cigarette smoking and asthma symptom severity among adult asthmatics

Contrary to what would be expected, smoking habits of asthmatics do not differ from those of the general population: approximately 30% of asthmatic patients smoke cigarettes. Although the relationship between smoking and the incidence of asthma has been well explored, little attention has been paid to documenting the relationship between smoking and asthma symptoms among adults with asthma. The objective of this study was to assess the association of cigarette smoking with asthma symptom severity. The present report is of a cross-sectional study of 225 asthmatics, aged 20-54 years, from six general practice clinics in East Anglia, U.K. The outcome measures are overall asthma symptom score (range 6.3-28) and three asthma symptom domains: respiratory (range 1.3-8), daily activity interference (range 2-8), and physical activity interference (range 3-12), generated from the sum of ordinal responses to questions on asthma symptom severity. Of the sample, 27.0% were current and 22.1% were former smokers. Current smokers more frequently had bothersome asthma symptoms than nonsmokers in both unadjusted analyses and analyses controlling for age, gender, recent visits to the general practitioner for asthma, and asthma medication use (p = 0.06). Respiratory symptoms (p = 0.03) and symptoms that affect daily activities (p = 0.03) were more strongly associated with smoking than symptoms that affect physical activities (p = 0.62). Our data suggest that smoking hastens asthma progression or affects disease control. Increased frequency of symptoms may be an indicator for potential morbidity among asthmatics, especially those who smoke cigarettes. The hazards associated with smoking among asthmatics need to be more clearly emphasized by physicians and public health officials in order to convince people with asthma who smoke to stop.

Cigarette smoking, alcohol consumption, and screening mammography among women ages 50 and older

BACKGROUND

The associations among cigarette smoking and alcohol consumption with recent screening mammograms were evaluated among women ages 50 years and older.

METHODS

The sample included 946 white and African-American women ages 50 years and older from the 1995 Maryland Behavioral Risk Factor Survey. Bivariate and logistic regression analyses were performed to evaluate the associations between current cigarette smoking and alcohol consumption in the past month (none, 1-7 drinks, >7 drinks) with obtaining a screening mammogram in the past 2 years (recent mammogram), controlling for sociodemographic and health variables.

RESULTS

Seventy-eight percent of respondents had recent mammograms, 15% smoked cigarettes, 18% reported 1-7 drinks, and 12% reported >7 drinks in the past month. Smokers had lower mammography rates than nonsmokers (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.30-0.75). Women who drank alcoholic beverages had higher mammography rates than nondrinkers (OR = 1.37, 95% CI = 1.03-1.83). Smokers had the lowest mammography rates, regardless of their consumption of alcohol. An interaction was observed among white but not African-American women: nonsmokers who consumed moderate amounts of alcohol (1-7 drinks) had the highest mammography rates in this subgroup.

CONCLUSIONS

To reduce breast cancer mortality, it is important to increase screening mammography among all women over age 50 and especially among smokers and the oldest women.

Sex differences in the use of asthma drugs: cross sectional study

OBJECTIVES

To assess the use of asthma drugs by men and women with asthma and to identify sex specific predictors for the use of oral steroids.

DESIGN

Cross sectional study.

SETTING

Six general practices in East Anglia.

SUBJECTS

103 men and 134 women aged 20-54 with asthma.

MAIN OUTCOME MEASURES

Self reported use of agonists, inhaled steroids, and oral steroids.

RESULTS

No sex difference was found in use of agonists or inhaled steroids. However a strong association existed between sex and oral steroid use. 40 (30%) women reported using oral steroids compared with nine (9%) men. Women were more than five times (odds ratio=5.5, 95% confidence interval 2.2 to 13.7) more likely to report use of oral steroids than men after asthma symptoms, age, visits to the general practitioner in previous six months, and time since diagnosis of asthma were controlled for. Women who had visited the general practitioner for asthma one or more times in the previous six months were four times (3.9, 1.6 to 9.5) as likely to report use of oral steroids. In addition, more frequent visits to the general practitioner for asthma were related in a dose-response manner to a greater likelihood of using oral steroids among women after asthma symptoms, age, and time since diagnosis were controlled for. This relation was not observed among men.

CONCLUSION

Women used oral steroids more than men. The more frequent consultations with a doctor by women may result in more requests for oral steroids or doctors may preferentially prescribe oral steroids to women.

The association of nocturnal asthma with asthma severity

The objective of this study is to assess nocturnal asthma as a marker for poor control of asthma. Cross-sectional study of asthmatic patients was conducted in six general practices in East Anglia, England. Subjects were 240 asthma patients, between the ages of 20 and 54 years, from the above general practices. A continuous asthma severity score (range 6-26), consisting of the summation of ordinal responses to questions regarding asthma symptoms during the last 6 months, was used for analysis. The crude association between nocturnal asthma and severity score was statistically highly significant. Regression analysis suggests that, after controlling for possible confounding variables, there remains a strong association between nocturnal asthma (NA) and severity, which is modified by self-report of current consultation for "nervous/emotional trouble" (current NT). In the absence of current NT, NA raises the severity score by 5.3 (95% CI 4.5, 6.2), whereas in the presence of current NT, NA raises the severity score by 8.2 (95% CI 4.8, 11.6). NA appears promising as a marker for poorly controlled asthma. Confirmation of the association found in this study by objective measures of severity would strengthen the utility of NA as a marker.

Relationship between blood lead and dietary iron intake in preschool children. A cross-sectional study

The relationship between dietary iron intake and blood lead levels in urban preschool children was investigated in a cross-sectional study of 299 children from 9 months to 5 years old. Mothers of children attending the University of Maryland Pediatric Ambulatory Clinic volunteered for the children and themselves to join the study. The data collected included nutritional status, socioeconomic status, medical history, and potential sources of lead exposure. Blood samples from all participants were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte protoporphyrin, calcium, and hematocrit. The average blood lead level (standard deviation) in the studied population was 11.4 (7.3) micrograms/dL. With multiple linear and logistic regression analyses to adjust for covariates, a negative association (P = 0.03) between blood lead and dietary iron intake was found. This finding is consistent with similar results from experimental studies. It is concluded that there is evidence that higher dietary iron intake is associated with lower blood lead among urban preschool children in the studied population.

Relationship between blood lead and nutritional factors in preschool children: a cross-sectional study

OBJECTIVE

The purpose of this study was to assess the relationships between selected nutritional factors and blood lead levels of preschool children.

METHODOLOGY

Data on 296 children, aged 9 to 72 months, who were cared for at the University of Maryland at Baltimore Pediatric Ambulatory Center were examined in this cross-sectional study. Nutritional status, socioeconomic aspects, medical history, and potential sources of lead exposure were assessed. Blood samples were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte photoporphyrin, calcium, and hematocrit.

RESULTS

The average blood lead level was 11.4 micrograms/dL. Multicollinearity of nutritional factors was addressed using regression techniques. After adjusting for confounders, significant positive associations with blood lead were found for total caloric intake (P = .01) and dietary fat (P = .05).

CONCLUSIONS

The findings of this study suggest that even when behavioral and environmental exposures to lead were statistically controlled, total caloric intake and dietary fat each had an independent and significant association with the level of blood lead.

The evolving role of radiation therapy in paediatric oncology, Philadelphia, USA, 19-21 January 1995

A summary of a conference reviewing recent developments and changes in the use of radiation therapy in paediatric oncology is reported. Although the use of radiation therapy has resulted in improved cure rates, the long-term complications of radiation in a paediatric population are recognised. More intensive systemic therapy and the increasing availability of prognostic data, including biological markers to tailor therapy to the individual patient, has resulted in a more selective use of radiation therapy. Changes in the management of specific tumour types are discussed.

Integrating smoking cessation into routine public prenatal care: the Smoking Cessation in Pregnancy project

OBJECTIVES

In 1986, the state health departments of Colorado, Maryland, and Missouri conducted a federally-funded demonstration project to increase smoking cessation among pregnant women receiving prenatal care and services from the Women, Infants, and Children (WIC) program in public clinics.

METHODS

Low-intensity interventions were designed to be integrated into routine prenatal care. Clinics were randomly assigned to intervention or control status; pregnant smokers filled out questionnaires and gave urine specimens at enrollment, in the eighth month of pregnancy, and postpartum. Urine cotinine concentrations were determined at CDC by enzyme-linked immunosorbent assay and were used to verify self-reported smoking status.

RESULTS

At the eighth month of pregnancy, self-reported quitting was higher for intervention clinics than control clinics in all three states. However, the cotinine-verified quit rates were not significantly different.

CONCLUSIONS

Biochemical verification of self-reported quitting is essential to the evaluation of smoking cessation interventions. Achieving changes in smoking behavior in pregnant women with low-intensity interventions is difficult.

Microcystic adnexal carcinoma of the skin. A reappraisal of the differentiation and differential diagnosis of an underrecognized neoplasm

BACKGROUND

Microcystic adnexal carcinoma (MAC) is a locally aggressive adnexal neoplasm whose histogenesis is disputed. Many cases referred to us had been misdiagnosed.

OBJECTIVE

Our purpose was to clarify the differential diagnosis and differentiation of MAC.

METHODS

We sought follow-up data and examined routinely stained sections from 17 cases. We performed immunoperoxidase stains for carcinoembryonic antigen, pilar keratin (AE13), proliferating cell nuclear antigen (PCNA), type IV collagen, p53, and CD34 on selected cases.

RESULTS

Nine biopsy specimens had initially been misinterpreted. Cysts containing compact keratin or shadow cells were present in 11 cases, which we interpret as evidence of follicular differentiation. Sebaceous gland and duct as well as inner root sheath structures were seen in one case each. CD34 did not mark the clear cells as it does those of the outer root sheath. Staining for PCNA, type IV collagen, and p53 did not distinguish MAC from benign adnexal neoplasms.

CONCLUSION

MAC can be distinguished from its simulants in adequate biopsy specimens. Incompletely excised lesions usually recur. Both follicular and sudoriforous differentiation is present. Type IV collagen, PCNA, and p53 antisera were not useful in differential diagnosis.

Radical radiation therapy for carcinoma of the vagina--impact of treatment modalities on outcome: Peter MacCallum Cancer Institute experience 1970-1990

To determine the outcome of radical radiation therapy for carcinoma of the vagina, a retrospective analysis has been made of 103 patients referred with this diagnosis to the Peter MacCallum Cancer Institute from 1970 to 1989. Eighty-four patients were treated for cure, seventy-four patients with definitive radical radiotherapy and 10 patients with adjuvant post-operative radiotherapy. Results were analyzed from two eras--before and after 1985--reflecting changes in referral pattern, treatment policy, and outcome. Forty-eight patients were treated before 1985 (Stage I--24, Stage II--6, Stage III--15, Stage IV--3) and 36 patients after 1985 (Stage I--20, Stage II--3, Stage III--6, Stage IV--7). After 1985 more patients were treated with combined beam radiation and brachytherapy (23/36 vs. 16/48 prior to 1985). More extensive tumors were systematically implanted (Ir 192). (No implants before 1985; 15 implants and 8 intracavitary applications post 1985). Fewer were treated with external beam alone after 1985; 11/36 (31%) vs. 27/48 (55%) before 1985. A small number (7/84-8%) were treated with brachytherapy alone. Survival results were markedly improved after 1985 (22/36-61% vs 16/48-33%) due partly to the shorter period of follow-up, but due also to marked improvement in local control particularly in early stage disease. (1/23 vs. 12/30 recurrences in Stage I, II disease). Results indicate optimal results with radical radiation therapy occur only with adequate dose delivery best achieved with a judicious combination of external beam radiotherapy and brachytherapy. Interstitial implantation plays a crucial role.

Characterization of antibody-mediated inhibition of Pseudomonas aeruginosa adhesion to epithelial cells

An enzyme-linked immunosorbent assay system was developed and used to study adhesion of Pseudomonas aeruginosa to human epithelial cells and the abilities of specific antibodies to inhibit this process. Human buccal epithelial cells coated onto microtiter plates were incubated with P. aeruginosa suspensions, and adherent bacteria were detected by using anti-P. aeruginosa serum and a horseradish peroxidase-conjugated secondary antiserum. Adhesion, quantitated as an increase in A405, varied linearly with increasing numbers of bacterial CFU added per well in the range of 10(5) to 10(8) CFU per well. Adhesion of P. aeruginosa increased following trypsinization of buccal epithelial cells. Preincubation of bacteria with monoclonal antibodies directed against P. aeruginosa outer membrane protein H2 inhibited adhesion with all eight of the isolates tested. Preincubation of P. aeruginosa with sera from infected cystic fibrosis patients also resulted in inhibition of adhesion in the enzyme-linked immunosorbent assay system. This inhibitory activity was shown to be due to two factors: P. aeruginosa-specific immunoglobulin G and a non-immunoglobulin G serum component. These data support the hypothesis that bacterial components other than pili are involved in adhesion and suggest that anti-P. aeruginosa antibodies may be of use in preventing adhesion and subsequent colonization with P. aeruginosa.

Baseline factors associated with smoking cessation and relapse. MRFIT Research Group

BACKGROUND

Data on smoking cessation and relapse for 6 yers of the Multiple Risk Factor Intervention Trial were evaluated in univariate and multivariate analyses to determine the relationship between variables measured at the beginning of the trial and smoking cessation and relapse for special intervention and usual care participants.

RESULTS

The variables positively associated with smoking cessation in both the SI and the UC groups included age, education, and past success in quitting; there was a negative association with the number of cigarettes smoked per day. The expectation of quitting was positively associated with cessation in the special intervention group only, while life events, alcohol, and the presence of a wife who smokes were significant predictors of reduced cessation for the usual care group. The special intervention program may have overcome obstacles which interfered with cessation among the usual care participants. Associations with relapse were generally stronger in the usual care group than in the special intervention group. For usual care participants, multivariate analyses showed that education, past success in quitting smoking, alcohol, and life events were associated with relapse rates. For special intervention participants, only alcohol emerged as a significant predictor. Conclusion. The data are relevant in terms of factors that govern smoking cessation and relapse for adult smokers who take part in formal intervention programs and for those who are left to modify their behavior on their own.

Occult herpesvirus folliculitis clinically simulating pseudolymphoma

Two cases of cutaneous herpesvirus infection are described that clinically masqueraded as pseudolymphoma. Light microscopy demonstrated typical viral changes involving pilosebaceous complexes with sparing of the surface epithelium. Dermal changes consisted of a dense perivascular and perifollicular inflammatory infiltrate. Multinucleated lymphoid cells were found in the dermis in one case and viral inclusions in fibroblasts were present in the other case. Immunoperoxidase stains with antisera to herpes simplex virus types I and II were positive in one case and negative in the other case. Ultrastructural examination demonstrated viral particles consistent with herpesvirus in both cases. Recognition of typical histologicl features of herpesvirus folliculitis will lead to an accurate diagnosis in these types of clinically unsuspected cases.

Cytomegalovirus diaper dermatitis

Cytomegalovirus inclusions have been reported in perineal ulcers from immunosuppressed adults. The importance of this finding is unknown. We report the first pediatric case of cutaneous cytomegalovirus infection in an infant with congenital human immunodeficiency virus infection, presenting as a diaper dermatitis. Cytomegalovirus was cultured from the skin biopsy specimen, and characteristic inclusions were seen on hematoxylin-eosin-stained sections. Results of this biopsy specimen analysis prompted further investigation revealing disseminated cytomegalovirus infection, including retinitis. Aggressive pursuit of a pathogen in common conditions such as diaper dermatitis is strongly recommended in immunosuppressed pediatric patients.

Recurrent pigmented melanocytic nevus. A benign lesion, not to be mistaken for malignant melanoma

Melanocytic nevi that recur after incomplete removal are pigmented lesions that may clinically and pathologically simulate malignant melanoma in situ. Five examples of recurrent pigmented melanocytic nevus, with emphasis on light microscopic and immunohistochemical findings, are reported herein. Prominent HMB-45 staining in these nevi may cause further confusion in differentiating them from malignant melanoma. The differential diagnosis of recurrent pigmented melanocytic nevi is discussed, with particular emphasis on distinguishing these lesions from malignant melanoma. Our immunohistochemical observations indicate that the recurrences most likely develop as a result of proliferation of melanocytes remaining in the epidermis and/or adnexae following incomplete removal. The approach and management of recurrent nevi are also discussed.

Histologic pattern analysis of basal cell carcinoma. Study of a series of 1039 consecutive neoplasms

This study attempts to define histologic patterns in 1039 consecutive cases of basal cell carcinoma and to correlate these patterns with adequacy of margins of surgical excision. Five major histologic patterns were identified: nodular, 218 cases (21%); superficial, 181 cases (17%); micronodular, 151 cases (15%); infiltrative, 77 cases (7%); and morpheic, 11 cases (1%). A mixed pattern (two or more major histologic patterns) was present in 401 cases (38.5%). Our study indicates that nodular and superficial basal cell carcinomas can be completely removed by simple surgical excision in a high percentage of cases (93.6% and 96.4%, respectively) whereas the micronodular, infiltrative, and morpheic basal cell carcinomas have a higher incidence of positive tumor margins (18.6%, 26.5%, and 33.3%, respectively) after excision. Mixed patterns that consisted of combinations of the nodular, micronodular, or infiltrative types exhibited a behavior similar to the pattern that resulted in a greater chance of incomplete surgical removal.

Recurrent carcinoma of the vulva after conservative treatment for "microinvasive" disease

Although the standard therapy of vulvar carcinoma remains radical surgery, this approach is accompanied by significant postoperative morbidity and psychological adjustment. Radical hemi-vulvectomy and ipsilateral superficial groin node dissection are increasingly used for patients with "early" or "microinvasive" disease. Two patients with an "early" vulvar carcinoma were treated conservatively and later developed recurrent disease. Despite further surgery and radiotherapy, both patients eventually died of disease. The case histories are described and the pertinent literature is discussed.

Hairy polyp of the oropharynx. A case report with speculation on nosology

The hairy polyp of the oronasopharynx is a rare congenital malformation that has been classified as a dermoid, teratoid, teratoma, or hamartoma in the past. A case of oropharyngeal hairy polyp is presented that occurred in a male neonate with severe intermittent respiratory obstruction. The precise nosology of this unusual malformation is discussed, with the speculation that it is classified as a choristoma.

Health care costs for employed hypertensives

Health care insurance claims were used to track costs associated with hypertension for an employed population. Employees were classified as hypertensive (n = 373), high normal (n = 363), or normotensive (n = 2,411) on the basis of hypertension screening done at the worksite. Claims activity was monitored for the three groups during a three-year period, including periods before, during, and after the screening done at the worksite. The average amount claimed per employee was significantly higher for the hypertensives as compared with the normotensives or high normals, even after adjustment for age, race, sex, salary, marital status, and duration of insurance coverage. There was no significant difference in the average amount claimed per employee between high normals and normotensives. The health care costs for hypertensives are estimated to be about 80% more than those for normotensives. Hospital, physicians, and nursing care accounts for about 50 percentage points of this increment while the remaining 30 percentage points derive from drug costs.

Cloning and expression of the Pseudomonas aeruginosa exoenzyme S toxin gene

The gene for exoenzyme S, an ADP-ribosyl transferase, was cloned from Pseudomonas aeruginosa strain DG1 using an oligonucleotide probe based on the partial N-terminal amino acid sequence to screen a library of DG1 SstI fragments inserted into pKT230 in Escherichia coli DH1. A positive clone, designated pPD3, hybridized with the oligonucleotide probe and contained a 15 kb SstI insert. In E. coli minicells pPD3 expressed a single protein of Mr 68,000. This protein was localized primarily in the periplasm in E. coli. A 3.6 kb HindIII-BamHI fragment was subcloned into the vector pT7-4 which contains the promoter from bacteriophage T7 to construct pT7-4HB. In E. coli strains expressing the T7 RNA polymerase on a second plasmid, the Mr 68,000 protein was expressed and shown to react with antibodies to exoenzyme S. No enzymatic activity was detected in cell sonicates or culture supernatants of E. coli (pPD3). Cell sonicates of E. coli (pT7-4HB) however were cytotoxic to HeLa cells and this cytotoxicity was neutralizable with anti-exoenzyme S antiserm. Thus, exoenzyme S expressed in E. coli is toxic but not enzymatically active. When plasmids carrying the exoenzyme S gene were introduced into P. aeruginosa, there was a significant increase in ADP-ribosyl transferase activity, indicating that the plasmid encoded protein is enzymatically active in P. aeruginosa.

Prenatal exposure to tobacco: II. Effects on cognitive functioning at age three

Three-year-old children, born to women who smoked ten or more cigarettes at the beginning of pregnancy and identified at the time of registration for prenatal care, were assessed by the McCarthy Scales of Children's Abilities and the Minnesota Child Development Inventory. Children whose mothers quit smoking during pregnancy relative to children whose mothers persisted in smoking performed at a statistically significant higher level on the General Cognitive Index of the McCarthy and on each of the three subscales from which the General Cognitive Index is derived. The scores on the Minnesota Child Development Inventory were similar in showing a higher performance in the children of quitters. Statistical adjustment for environmental factors, characteristics of the child, and fetal maturity did not account for the observed differences between children of women who quit smoking and those of women who continued to smoke.

Prenatal exposure to tobacco: I. Effects on physical growth at age three

The height and weight of 714 children whose mothers smoked at the beginning of their pregnancies were assessed at three years of age. The children of women who quit smoking during pregnancy were taller and heavier than those of women who continued to smoke throughout pregnancy. Adjustment for maternal postpartum smoking status reduced the difference in weight, but had little effect on height. The differences in both height and weight at three years of age were greatly reduced when adjusted for size at birth and length of gestation. These results suggest that deficits associated with maternal smoking are not overcome by three years of age and that at least some of the observed anthropometric deficits may be extensions of deficits in fetal growth.