Phase 1 Open-Label Dose Escalation Trial for the Development of a Human Bacillus Calmette-Guérin Challenge Model for Assessment of Tuberculosis Immunity In Vivo

BACKGROUND

A controlled human infection model for assessing tuberculosis (TB) immunity can accelerate new vaccine development.

METHODS

In this phase 1 dose escalation trial, 92 healthy adults received a single intradermal injection of 2 × 106 to 16 × 106 colony-forming units of Bacillus Calmette-Guérin (BCG). The primary endpoints were safety and BCG shedding as measured by quantitative polymerase chain reaction, colony-forming unit plating, and MGIT BACTEC culture.

RESULTS

Doses up to 8 × 106 were safe, and there was evidence for increased BCG shedding with dose escalation. The MGIT time-to-positivity assay was the most consistent and precise measure of shedding. Power analyses indicated that 10% differences in MGIT time to positivity (area under the curve) could be detected in small cohorts (n = 30). Potential biomarkers of mycobacterial immunity were identified that correlated with shedding. Transcriptomic analysis uncovered dose- and time-dependent effects of BCG challenge and identified a putative transcriptional TB protective signature. Furthermore, we identified immunologic and transcriptomal differences that could represent an immune component underlying the observed higher rate of TB disease incidence in males.

CONCLUSIONS

The safety, reactogenicity, and immunogenicity profiles indicate that this BCG human challenge model is feasible for assessing in vivo TB immunity and could facilitate the vaccine development process.

CLINICAL TRIALS REGISTRATION

NCT01868464 (ClinicalTrials.gov).

Baseline and on-treatment serum bicarbonate, intensive blood pressure lowering, and mortality: the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

Low bicarbonate levels are associated with higher mortality among patients who are hospitalized or have chronic kidney disease. However, the relationship between bicarbonate and mortality among outpatients on antihypertensive treatment is unclear.

Purpose

To assess the relationship between serum bicarbonate levels, treatment response to intensive blood pressure lowering, and mortality.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high cardiovascular (CV) risk, but without diabetes, and a systolic blood pressure (BP) 130–180 mmHg, were randomized to intensive (target systolic BP <120mmHg) or standard antihypertensive treatment (target systolic BP <140mmHg). Patients with an estimated glomerular filtration rate <25 ml/min/1.73 m2 or end-stage renal disease were excluded. Serum chemistry was drawn at baseline, prespecified intervals, and at close out. We defined on-treatment bicarbonate as the last measurement available for each participant. We then examined the prognostic implications (for death from any cause and death from CV causes) of baseline and on-treatment bicarbonate, using restricted cubic splines, unadjusted and adjusted for demographic, clinical, and laboratory variables. Finally, we explored the effects of intensive blood pressure lowering across the spectrum of bicarbonate using interaction analysis.

Results

A total of 9,334 (99.7%) individuals had a bicarbonate measurement available at baseline and 9,232 (98.6%) had at least one measurement after baseline. Mean baseline bicarbonate was similar between the two study groups (26.3 mmol/l in both; P=0.84), as was on-treatment bicarbonate (25.2 mmol/l in both; P=0.51). Median follow-up was 3.3 years (range 0–4.8), with 365 deaths from any cause (3.9%) and 102 deaths from CV causes (1.1%) recorded during the study period. Baseline and on-treatment bicarbonate both displayed a significant, U-shaped association with death from any cause (adjusted overall trend, P<0.05; non-linearity vs. linearity, P<0.05). Although both were significantly associated with death from CV causes in unadjusted analysis, the significance was lost upon multivariable adjustment (P>0.05) (Figure). Low baseline bicarbonate was significantly associated with death from any cause (<23 vs. 23–29 mmol/l, adj. hazard ratio (HR) 1.45, 95% confidence interval (CI), 1.06–2.00; P=0.02), but high baseline bicarbonate was not (>29 vs. 23–29 mmol/l; P=0.84). Conversely, both low (adj. HR 1.50, 95% CI, 1.14–1.97; P=0.004) and high (adj. HR 4.77, 95% CI, 3.49–6.52; P<0.001) on-treatment bicarbonate was significantly associated with death from any cause. Bicarbonate did not modify the efficacy of intensive blood pressure lowering (P>0.05).

Conclusions

Baseline and on-treatment serum bicarbonate levels both displayed a U-shaped association with the risk of death. The association was not affected by intensive vs. standard blood pressure lowering.

Figure 1

Funding Acknowledgement

Type of funding source: None

Baseline and on-treatment serum potassium and mortality in high risk patients: the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

Observational studies in patients with hypertension have indicated a U-shaped association between on-treatment serum potassium levels and short-time mortality. However, the association between long-time mortality and serum potassium, and the potential modification of this association by intensive blood pressure lowering, are yet to be explored.

Purpose

To assess the relationship between serum potassium levels, treatment response to intensive blood pressure lowering, and mortality.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high cardiovascular (CV) risk, but without diabetes, who had an systolic blood pressure (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). Patients with an estimated glomerular filtration rate (eGFR) <25 ml/min/1.73 m2 or end-stage renal disease were excluded. Serum chemistry was drawn at baseline, prespecified intervals, and at close out. On-treatment serum potassium was defined as the last measurement for each participant. We examined the prognostic implications (for death from CV causes and death from any cause) of baseline and on-treatment serum potassium, using restricted cubic splines, unadjusted and adjusted for demographic, clinical, and laboratory variables. We further explored the effects of intensive blood pressure lowering across the serum potassium spectrum using interaction analyses.

Results

A total of 9,336 individuals had a serum potassium measurement available at baseline and 9,233 individuals had at least one subsequent measurement. Mean serum potassium was similar between the two study groups (intensive 4.21 mmol/l vs. standard 4.20 mmol/l; P=0.74); however, on-treatment serum potassium was significantly lower in the intensive group (intensive 4.17 mmol/l vs. standard 4.20 mmol/l; P=0.001). Median follow-up was 3.3 years (range 0–4.8), with 365 deaths from any cause (3.9%) and 102 deaths from CV causes (1.1%) recorded during the study period. Baseline serum potassium appeared to be linearly associated with both types of mortality events (test for overall trend, P<0.05; test for non-linearity versus linearity, P>0.05) on unadjusted analysis. On-treatment serum potassium displayed a U-shaped curve with death from any cause (test for overall trend, P=0.004; test for non-linearity versus linearity, P=0.006), but was not significantly associated with death from CV causes (P>0.05) (Figure). Associations were completely lost upon multivariable adjustment (P>0.05). This was particularly due to adjustment for eGFR. The efficacy of intensive blood pressure lowering was not modified by baseline or on-treatment serum potassium (P>0.05).

Conclusions

Neither baseline nor on-treatment serum potassium levels were associated with death after multivariable adjustment, including renal function. The efficacy of intensive blood pressure lowering was not modified by serum potassium.

Serum Potassium and death

Funding Acknowledgement

Type of funding source: None

Post-mitotic odontoblasts in health, disease, and regeneration

OBJECTIVE

Description of the odontoblast lifecycle, an overview of the known complex molecular interactions that occur when the health of the dental pulp is challenged and the current and future management strategies on vital and non-vital teeth.

METHODS

A literature search of the electronic databases included MEDLINE (1966-April 2019), CINAHL (1982-April 2019), EMBASE and EMBASE Classic (1947-April 2019), and hand searches of references retrieved were undertaken using the following MESH terms 'odontoblast*', 'inflammation', 'dental pulp*', 'wound healing' and 'regenerative medicine'.

RESULTS

Odontoblasts have a sensory and mechano-transduction role so as to detect external stimuli that challenge the dental pulp. On detection, odontoblasts stimulate the innate immunity by activating defence mechanisms key in the healing and repair mechanisms of the tooth. A better understanding of the role of odontoblasts within the dental pulp complex will allow an opportunity for biological management to remove the cause of the insult to the dental pulp, modulate the inflammatory process, and promote the healing and repair capabilities of the tooth. Current strategies include use of conventional dental pulp medicaments while newer methods include bioactive molecules, epigenetic modifications and tissue engineering.

CONCLUSION

Regenerative medicine methods are in their infancy and experimental stages at best. This review highlights the future direction of dental caries management and consequently research.

Microbiological investigation of the mandibular condyle in patients with advanced osteoarthritis of the temporomandibular joint

PURPOSE

The aim of this study was to investigate the presence of bacteria in samples of the temporomandibular joint taken from patients suffering from advanced osteoarthritis of the temporomandibular joint (TMJ).

MATERIALS AND METHODS

25 fresh mandibular condyle samples were taken from 17 consecutive patients undergoing mandibular condylectomy (8 bilateral) for advanced TMJ osteoarthritis (Dimitroulis Category 5 joints). The joint samples were stained and cultured for the presence of microorganisms following a standardised joint culture protocol.

RESULTS

No evidence of bacteria was found on staining or solid culture mediums. Late growth (day 12) of commensal skin organisms (P. Acnes, S. Epidermitis, S. Capitis) were identified in enriched broth samples in 5 joint samples. No statistically significant associations were noted between positive broth samples and age or previous joint intervention (p > 0.05) CONCLUSIONS: Within the limitations of this study, we have failed to identify meaningful bacterial growth in tissues (i.e. condylar head) of the TMJ that would suggest a contributory bacterial pathogenesis for arthritis of the TMJ.

Non-invasive screening of a microRNA-based dysregulation signature in oral cancer and oral potentially malignant disorders

INTRODUCTION

We have previously shown that oral swirls are a robust source of microRNA protected by extracellular vesicles, potentially useful to detect oral squamous cell carcinoma (OSCC)-associated molecular aberration.

OBJECTIVES

To study a developed dysregulation score and risk classification algorithm based upon a panel of OSCC-associated microRNA in oral swirls from individuals with OSCC and oral potentially malignant disorders (OPMDs).

MATERIALS AND METHODS

An OSCC-associated panel of 5 microRNAs (miR-24; miR-21; miR-99a; let-7c; miR-100;) was quantified by qPCR in 190 individuals with and without mucosal abnormalities, including OSCC (n = 53) and OPMDs (n = 74). Each sample was analyzed using a developed dysregulation score (dSCORE) and risk classification algorithm, allocating a LOW- or HIGH-RISK score. The influence of demographic, systemic, oral health and mucosal disease factors on the developed test was analyzed.

RESULTS

MicroRNA for analysis can be predictably isolated from oral swirls sourced from individuals with a range of demographic, systemic and oral health findings. Utilizing the presence of HIGH-RISK identified OSCC patients with 86.8% sensitivity and 81.5% specificity. Older age and female gender were associated with higher dSCOREs and higher proportions of HIGH-RISK classification amongst individuals with no mucosal abnormalities. The dSCOREs for all subgroups of OPMDs were significantly different from the OSCC group.

CONCLUSION

This is the first comparison of microRNA sourced from oral swirls from individuals with OPMDs with individuals with and without OSCC. A HIGH-RISK dysregulation signature was found to be accurate in indicating the presence of OSCC and exampled to parallel malignant transformation.

Abstract P4-10-06: Factors impacting the accuracy of self-reported breast procedures among women with and without breast cancer

Background: Clinical/epidemiologic observational studies frequently rely on participants' recall for information about breast procedures. However, there is limited data on the accuracy of self-reported breast procedures. To address this knowledge gap and inform future study design and collection and interpretation of similar data, we investigated the impact of type, diagnosis, age, time, and other patient characteristics on the accuracy of self-report in a prospective cohort.

Methods: All benign breast biopsies, lumpectomies, and mastectomies for breast cancer treatment among women enrolled in the BOSS Cohort, a prospective study of women and men with a familial risk of breast/ovarian cancer, were identified. Study staff obtained pathology reports for 93% of women from self-reported breast procedure locations. For this analysis, we focused on 577 women who had at least one ascertained pathology report, and who self-reported at least one breast procedure at baseline. We estimated the percentage of self-reports (95% confidence interval (CI)) with matching pathology report within 6 months (+/- 6 months), and agreement between self-reported procedures and pathology-confirmed diagnoses (normal/benign vs. atypical hyperplasia vs. LCIS, and DCIS vs. invasive cancer) with the Kappa statistic. We also examined predictors of an accurate biopsy self-report, including age at baseline, personal and family history of breast cancer, educational attainment, and time between biopsy and baseline, using logistic regression models.

Results: At baseline, 158 women reported having at least one benign biopsy, 193 women reported having a lumpectomy for cancer treatment, and 174 women reported having a mastectomy for cancer treatment. The median time between biopsy, lumpectomy, mastectomy, and baseline was 9 years, 2 years, and 2 years, respectively. Fifty-seven percent (95% CI: 49-64.5%) of benign biopsy self-reports, 90.7% (95% CI: 85.6-94.1%) of lumpectomy self-reports, and 85.1% (95% CI: 78.9-89.7%) of mastectomy self-reports had a matching pathology report within 6 months. Further diagnostic agreement was moderate for biopsies, lumpectomies, and mastectomies with Kappa statistics of 0.65, 0.66, 0.65, respectively. Age at baseline (p-interaction =0.01) and time (p-interaction = 0.03) were independent and joint predictors of accurate biopsy self-reports. Women less than 49 years old had the largest reduction in odds of having an accurate self-report (26%) for every additional year between biopsy and baseline [adjusted odds ratio = 0.74 (95% CI: 0.63-0.88)]. Similarly, women with a biopsy within 4 years prior to baseline had a 10% reduction in the odds of having an accurate self-report with increasing age [adjusted odds ratio = 0.9 (95% CI: 0.84-0.97)].

Conclusions: In this highly-educated cohort, the overall accuracy of self-report of benign biopsies was only modest, and the accuracy of self-report of lumpectomies and mastectomies was lower than expected. This study suggests that age at baseline and time between procedure and baseline are important predictors of accuracy of self-report and should be considered when utilizing self-reported information. Furthermore, where possible, prospective collection of breast procedure data should be prioritized.

Citation Format: Schaeffer ML, May B, Cimino-Mathews A, Orellana M, McCullough M, Hogan B, Armstrong D, Visvanathan K. Factors impacting the accuracy of self-reported breast procedures among women with and without breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-06.

Abstract P6-08-12: Understanding the etiology of osteopenia and osteoporosis in young breast cancer survivors compared to cancer-free women

Background: Our group previously reported that young breast cancer (BC) survivors have a higher risk of osteopenia/osteoporosis compared to their cancer-free peers. In order to develop successful interventions we need to understand the major contributing factors. Therefore, we investigated bone loss in young BC survivors by age at diagnosis, tumor characteristics and BC treatment compared to their cancer-free peers.

Methods: We studied 775 women (211 BC survivors, 564 cancer-free) with familial risk of breast and/or ovarian cancer in the Breast and Ovarian Surveillance Service (BOSS) cohort at Johns Hopkins. Survivors were diagnosed with stage 0-III BC <5 years prior to enrollment. The comparison group was cancer-free women at enrollment. Osteopenia and osteoporosis were ascertained based on self-reported physician diagnosis in baseline and follow-up questionnaires. Prevalent cases of osteopenia or osteoporosis were excluded. Multivariable (MV)-adjusted Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of osteopenia and/or osteoporosis among BC survivors compared to cancer-free women. BC survivors were stratified by age at diagnosis, estrogen-receptor (ER) tumor status, and BC treatment. MV models were adjusted for age, menopausal status, body mass index, physical activity, smoking, alcohol use, hormone replacement therapy and early oophorectomy.

Results: Mean time from BC diagnosis to enrollment was 1.4 years for survivors and mean age at BC diagnosis was 47 years. At baseline, BC survivors were more likely to be slightly older, postmenopausal, and current vitamin D users and less likely to have had an early bilateral oophorectomy compared to cancer-free women. During a mean follow-up time of 5.7 years, 66% of BC survivors and 54% of cancer-free women reported having ≥1 bone density exam and 112 incident cases of osteopenia/osteoporosis were identified (75% osteopenia only). BC survivors diagnosed at age ≤50 years had a 2-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.05, 95% CI=1.24-3.40). Risk of bone loss was similar among survivors with ER-positive tumors compared to cancer-free women (HR=2.04, 95% CI=1.30-3.22). No association was observed for BC survivors treated with tamoxifen only or chemotherapy only. BC survivors treated with aromatase inhibitors (AIs) only had almost 3-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.92, 95% CI=1.38-6.17). BC survivors treated with chemotherapy + tamoxifen and chemotherapy + AIs had over 2- and 4-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.28, 95% CI=1.04-5.00; HR=4.09, 95% CI=1.99-8.42, respectively). Results suggest that risk of bone loss was highest within 5 years after BC diagnosis.

Conclusion: Our results demonstrate that osteopenia/osteoporosis incidence is higher in BC survivors compared to cancer-free women and risk varies by age at diagnosis, ER-status and BC treatment. Our findings provide support for a baseline evaluation of bone density close to diagnosis in BC survivors with familial risk. Future studies are needed to address the frequency of monitoring among specific age and treatment groups.

Citation Format: Ramin CA, May BJ, Roden RBS, McCullough M, Armstrong DK, Visvanathan K. Understanding the etiology of osteopenia and osteoporosis in young breast cancer survivors compared to cancer-free women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-12.

Multiscale ordinal network analysis of human cardiac dynamics

In this study, we propose a new information theoretic measure to quantify the complexity of biological systems based on time-series data. We demonstrate the potential of our method using two distinct applications to human cardiac dynamics. Firstly, we show that the method clearly discriminates between segments of electrocardiogram records characterized by normal sinus rhythm, ventricular tachycardia and ventricular fibrillation. Secondly, we investigate the multiscale complexity of cardiac dynamics with respect to age in healthy individuals using interbeat interval time series and compare our findings with a previous study which established a link between age and fractal-like long-range correlations. The method we use is an extension of the symbolic mapping procedure originally proposed for permutation entropy. We build a Markov chain of the dynamics based on order patterns in the time series which we call an ordinal network, and from this model compute an intuitive entropic measure of transitional complexity. A discussion of the model parameter space in terms of traditional time delay embedding provides a theoretical basis for our multiscale approach. As an ancillary discussion, we address the practical issue of node aliasing and how this effects ordinal network models of continuous systems from discrete time sampled data, such as interbeat interval time series.This article is part of the themed issue 'Mathematical methods in medicine: neuroscience, cardiology and pathology'.

Oral swirl samples - a robust source of microRNA protected by extracellular vesicles

BACKGROUND

MicroRNAs are small non-coding RNAs which are dysregulated in disease states, such as oral cancer. Extracellular vesicles, a potential source of microRNA, are found in saliva.

OBJECTIVE

To demonstrate that a quantifiable amount of microRNA can be isolated from oral swirl samples. Additionally, we hypothesized that extracellular vesicles may protect contained microRNA from degradation in these samples.

METHOD

A polyethylene glycol-based precipitation was used for extracellular vesicle enrichment of oral swirl samples. Comparison was made between samples treated with and without RNase. Further, samples from three subjects were exposed to a range of conditions over 7 days and assessed for presence of microRNA by reverse-transcription quantitative PCR. Extracellular vesicles from samples were identified under transmission electron microscopy.

RESULTS

An adequate quantity of microRNA for qPCR analysis was extractable from samples despite exposure to conditions under which degradation of RNA would be expected.

CONCLUSION

A technique was developed to isolate an adequate quantity of microRNA for analysis from oral swirl samples. Extracellular vesicle-associated microRNA may be protected from degradation. This technique moves towards chairside application of translational microRNA research in the field of oral cancer prognostics.

Steven Johnson Syndrome and Toxic Epidermal Necrolysis in a burn unit: A 15-year experience

INTRODUCTION

The diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients.

METHODS

Records were reviewed for all patients admitted to the LAC+USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program.

RESULTS

Our treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days.

DISCUSSION

With our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.

Field-scale monitoring of pharmaceutical compounds applied to active golf courses by recycled water

The scarcity of potable water in arid and semiarid environments has led to the wider use of recycled water for irrigating agricultural fields, parks, golf courses, and other areas. One concern using recycled water as a source of irrigation has been the presence, fate, and transport of pharmaceutical compounds in water that percolates below the root zone of plants; however, very few multiyear field studies have been reported in the peer-reviewed literature. Here, we assessed compound mass flux of 13 pharmaceuticals in the fairways of four golf courses in the southwestern United States during a 2-yr field study. The sites varied by climate and soil type but were similar regarding turfgrass management. The results showed the presence of at least one pharmaceutical compound in nearly all samples collected, although concentrations were substantially lower after transport through the soil. Percent reduction in compound mass fluxes in drainage water was effectively 100% in 22 of 52 cases, 98 to 100% in 27 of 52 cases, and 73 to 94% in 3 of 52 cases (a case is defined as a specific compound measured at a specific site). Mass fluxes migrating below the root zone were calculated as <250 × 10 g ha for all compounds and >100 × 10 g ha in only two cases. For cases where the majority of the analyses were reportable, all fluxes were <8.80 × 10 g ha. Carbamazepine, meprobamate, and sulfamethoxazole were most commonly found in drainage water, representing nearly 80% of all reportable detections. This research demonstrates the potential of turfgrass/soil systems to reduce contaminant loading below the root zone and potentially toward groundwater.

Leaching of pharmaceuticals and personal care products in turfgrass soils during recycled water irrigation

An important beneficial reuse of treated wastewater (recycled water) in arid and semiarid regions is landscape irrigation. However, the environmental fate, especially groundwater contamination potential, of trace contaminants such as pharmaceuticals and personal care products (PPCPs) is a significant concern that can hinder the acceptance and adoption of such reuses. In this study, we irrigated mature turfgrass plots with nonspiked tertiary treated wastewater for over 6 mo at 100 or 130% of the reference evapotranspiration rate (ETo) and collected leachate water at the 90-cm depth on a weekly basis. In the recycled water, all 14 target PPCPs were consistently found, and the mean levels of atenolol, gemfibrozil, meprobamate, carbamazepine, and sulfamethoxazole were above 100 ng L. However, only five compounds were detected in the leachate at trace levels. Trimethoprim and primidone were frequently found, whereas the detection of sulfamethoxazole, meprobamate and carbamazepine was less frequent (<50%). When detected, the overall mean concentration in the leachate was 10.2 ng L for trimethoprim, 7.1 ng L for primidone, and 2.9 to 12.4 ng L for carbamazepine, sulfamethoxazole, and meprobamate. The majority of the target PPCPs were completely removed. Given that the irrigation rates were higher than normal, this study clearly demonstrated the efficacy of turfgrass systems in attenuating PPCPs during recycled water irrigation. However, it is also apparent that some PPCPs are more susceptible to leaching than others, and these PPCPs thus merit further research attention.

New approaches to Candida and oral mycotic infections: Workshop 2A

This workshop reviewed aspects of the following: oral fungal disease in HIV-infected patients and the predictive value of oral mucosal disease in HIV progression; the role of the oral biofilms in mucosal disease; microbial virulence factors and the pseudomembranous oral mucosal disease process; the role that oral mucosal disease may have in HIV transmission; and the available topical antifungal treatment. This article summarizes the ensuing discussions and raises pertinent problems and potential research directions associated with oral fungal disease in HIV-infected patients, including the frequency of oral candidosis, the role of the intraoral biofilm in the development of oral mucosal disease, and host-pathogen interactions, as well as the development of the fetal oral mucosa, neonatal nutrition, and the role of oral candidosis in this setting. Finally, discussions are summarized on the use of inexpensive effective antifungal mouthwashes in resource-poor countries, the potential stigmata that may be associated with their use, as well as novel topical medications that may have clinical applicability in managing oral candidal infections in HIV-infected patients.

Orofacial granulomatosis--a 20-year review

Orofacial granulomatosis (OFG) is the presence of persistent enlargement of the soft tissues of the oral and maxillofacial region, characterized by non-caseating granulomatous inflammation in the absence of diagnosable systemic Crohn's disease (CD) or sarcoidosis. Over 20 years have passed since OFG was first described and an extensive review of the literature reveals that there is no consensus whether OFG is a distinct clinical disorder or an initial presentation of CD or sarcoidosis. Furthermore, the precise cause of OFG is still unknown although several theories have been suggested including infection, genetic predisposition and allergy. The clinical outcome of OFG patients continues to be unpredictable. Current therapies remain unsatisfactory. Regular clinical review is indicated to identify the development of gastrointestinal or systemic involvement. The aim of this review was to analyse the developments in our understanding of the aetiology, pathogenesis and treatment protocols, with particular emphasis on management and outcomes of OFG since this entity was first described in 1985.

Craniofacial identification by computer-mediated superimposition

Mass disasters are associated with a large number of fatalities, with victims being visually unidentifiable in most cases. Dental identification, although being an important and valuable identification method, is subject to the availability and quality of antemortem and postmortem dental records. This paper presents a simple-to-use method of human identification using an antemortem photograph showing anterior teeth with superimposition onto a postmortem image using specific features of Adobe Photoshop. We present cases and discuss the benefits and difficulties of this method.

Oral yeast carriage correlates with presence of oral epithelial dysplasia

Previous studies have suggested a link between the presence of Candida albicans and the development of oral squamous cell carcinoma (OSCC). The aim of the present study was to assess the presence and level of colonisation of oral yeast in patients undergoing an incisional oral mucosal biopsy in order to assess whether the amount of oral yeast present correlated with the presence and degree of oral epithelial dysplastic or neoplastic change. Two hundred and twenty-three patients who were undergoing an incisional biopsy for the diagnosis of an oral mucosal lesion were enrolled in this study. Mouth swills were obtained from each patient for the presence and amount of oral yeast present. Some of the patients (44.6%) had a histopathological diagnosis of either oral epithelial dysplasia (OED) or OSCC and the frequency of oral yeast carriage was significantly greater (P<0.001) in these patients than those without histopathologically detected dysplastic or neoplastic oral lesions. Furthermore, significantly (P<0.001) more patients with OED or OSCC had a higher number of yeast (over 1000 cfu/ml) in their oral cavity than patients without any evidence of epithelial dysplasia or neoplasia histopathologically. The degree of epithelial dysplasia present in these patients also correlated with higher amounts of yeast in the oral cavity (P=0.017). The results of the present study reveal that there is an interaction between oral carriage of yeast and oral epithelial dysplasia, however it remains unclear how yeast infection influences the development and progression of dysplasia.

Age, renal perfusion and function in island-dwelling indigenous Kuna Amerinds of Panama

BACKGROUND/AIMS

Among possible contributors to a progressive fall in renal perfusion and function with increasing age, some hypotheses have invoked the rise in blood pressure that occurs with age, and a high-protein diet typical of urban cultures. Kuna Amerinds residing in isolated islands off the Panamanian Coast have a very low protein intake and show no tendency for blood pressure to rise with age, thus providing an opportunity to test these hypotheses.

METHODS

We measured renal plasma flow and glomerular filtration rate (PAH and inulin clearance) in 16 Kuna Indians ranging in age from 18 to 86 years (51 +/- 6 years) who have resided on Ailigandi, an isolated Panamanian island for all of their lives. Inulin and PAH were infused with a battery-driven pump for 60 min, and a metabolic clearance rate used to calculate inulin and PAH clearance. For comparison, we employed identical techniques in 29 residents of Boston, ranging in age from 19 to 79 years (52 +/- 4 years), all normotensive and free of disease or medication use. Twenty-four were Caucasian.

RESULTS

The Bostonian controls showed the anticipated fall in PAH clearance with age (y = 806 - 4.9 x; r = -0.82; f = 38.0; p < 0.0001). Our hypothesis was that the absence of a blood pressure rise with age and the low protein intake would flatten the slope relating renal perfusion to Kuna age. Our finding was a numerically steeper slope relating age and renal plasma flow in the Kuna (y = 936 - 6.48x; r = -0.81; p < 0.001). Filtration fraction rose with age in both populations, and again the rise was steeper in the Kuna. GFR in the Kuna, on the other hand, was very much higher at any age (139 +/- 4 ml/min/1.73 m2) than in Bostonians (112 +/- 3 ml/min/1.73 m2; p < 0.001).

CONCLUSION

The findings are not in accord with the hypothesis that age-related changes in renal perfusion and glomerular filtration rate reflect an important contribution from blood pressure rise and a high protein intake, typical of modern, urban life.

Hypospadias repair in the 1990s

Hypospadias is a congenital anomaly in which the urethral meatus is abnormally located anywhere from the glans to the perineum. Refinements in pediatric anesthesia, surgical technique and instrumentation, and a greater understanding of the psychologic and emotional issues related to hypospadias repair have led to this procedure being performed at an earlier age. The goal of reconstruction is to bring the urethral meatus to the tip of the penis, to correct associated penile curvature if present, to create a conical-shaped glans, and to achieve cosmetically acceptable penile shaft skin coverage. The surgical technique employed varies with the penile anatomy and surgeon's preference. Complications may occur both immediately and long after the surgical procedure, and thus follow-up is necessary.

Outbreak of sterile peritonitis among continuous cycling peritoneal dialysis patients

BACKGROUND

Approximately 30,000 patients receive peritoneal dialysis in the United States. In August 1996, several dialysis centers from different states reported sterile peritonitis among CCPD patients using sterile peritoneal dialysis solution (PDS) from a single manufacturer. The manufacturer recalled 53 lots of PDS that had passed established industry guidelines and Food and Drug Administration (FDA) approved quality control tests [including endotoxin levels <0.5 endotoxin units (EU)/ml], but had pre-sterilization bacterial colony counts >1 cfu/ml.

METHODS

At one outpatient dialysis center, Hospital of the University of Pennsylvania (HUP), we conducted a retrospective cohort study of all CCPD patients treated during July 15 to August 30, 1996. A case-patient was defined as any HUP patient with culture-negative peritoneal fluid with a white blood cell count >100/mm3, cloudy peritoneal fluid, and/or abdominal pain. PDS and tubing were cultured for bacteria and assayed for endotoxin.

RESULTS

Overall, 14 of 28 patients had sterile peritonitis. The only risk factor identified was exposure to > or =1 lot of recalled PDS (14 of 22 vs. 0/6, P = 0.02); the more recalled lots received, the higher the attack rate (P = 0.0001). Five of 47 PDS bags had detectable endotoxin; recalled lots were more likely to have measurable endotoxin than nonrecalled lots (5/19 vs. 0/17, P = 0.05). When case-patients resumed CCPD using PDS from non-recalled lots, no further cases were reported.

CONCLUSIONS

Our results suggest that this outbreak was caused by intrinsic PDS contamination with endotoxin. Pre-sterilization colony counts may be an important quality control indicator for CCPD fluids in conjunction with endotoxin levels.

Family-of-origin interaction and adolescent mothers' potential for child abuse

This study examined the relationship between family-of-origin interaction and environment and the potential for young mothers to abuse their children. Females aged 14 to 21 from three teen parenting programs completed the Teen Parenting Questionnaire, the Family Environment Scale, and the Child Abuse Potential Inventory. Low scores on family cohesion were found to correlate with high scores on child abuse potential. This suggests that providing the teenager with an accepting and supportive atmosphere may assist her in building a positive identity as a mother. Increased understanding of how family-of-origin issues contribute to young mothers' potential to abuse their children will aid school and community professionals in providing better services for this population.

Aging, acculturation, salt intake, and hypertension in the Kuna of Panama

The indigenous Kuna who live on islands in the Panamanian Caribbean were among the first communities described with little age-related rise in blood pressure or hypertension. Our goals in this study were to ascertain whether isolated island-dwelling Kuna continue to show this pattern, whether migration to Panama City and its environs changed the patterns, and whether the island-dwelling Kuna have maintained their normal blood pressure levels despite partial acculturation, reflected in an increased salt intake. We enrolled 316 Kuna participants who ranged in age from 18 to 82 years. In 50, homogeneity was confirmed by documentation of an O+ blood group. In 92 island dwellers, diastolic hypertension was not identified and blood pressure levels were as low in volunteers over 60 years of age as in those between 20 and 30 years of age. In Panama City, conversely, hypertension prevalence was 10.7% and exceeded 45% in those over 60 years of age (P < .01), blood pressure levels were higher in the elderly, and there was a statistically significant positive relationship between age and blood pressure (P < .01). In Kuna Nega, a Panama City suburb designed to maintain a traditional Kuna lifestyle but with access to the city, all findings were intermediate. Sodium intake and excretion assessed in 50 island-dwelling Kuna averaged 135 +/- 15 mEq/g creatinine per 24 hours, exceeding substantially other communities free of hypertension and an age-related rise in blood pressure. Despite partial acculturation, the island-dwelling Kuna Indians are protected from hypertension and thus provide an attractive population for examining alternative mechanisms.

Salt sensitivity of hypertension and responses to angiotensin converting enzyme inhibition with benazepril

Salt intake, and the sensitivity of blood pressure (BP) to excessive salt intake is thought to contribute to the pathogenesis of essential hypertension in some patients. This study was designed to ascertain whether salt sensitivity of BP is a determinant of BP and renal vascular responsiveness to angiotensin converting enzyme (ACE) inhibition. In 24 patients with essential hypertension, ranging in age from 30 to 68 years, renin status, renal hemodynamics, and sensitivity of BP to steady state changes in salt intake were assessed. Twenty-four hour ambulatory BP monitoring (ABPM) was employed to measure baseline BP and BP response to 4 weeks' treatment with benazepril at 20 or 40 mg/day. Benazepril induced a highly-significant reduction in BP (P < .001) and increase in renal plasma flow (530 +/- 17 to 580 +/- 19 mL/min/1.73 m2; P < .001). Systolic BP fell from 143 +/- 2 to 129 +/- 2 mm Hg (P < .001), and diastolic BP fell from 91 +/- 1.6 to 80 +/- 2 mm Hg (P < .001). The magnitude of the BP and renal vascular response to ACE inhibition was not influenced by the sensitivity of BP to salt intake. In a multivariate analysis neither body mass index nor age influenced the BP response to ACE inhibition or the relationships between salt intake and a BP response to ACE inhibition. We conclude that the factors that influence sensitivity of BP to salt intake do not influence the systemic or renal hemodynamic response to ACE inhibition.

Oral Candida albicans from patients infected with the human immunodeficiency virus and characterization of a genetically distinct subgroup of Candida albicans

Candida albicans has been shown to vary in its phenotypic expression with the progression of human immunodeficiency virus (HIV) infection. This study was designed to investigate whether in Category IV HIV infected patients (CDC, Atlanta, USA) these phenotypic changes were related to changes in the genetic strain of the organism. Isolates of C. albicans were obtained from 45 patients with HIV infection during the progression of their disease as determined by percentage T4 lymphocyte count. Isolates were strain differentiated using two methods. In 67 per cent of the patients a single strain of C. albicans, as determined by the DNA analysis, was isolated from each individual over the experimental period. The phenotypic expression of the genetically identical strains isolated from each patient varied considerably over the experimental period with the morphotype 754 being predominant. These results showed that the genotype of C. albicans isolated persisted in the majority of HIV infected individuals, but that the phenotypical expression of this strain changed. A finding in this study was that 18 strains of C. albicans had DNA which did not hybridize to the probe used. These strains were analysed for the presence of two other C. albicans specific DNA segments using PCR. The probe 27A hybridizing strains yielded PCR products which differed from the non-hybridizing strains. Five of these genetically atypical C. albicans strains and 98 of the C. albicans strains were then analysed for purported virulence factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure

Epidemiologic studies have found that dietary patterns characterized by high intakes of certain minerals and fiber are associated with low blood pressure. Dietary Approaches to Stop Hypertension (DASH) is a multicenter, randomized, controlled-feeding trial designed to test the effects on blood pressure of two such dietary patterns consumed for 8 weeks. The two experimental diets will be compared with each other and with a control dietary pattern that is relatively low in potassium, magnesium, calcium, and fiber, and has a fat and protein profile mirroring current consumption. The first experimental diet, arguably termed "ideal," is high in fruits, vegetables, whole cereal products, low-fat dairy products, fish, chicken, and lean meats designed to be low in saturated fat and cholesterol; moderately high in protein; and high in minerals and fiber. The second experimental diet tests the effect of fruits and vegetables alone. Its potassium, magnesium, and dietary fiber content will be at the same high levels as the ideal dietary pattern, while its fat, protein, and calcium content will resemble that of the control dietary pattern. The study population will consist of 456 healthy men and women, aged 22 years or older, with systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg. African-American and other minority groups will comprise 67% of the population. Participants will eat one of the three dietary patterns. The DASH trial has unique features. First, dietary patterns rather than single nutrients are being tested. Second, all food for the experimental diets is provided to the participants using a standardized multicenter protocol. Because the dietary patterns are constructed with commonly consumed food items, the results, if positive, may be conveniently implemented in dietary recommendations to the general public.