FRAX without BMD can be used to risk-stratify Veterans who recently sustained a low trauma non-vertebral/non-hip fracture

We evaluated the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients with a recent low trauma fracture other than hip or vertebral. The concordance, sensitivity, and specificity were 75.6%, 67.3%, and 78.2%, respectively. FRAX without BMD can be used after a fracture to expedite treatment.

INTRODUCTION

The objective of this study was to evaluate the performance of the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients who recently sustained a low trauma fracture other than hip or vertebral.

METHODS

We utilized a clinical database established by the Fracture Liaison Service at the Durham Veterans Affairs Medical Center to identify male and female Veterans age ≥ 50 years who sustained a low trauma non-hip/non-vertebral fracture and underwent dual-energy x-ray absorptiometry (DXA) between October 2013 and April 2018. FRAX without BMD (FRAX-BMI) and FRAX with BMD (FRAX-BMD) were calculated for the 229 patients identified, and whether or not they met the National Osteoporosis Foundation (NOF) guideline treatment thresholds was compared.

RESULTS

There were 55 (24.0%) patients that met criteria for treatment based on NOF guideline established FRAX-BMD thresholds including 27 (11.8%) patients with osteoporosis by DXA. The concordance of FRAX-BMI in predicting treatment recommendations was 75.6% with a sensitivity of 67.3% and a specificity of 78.2%. The area under the curve (AUC) of FRAX-BMI hip fracture risk was 0.79. Assessment/treatment thresholds for hip fracture risk of 1% < FRAX-BMI < 4% were proposed to maximize sensitivity and specificity.

CONCLUSION

Among patients who sustained a low trauma non-hip/non-vertebral fracture, FRAX-BMI can be used to stratify risk and identify high-risk patients who could be treated without DXA, low-risk patients who may not need treatment, and intermediate-risk patients to undergo DXA testing.

Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department

BACKGROUND

In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment.

METHODS

During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors.

RESULTS

During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants.

CONCLUSION

Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

AZD3514, an oral selective androgen receptor down-regulator in patients with castration-resistant prostate cancer - results of two parallel first-in-human phase I studies

BACKGROUND

AZD3514 is a first-in-class, orally bio-available, androgen-dependent and -independent androgen receptor inhibitor and selective androgen-receptor down-regulator (SARD).

METHODS

In study 1 and 2, castration-resistant prostate cancer (CRPC) patients (pts) were initially recruited into a once daily (QD) oral schedule (A). In study 1, pharmacokinetic assessments led to twice daily (BID) dosing (schedule B) to increase exposure. Study 2 explored a once daily schedule.

RESULTS

In study 1, 49 pts were treated with escalating doses of AZD3514 (A 35 pts, B 14 pts). Starting doses were 100 mg (A) and 1000 mg (B). The AZD3514 formulation was switched from capsules to tablets at 1000 mg QD. 2000 mg BID was considered non-tolerable due to grade (G) 2 toxicities (nausea [N], vomiting [V]). No adverse events (AEs) met the dose-limiting toxicity (DLT) definition. Thirteen pts received AZD3514 in study 2, with starting doses of 250 mg QD. The most frequent drug-related AEs were N: G1/2 in 55/70 pts (79 %); G3 in 1 pt (1.4 %); & V: G1/2 in 34/70 pts (49 %) & G3 in 1 pt (1.4 %). PSA declines (≥50 %) were documented in 9/70 patients (13 %). Objective soft tissue responses per RECIST1.1 were observed in 4/24 (17 %) pts in study 1.

CONCLUSION

AZD3514 has moderate anti-tumour activity in pts with advanced CRPC but with significant levels of nausea and vomiting. However, anti-tumour activity as judged by significant PSA declines, objective responses and durable disease stabilisations, provides the rationale for future development of SARD compounds.

Symptoms, Weight Loss and Physical Function in a Lifestyle Intervention Study of Older Cancer Survivors

Cancer is most often a disease of aging, and frequently, a disease for which obesity serves as a risk factor. Thus, many cancer survivors are older, overweight or obese, with higher illness burden, symptoms, and comorbidities. Against this backdrop, survivors are at increased risk for functional decline. The question is whether lifestyle interventions can still benefit older, sicker survivors? The purpose of this study was to examine how overweight long-term survivors' symptom severity prior to a diet and exercise intervention is associated with post-intervention function and to determine symptoms' effects on function through change in physical activity, diet quality, and weight status. Methods This is a secondary data analysis of 514 breast, prostate, and colorectal cancer survivors who participated in the one-year home-based diet and exercise intervention, Reach-Out to Enhance Wellness (RENEW) trial. Pre- and post-intervention data were analyzed. Measures of this study included pre-intervention symptoms, changes in weight, physical activity, diet quality, and post-intervention overall physical function (PF), and basic and advanced lower extremity function (BLEF and ALEF). Simple and serial mediation analyses were conducted to examine direct effects of symptom severity on BLEF and ALEF and the indirect effects of symptom severity through changes in diet quality, physical activity, and weight status. Results Increased symptom severity was directly associated with lower functioning scores for PF (b = −0.63 P &lt; 0.001), BLEF (b = −0.33, P &lt; 0.001) and ALEF (b = −0.22, P &lt; 0.001). Indirect effects of symptom severity through weight loss, physical activity and diet were not significant. Weight loss and increased physical activity were significantly associated with higher PF and ALEF and higher diet quality was associated with higher BLEF. Conclusion Symptom severity of older, overweight cancer survivors negatively affects physical function. However, greater weight loss and physical activity were associated with higher functioning scores, regardless of symptom severity. Findings build from the recent emphasis on the negative effects of obesity on survivor outcomes to highlight weight loss as an important factor in maintaining function in older cancer survivors.

A pilot study to explore circulating tumour cells in pancreatic cancer as a novel biomarker

Background:

Obtaining tissue for pancreatic carcinoma diagnosis and biomarker assessment to aid drug development is challenging. Circulating tumour cells (CTCs) may represent a potential biomarker to address these unmet needs. We compared prospectively the utility of two platforms for CTC enumeration and characterisation in pancreatic cancer patients in a pilot exploratory study.

Patients and methods:

Blood samples were obtained prospectively from 54 consenting patients and analysed by CellSearch and isolation by size of epithelial tumour cells (ISET). CellSearch exploits immunomagnetic capture of CTCs-expressing epithelial markers, whereas ISET is a marker independent, blood filtration device. Circulating tumour cell expression of epithelial and mesenchymal markers was assessed to explore any discrepancy in CTC number between the two platforms.

Results:

ISET detected CTCs in more patients than CellSearch (93% vs 40%) and in higher numbers (median CTCs/7.5 ml, 9 (range 0–240) vs 0 (range 0–144)). Heterogeneity observed for epithelial cell adhesion molecule, pan-cytokeratin (CK), E-Cadherin, Vimentin and CK 7 expression in CTCs may account for discrepancy in CTC number between platforms.

Conclusion:

ISET detects more CTCs than CellSearch and offers flexible CTC characterisation with potential to investigate CTC biology and develop biomarkers for pancreatic cancer patient management.

The impact of self-reported arthritis and diabetes on response to a home-based physical activity counselling intervention

OBJECTIVES

Physical activity (PA) has the potential to improve outcomes in both arthritis and diabetes, but these conditions are rarely examined together. Our objective was to explore whether persons with arthritis alone or those with both arthritis and diabetes could improve amounts of PA with a home-based counselling intervention.

METHODS

As part of the Veterans LIFE (Learning to Improve Fitness and Function in Elders) Study, veterans aged 70-92 were randomized to usual care or a 12-month PA counselling programme. Arthritis and diabetes were assessed by self-report. Mixed models were used to compare trajectories for minutes of endurance and strength training PA for persons with no arthritis (n = 85), arthritis (n = 178), and arthritis plus diabetes (n = 84).

RESULTS

Recipients of PA counselling increased minutes of PA per week independent of disease status (treatment arm by time interaction p < 0.05 for both; endurance training time p = 0.0006 and strength training time p < 0.0001). Although PA was lower at each wave among persons with arthritis, and even more so among persons with arthritis plus diabetes, the presence of these conditions did not significantly influence response to the intervention (arthritis/diabetes group x time interactions p > 0.05 for both outcomes) as each group experienced a nearly twofold or greater increase in PA.

CONCLUSIONS

A home-based PA intervention was effective in increasing minutes of weekly moderate intensity endurance and strength training PA in older veterans, even among those with arthritis or arthritis plus diabetes. This programme may serve as a useful model to improve outcomes in older persons with these pervasive diseases.

Is diabetes associated with poorer self-efficacy and motivation for physical activity in older adults with arthritis?

OBJECTIVES

The primary aim was to explore whether arthritis is associated with poorer self-efficacy and motivation for, and participation in, two specific types of physical activity (PA): endurance training (ET) and strength training (ST). A further objective was to determine whether the added burden of diabetes contributes to a further reduction in these PA determinants and types.

METHODS

Self-efficacy and motivation for exercise and minutes per week of ET and ST were measured in 347 older veterans enrolled in a home-based PA counselling intervention. Regression analyses were used to compare high versus low self-efficacy and motivation and PA minutes in persons without arthritis, with arthritis alone, and with arthritis plus diabetes.

RESULTS

Persons with arthritis alone reported lower self-efficacy for ET and ST than those without arthritis [odds ratio (OR)ET 0.71, 95% confidence interval (CI) 0.39–1.20; ORST 0.69, 95% CI 0.39–1.20]. A further reduction in self-efficacy for these two types of PA was observed for those with both arthritis and diabetes (ORET 0.65, 95% CI 0.44–0.92; ORST 0.64, 95% CI 0.44–0.93; trend p < 0.001). There was no trend towards a reduction in motivation for PA in those with arthritis alone or with arthritis and diabetes. Persons with arthritis exhibited higher motivation for ET than those without arthritis (ORET 1.85, 95% CI 1.12–3.33). There were no significant differences between the three groups in minutes of ET (p = 0.93), but persons with arthritis plus diabetes reported significantly less ST compared to individuals with arthritis only (p = 0.03).

CONCLUSIONS

Despite reduced self-efficacy for ET and ST and less ST in older persons with arthritis, motivation for both PA types remains high, even in the presence of diabetes.

How durable are behavioral changes? Results from FRESH START: A randomized controlled trial to improve diet and exercise behaviors in breast and prostate cancer survivors

9019

Background: A healthy diet and regular exercise may improve the health, well-being and ultimate survival of cancer survivors. Last year, results of the FRESH START trial (n=543) were presented at ASCO; significant improvements in diet and exercise behaviors of breast and prostate cancer survivors were observed with two 10-month mailed print interventions - one that was sequentially- tailored and another using non-tailored print materials in the public domain (attention control). While both arms achieved significant improvements, those receiving the tailored intervention reported significantly greater changes (all p-values <.05). The durability of these changes, however, is not known. Methods: At 2-year follow-up, and after a 12-month wash-out, telephone surveys that were conducted at baseline and post-intervention (Diet History Questionnaire and 7-Day Physical Activity Recall) were repeated. Results: Ordinary Least Square analysis suggest that changes from baseline largely remain significant at 2-year follow-up for both interventions (see table ). Moreover, significant differences between arms are observed for dietary fat restriction and the practice of more lifestyle behaviors at goal level [i.e., consumption of ≥ 5 servings/day of fruits & vegetables (F&V), < 30% kcal from fat, and >150 min/week of exercise], with the tailored intervention arm achieving levels superior to those achieved in the attention control arm. Conclusions: Tailored and untailored interventions delivered over a 10-month period to cancer survivors exert durable effects on several lifestyle behaviors. However, the effects of the tailored intervention were initially more powerful and largely sustained over time (especially, with regard dietary fat restriction).

No significant financial relationships to disclose.

[Table: see text]

Results of FRESH START: A randomized controlled trial to improve diet and exercise behaviors in breast and prostate cancer survivors

8503

Background: Cancer survivors are at increased risk for cardiovascular disease, diabetes, osteoporosis and other cancers. A healthy diet and regular exercise may improve the health and well-being of survivors and ultimately reduce health risks. Methods: 543 individuals within 9-mths of diagnosis with locoregional breast or prostate cancer were referred by 445 providers and recruited from 39 states and 2 provinces within North America. Subjects were randomized to an arm that received a 10-mth program of tailored mailed print materials to promote fruit and vegetable (F&V) consumption, reduce total/saturated fat intake and/or increase exercise or an arm that received a 10-mth program of non-tailored mailed materials on diet and exercise available in the public domain. Telephone surveys conducted at baseline and 1-yr follow-up assessed body mass index (BMI), and responses to the Diet History Questionnaire, the 7-Day Physical Activity Recall and psychosocial/behavioral indices. Anthropometric data were obtained on a 22% subsample to validate self-reports. Results: Complete baseline and follow-up data were obtained on 519 participants (4% attrition). Sample demographics were as follows: mean age = 57 (range: 22–85), 85% white, 56% female, and 64% overweight/obese (none were underweight). Uncontrolled analyses (t-tests) indicate that both arms significantly improved their diet and exercise behaviors (p’s <.05) over the 1-year study period; however significantly greater changes occurred in the experimental arm (see table). Conclusion: The FRESH START intervention was successful in changing the behaviors of individuals with newly diagnosed cancers. Serum assays and collection of 2-yr follow-up data (to determine the durability of longer term behavior change) are currently underway. Further study is needed to determine if the effects of this intervention generalize to other populations of cancer survivors (i.e., other cancers and individuals further-out from diagnosis).

[Table: see text]

No significant financial relationships to disclose.

The relationship between older cancer survivors’ reports of depression, anxiety and pain to health providers’ findings and mortality

8597

Background: Older cancer survivors may experience psychological distress due to their cancer experience and aging health. This study aimed to compare primary care and specialty providers’ inquiries of pain, depression and anxiety to older cancer survivors’ questionnaire responses. Methods: 153 patients seen in oncology clinics at the Veterans Affairs Medical Center (Durham, NC) from November 1999 until April 2000 completed the Hospital Anxiety and Depression Scale and a pain thermometer questionnaire. Blinded chart review examined health provider inquiries of pain, anxiety and depression. Cox proportional hazards survival analyses were performed on subjective pain, anxiety and depression with comorbidities and Karnofsky performance status (KPS) added in controlled models. Results: Patients were on average aged 68, had 5.4 comorbidities, 87.4% KPS, and were 3.1 years from a cancer diagnosis. Health providers missed 17 of 94 patients with significant levels of self-reported pain (sensitivity 0.82). Although 28 (20.6%) and 33 (25.8%) patients screened positively for depression and anxiety respectively, providers asked 7 patients about anxiety (sensitivity 0.15) and 16 patients about depression (sensitivity 0.25). The overall three year mortality was 37.9%. Pain was not associated with mortality. Patients screening for depression [HR 2.03 (95% CI: 1.03, 4.01)] and anxiety [HR 2.02 (95% CI: 1.01, 4.04)] had lower 3 year survival. KPS and comorbidities diminished these effects. Conclusions: In older cancer survivors, anxiety and depression may have an association with mortality. To improve detection, oncology and primary care providers should routinely inquire about mood and aim to intervene with pharmacologic or supportive treatments.

No significant financial relationships to disclose.

A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults

The Internet (electronic mail and the World Wide Web) may provide new opportunities for communication that can help older adults avoid social isolation. This randomized controlled trial assessed the psychosocial impact of providing Internet access to older adults over a five-month period. One hundred volunteers from four congregate housing sites and two nursing facilities were randomly assigned to receive Internet training or to a wait list control group. The pre & post measures included the UCLA Loneliness scale, modified CES Depression scale, a measure of locus of control, computer attitudes, number of confidants, and overall quality of life. Participants received nine hours of small group training in six sessions over two weeks. Computers were available for continued use over five months and the trainer was available two hours/week for questions. At the end of the trial, 60% of the intervention group continued to use the Internet on a weekly basis. Although there was a trend toward decreased loneliness and depression in intervention subjects compared to controls, there were no statistically significant changes from baseline to the end of trial between groups. Among Internet users (n = 29) in the intervention group there were trends toward less loneliness, less depression, more positive attitudes toward computers, and more confidants than among intervention recipients who were not regular users (n = 19) of this technology. Most elderly participants in this trial learned to use the Internet and the majority continued to use it on a weekly basis. The psychosocial impact of Internet use in this sample suggested trends in a positive direction. Further research is needed to determine more precisely, which older adults, residing in which environmental contexts are more likely than others to benefit from this rapidly expanding information and communication link.

Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals

OBJECTIVE

To examine the relationship of services for post-acute care (PAC) to stroke patient outcomes.

DATA SOURCES/STUDY SETTING

Veterans Health Administration (VHA) hospitals from two facility-level surveys and extant data files.

STUDY DESIGN

Cross-sectional study of veterans hospitalized with acute stroke during the period June 1995 through May 1996 in one of 182 geographically distinct locations within the VHA. Study variables included (1) a typological classification of hospitals according to the level of PAC; (2) a taxonomy of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (3) patient outcomes (discharge destination, length of stay).

DATA COLLECTION/EXTRACTION METHODS

Data were collected from two mailed surveys and extant data files. Rehabilitation variables were identified for the study in conjunction with a panel of expert rehabilitation researchers and clinicians, using an a priori model for measuring rehabilitation characteristics. Two sets of variables were derived to categorize these rehabilitation characteristics: (1) a rehabilitation typology, classifying the VA hospitals according to the continuum of PAC settings in the facility, and (2) a rehabilitation taxonomy that used an empirical approach to derive a list of key rehabilitation characteristics.

PRINCIPAL FINDINGS

Twenty-seven percent of veterans with acute stroke were cared for in VA hospitals with neither a geriatric nor a rehabilitation unit, and 50 percent were cared for in hospitals without a rehabilitation unit. Hospitals with rehabilitation units had the greatest sophistication, and those with geriatric units had intermediate sophistication in rehabilitation organization and resources. Statistically significant differences were found in outcomes for stroke patients cared for in hospitals classified according to the continuum of post-acute care on site. Exploratory multivariable analyses revealed independent associations between stroke patient outcomes and (1) staffing ratios for nurses and physicians, (2) the diversity of physician and rehabilitation staff, (3) presence of a simulated home environment, and (4) the total number of care settings on site.

CONCLUSIONS

The PAC continuum defines an important hierarchy of stroke rehabilitation services.

Minimization and management of wastes from biomedical research

Several committees were established by the National Association of Physicians for the Environment to investigate and report on various topics at the National Leadership Conference on Biomedical Research and the Environment held at the 1--2 November 1999 at the National Institutes of Health in Bethesda, Maryland. This is the report of the Committee on Minimization and Management of Wastes from Biomedical Research. Biomedical research facilities contribute a small fraction of the total amount of wastes generated in the United States, and the rate of generation appears to be decreasing. Significant reductions in generation of hazardous, radioactive, and mixed wastes have recently been reported, even at facilities with rapidly expanding research programs. Changes in the focus of research, improvements in laboratory techniques, and greater emphasis on waste minimization (volume and toxicity reduction) explain the declining trend in generation. The potential for uncontrolled releases of wastes from biomedical research facilities and adverse impacts on the general environment from these wastes appears to be low. Wastes are subject to numerous regulatory requirements and are contained and managed in a manner protective of the environment. Most biohazardous agents, chemicals, and radionuclides that find significant use in research are not likely to be persistent, bioaccumulative, or toxic if they are released. Today, the primary motivations for the ongoing efforts by facilities to improve minimization and management of wastes are regulatory compliance and avoidance of the high disposal costs and liabilities associated with generation of regulated wastes. The committee concluded that there was no evidence suggesting that the anticipated increases in biomedical research will significantly increase generation of hazardous wastes or have adverse impacts on the general environment. This conclusion assumes the positive, countervailing trends of enhanced pollution prevention efforts by facilities and reductions in waste generation resulting from improvements in research methods will continue.

Expert physician recommendations and current practice patterns for evaluating and treating men with osteoporotic hip fracture

OBJECTIVES

To develop recommendations for the evaluation and the treatment of men with osteoporotic hip fracture from expert publications in the field of male osteoporosis, and to define the current practice patterns in a tertiary care VA Medical Center in Durham, North Carolina.

DESIGN

Survey research; a retrospective cohort study.

SETTING

Tertiary care VA Medical Center in Durham, North Carolina.

PARTICIPANTS

(1) US physicians who published on the subject of male osteoporosis in the peer-reviewed literature between 1993 and 1997 identified by MEDLINE database search. (2) All 119 men admitted to the Durham VA Medical Center with ICD9 code for hip fracture between 1994 and 1998.

OUTCOME MEASURES

(1) Osteoporosis evaluation and treatment recommendations of published physicians obtained by survey instrument. (2) Actual osteoporosis evaluation completed and therapy prescribed during index hospitalization in a cohort of men with hip fractures, determined by chart and database review.

RESULTS

(1) Forty-three physician-researchers were surveyed with an 84% response rate. For an osteoporosis evaluation, 89% of respondents recommended measuring serum testosterone, 85% serum calcium, 75% 25-OH vitamin D levels, 73% myeloma screen, and 61% serum thyroid-stimulating hormone (TSH). Dual Energy X-ray Absorptiometry would be obtained by 92%. More than 70% recommended calcium, vitamin D, and bisphosphonates for men with a normal metabolic evaluation, and 60% suggested weight-bearing exercise. (2) In the cohort of men admitted with hip fractures, 50% had a serum calcium level and 3% had a serum TSH level measured. Vitamin D was prescribed to 25% of patients in the form of a multivitamin, and 4% received calcium. There was no bisphosphonate, testosterone, or calcitonin use.

CONCLUSIONS

Physicians who have published on osteoporosis recommended metabolic evaluation and osteoporosis therapy after hip fracture. Only minimal evaluation and treatment occurred in a cohort of men with osteoporotic hip fractures.

The structure and structural effects of VA rehabilitation bedservice care for stroke

The purpose of this study was to: 1) examine the variation in organizational structure within rehabilitation bed-service units (RBU) in the Veterans Health Administration (VHA), and 2) evaluate the effects of RBU and parent hospital structure on stroke rehabilitation outcomes. Two VHA-wide surveys of acute and rehabilitation services for stroke were linked with 2 y of VHA rehabilitation outcomes for stroke patients. A random effects mixed model was used to adjust for patient level covariates, control for unique site effects, and test for facility level structural effects. After adjusting for patient covariates, four structural variables were associated with length of stay or patient functional gain. These results indicate that rehabilitation structure is important to rehabilitation outcome. The individual variables identified in this study, namely, diverse multidisciplinary staff, expert physician leadership, staff participation in team care, and richer rehabilitation equipment resources, may represent the distinct aspects of a successful, comprehensive rehabilitation unit.

A taxonomy for classification of stroke rehabilitation services

OBJECTIVE

To develop a taxonomy for use in measuring stroke rehabilitation services.

DESIGN

A cross-sectional study using facility-level survey data and extant data files.

SETTING

Veterans Administration medical centers (VAMCs).

VARIABLES

(1) A list of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (2) a classification or typology of VAMCs according to the type of postacute stroke care on-site.

MAIN OUTCOME MEASURES

Data sources included extant Veterans Administration (VA) computerized databases, VA central office administrative files, and 2 mailed surveys to VA rehabilitation medicine services and stroke acute care services. The rehabilitation taxonomy was derived using 2 methods that assess face and construct validity, respectively: (1) an expert panel rating, using a modified Delphi process, of the clinical importance of each of the rehabilitation characteristics; and (2) a comparison of rehabilitation characteristics across the different types of VAMCs. Variables were included in the final taxonomy if the expert panel reached consensus that the variable was clinically important, or if there were statistically significant differences in these characteristics across the different types of medical centers.

RESULTS

Of 67 possible rehabilitation characteristics, a multidisciplinary expert panel reached consensus about the likely clinical importance of 21 rehabilitation characteristics, 11 of which showed statistically significant differences across different types of VAMCs. An additional 9 variables that lacked expert panel consensus differed significantly among the different medical centers. These 30 variables represent a preliminary taxonomy of key rehabilitation characteristics. Among the 20 variables that varied significantly across the different types of medical centers, 18 showed a pattern with the greatest amount of resources and organizational sophistication being found in VAMCs with rehabilitation units, followed by medical centers with geriatric units, and the least amount of resources and organizational sophistication was seen in medical centers whose postacute care services were limited to nursing home or intermediate care.

CONCLUSION

Thirty rehabilitation characteristics had face validity and/or construct validity, and can be considered to represent a preliminary taxonomy for measuring stroke rehabilitation services. This study also shows that there are significant differences among hospitals in resources and organization of care deemed to be important for stroke patients.

Timed loaded standing: a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis

Chronic back tiredness or fatigue is a common complaint of people who have a history of osteoporotic vertebral fracture. Trunk muscle endurance has not been studied in people with vertebral osteoporosis, partly due to the lack of assessment tools. We developed a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis, timed loaded standing (TLS). TLS measures the time a person can stand while holding a two-pound dumbbell in each hand with the arms at 90 degrees of shoulder flexion and the elbows extended. Intraclass correlation coefficients (ICCs) for same day inter-trial and six to ten day test-retest reliability were 0.89 (lower bound 95% confidence interval [LB 95% CI] 0.79) and 0.84 (LB 95% CI 0.68), respectively, in a sample of 21 older women with no known osteoporosis. In 127 women with vertebral fractures, the ICC for same day inter-trial reliability was 0.81 (LB 95% CI 0.75). In a sub-sample of 30 of these women with vertebral fractures, the six to ten day test-retest reliability was 0.85 (LB 95% CI 0.75). Moderately strong and statistically significant (p < or = 0.05) correlations were found between TLS and sixteen of eighteen measures of physical impairment and function. Functional reach distance, gait velocity, MOS-36 Physical Function Subscale, shoulder flexion strength, and six minute walk distance were most strongly associated with TLS time. Women with vertebral fractures who endorsed having back tiredness when standing and working with the arms in front of the body, sitting to rest because of back tiredness or pain, and planning rest periods because of back tiredness or pain had significantly lower TLS times. TLS is a simple, safe physical performance measure of combined trunk and arm endurance that demonstrates acceptable reliability (inter-trial and test- retest) and concurrent validity.

Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy

BACKGROUND AND PURPOSE

We sought to determine whether there are racial differences in use of carotid artery imaging after controlling for clinical factors and to ascertain racial differences in presenting signs and symptoms and overall appropriateness for carotid endarterectomy (CE).

METHODS

We performed a retrospective cohort study of 803 patients older than 45 years, hospitalized between 1991 and 1994 at any of 4 Veterans Affairs Medical Centers, with a discharge diagnosis of transient ischemic attack or ischemic stroke. Clinical data were abstracted from the medical record, including presenting symptoms, diagnostic test results, and use of surgical procedures. Appropriateness for CE was determined according to RAND criteria.

RESULTS

Black patients were more likely than white patients to present with stroke (78% versus 55%) but less likely to present with transient ischemic attack (22% versus 45%; P=0.001). There was no racial difference in medical comorbidity or preoperative risk. Black patients were less likely to have an imaging study of their carotid arteries (67% versus 79%; P=0.001). Race remained an independent predictor of imaging after adjustment for clinical factors (odds ratio=1.50; 95% CI, 1.06 to 2.13). Because of higher prevalence of significant carotid artery stenosis, whites were significantly more likely than blacks to be assessed as appropriate candidates for surgery with the use of RAND criteria (18% versus 4%; P=0.001).

CONCLUSIONS

Use of carotid artery imaging, a critical step in determining eligibility for CE, is influenced by the patient's race after controlling for clinical presentation. Adjustment for appropriateness of CE reduces but does not eliminate the importance of race.

The reliability of a self-reported measure of disease, impairment, and function in persons with spinal cord dysfunction

OBJECTIVE

To develop a self-report instrument that would provide information about the different levels of the disablement process, and that (1) was suitable for persons with spinal cord disease (SCD), (2) could be completed quickly, (3) could be mailed, (4) had acceptable reliability, and (5) would be clinically useful.

STUDY DESIGN

Test-retest using a convenience sample.

METHODS

Review of the literature and an expert panel were used to develop the instrument. It was mailed to 49,458 individuals in June 1995 and a second mailing was done in August 1995. A subset of 725 individuals who responded to both mailings was used to examine the instrument's test-retest reliability.

RESULTS

The instrument has a 4th grade reading level and has questions on causal disease, disease severity, impairment, activities of daily living (including a self-reported version of the Functional Independence Measure, the SRFM), and resource utilization. Individual item test-retest reliability was high for a mailed questionnaire; all kappa coefficients were near or above .60 and most were over .70. Intraclass correlation coefficient for the SRFM was .90 and internal consistency (Chronbach's alpha) was .96.

CONCLUSION

This instrument provides a new, rapid way to obtain information relative to the differing levels of the disablement process.

Predictors of mammography use among women veterans

We examined mammography use patterns of women veterans and explored Veterans Administration (VA) health care use and military experience as predictors of mammography use by this population. We conducted a national telephone survey of women veterans. A sample of 397 women veterans was selected from all military discharges from 1971 through 1994. A 3 x 2 stratification scheme was used: three age groups (35-49, 50-64, > or = 65 years old) and two VA user groups indicating whether (VA user) or not (VA nonuser) they received any health care from a VA Medical Center in the last 5 years. The response rate was 75% (297 of 397). Analyses included bivariate techniques and weighted logistic regression. We found that women veterans told to have a mammogram by a health care professional were more than five times more likely to have ever had a mammogram (OR 5.41, CI 4.63-6.32) and nearly twice as likely to have had a mammogram within the past 2 years (OR 1.81, CI 1.57-2.09) as those who were not told to do so, controlling for age, race, VA user status, and length of military service. Regular VA users were more likely to have had a mammogram ever and within the past 2 years, controlling for other factors. Mammography use was not necessarily at a VA medical center. Interventions that promote better provider-patient communication and target older women veterans may have the most potential benefit. Whether VA health care is filling an important gap in access to mammography for older women veterans is an important policy question and warrants further research.

Developing a national registry of veterans with spinal cord dysfunction: experiences and implications

We describe the development of a registry of veterans with spinal cord dysfunction who have been treated within the Department of Veterans Affairs health care facilities. The registry departs from the function and structure of traditional registries by a more extensive utilization of advances in computer technology; in particular, by its reliance upon computerized record linkage and by its association with a set of computer-based clinical management and reporting tools. We discuss some of the applications of the registry to research for persons with spinal cord dysfunction as well as implications that our experiences provide for developing other registries of persons with disabilities.

What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture?

OBJECTIVE

To determine the relationship of surgical repair of acute hip fracture within 2 days of hospital admission, followed by more than 5 sessions per week of physical and occupational therapy (PT/OT), to outcomes after acute hip fracture.

DESIGN

Comparison of hip fracture outcomes via secondary analysis of data obtained by retrospective medical record review according to timing of surgical repair and frequency of PT/OT, adjusted for patient, medical care, and hospital characteristics.

SAMPLE

The study included the medical records of 1880 elderly Medicare recipients admitted from the community to 284 acute care hospitals in 5 states during 1981 and 1982 or 1985 and 1986 with a primary diagnosis of acute hip fracture who underwent surgical repair and received PT/OT.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The postoperative day when ambulation first occurred, the length of hospital stay, and return to the community.

RESULTS

Earlier surgical repair was associated with a shorter length of hospital stay (5 fewer days, P < .001) without a statistically significant increase in medical complications. High frequency PT/OT was associated with earlier ambulation (odds ratio [OR], 1.76; 95% confidence limits [CL], 1.50, 2.07). Patients who ambulated earlier [corrected] had shorter lengths of stay (6.5 fewer days, P < .001), were more likely to return to the community (OR, 1.45; 95% CL, 1.16, 1.81), and had better 6-month survival (OR, 2.8; 95% CL, 2.06, 3.88), and patients younger than 85 years had fewer in-hospital complications (11% vs 4%, P < .001).

CONCLUSION

Surgical repair within the first 2 days of hospitalization and more than 5 PT/OT sessions per week were associated with better health outcomes in a nationally representative sample of elderly patients with hip fracture.

Racial differences in the utilization of inpatient rehabilitation services among elderly stroke patients

BACKGROUND AND PURPOSE

We undertook this study to ascertain whether elderly black and white patients who are hospitalized for stroke utilize inpatient physical and occupational therapy (PT/OT) services differently, adjusting for characteristics associated with use of these services.

METHODS

We retrospectively reviewed medical records regarding the care received by a nationally representative sample of 2497 black and white Medicare patients, aged 65 years of older, who were hospitalized at any of 297 acute-care hospitals located in 30 communities within five states.

RESULTS

Compared with whites, black stroke patients were younger and more likely to have Medicaid coverage, have an ischemic stroke, and have a motor deficit noted at the time of admission. There was no difference in either sex or level of consciousness on admission. Overall, a larger proportion of black stroke patients used inpatient PT/OT at some point during the hospitalization (66.3% versus 55.8%; P < .01). However, after adjustment for characteristics associated with use of PT/OT, there was no racial difference in either the likelihood of inpatient PT/OT use (adjusted relative risk, 1.06; 95% confidence limits, 0.89 to 1.27; P = .42) or time to initial contact (median: blacks, 6.6 days; whites, 7.4 days; P = .42). Adjusted analyses also indicated a similarity between the racial groups in the number of inpatient PT/OT days overall or as a proportion of the hospital stay.

CONCLUSIONS

Elderly black and white stroke patients who have Medicare coverage have similar patterns of use of inpatient PT/OT services.

Interobserver agreement and predictive value of endoscopic findings for H. pylori and gastritis in normal volunteers

BACKGROUND

Endoscopic findings such as erythema are frequently labeled as gastritis. We sought to determine interobserver agreement for specific endoscopic features and assess the diagnostic value of features with good agreement for Helicobacter pylori and histologic gastritis.

METHODS

Fifty-two healthy subjects without ulcers, erosions, or hemorrhages had a full endoscopy recorded on video tape. Biopsy specimens were examined for H. pylori and gastritis. Two endoscopists independently reviewed the tapes for predefined features (erythema, area gastricae, clefts, and nodularity) in the gastric body and antrum. Diagnostic value of endoscopic features with acceptable agreement (kappa > 0.40) was then determined for H. pylori and gastritis.

RESULTS

Kappa was greater than 0.40 only for prominent body area gastricae (0.49), body nodularity (0.65), and antral nodularity (0.68). For antral nodularity, sensitivity was 32%, specificity was 96%, and positive predictive value was 90% for H. pylori. when both antral nodularity and body area gastricae were both present, sensitivity was only 18% but specificity and positive predictive value were 100%. CIRCULATION: Interobserver agreement is poor for some features such as erythema labeled as gastritis. Antral nodularity is a fairly reproducible finding and is very specific, though not sensitive, for H. pylori gastritis.

A randomized double-blind comparison of placebo, etodolac, and naproxen on gastrointestinal injury and prostaglandin production

BACKGROUND

NSAIDs frequently cause gastrointestinal injury and increase the risk of ulcer complications. We compared an NSAID suggested to cause less gastric injury (etodolac) with a standard NSAID (naproxen) and a placebo in a 4-week double-blind trial assessing the effects on gastroduodenal injury, symptoms, and prostaglandin production in healthy volunteers.

METHODS

Fifty-two healthy volunteers not taking NSAIDs, alcohol, antibiotics, bismuth, or anti-ulcer drugs: placebo, etodolac 400 mg, or naproxen 500 mg b.i.d. for 4 weeks. Endoscopies with biopsies were repeated at weeks 1 and 4. The number and dimensions of ulcers and erosions were recorded to quantitate injury.

RESULTS

At week 1 the mean number and area of gastric ulcers per subject were greater with naproxen than placebo or etodolac (area: naproxen, 7.4 mm2; placebo, 0.6 mm2, p = 0.02 vs naproxen; etodolac, 2.1 mm2, p = 0.06 vs naproxen). Ulcer scores at week 4 were low and comparable in the three groups. The mean number and area of gastric erosions per subject were greatest with naproxen at both weeks 1 and 4 (week 4 area: naproxen, 58.3 mm2; placebo, 29.0 mm2; etodolac, 13.9 mm2, p < 0.02, naproxen vs placebo and vs etodolac). Placebo injury was presumably due to biopsies at prior endoscopy. Gastric mucosal prostaglandin E2 production did not change significantly from baseline after 1 or 4 weeks of treatment with placebo or etodolac, but did decrease significantly with naproxen (week 0, 1689; week 1, 479; week 4, 577 pg/mg protein). Gastrointestinal symptoms were present in only 1 (5%) of 20 visits in which endoscopy showed no erosions or ulcers vs 21 (26%) of 82 visits in which a mucosal defect was identified (p = 0.666).

CONCLUSION

Gastric injury with 4 weeks of etodolac is comparable to that seen with placebo and significantly less than that occurring with naproxen, presumably due to the fact that etodolac does not suppress gastric mucosal prostaglandin production, whereas naproxen leads to a significant reduction.

Sonographic measurement of renal enlargement in children with acute pyelonephritis and time needed for resolution: implications for renal growth assessment

OBJECTIVE

Failure of a kidney to grow satisfactorily in childhood is evidence of renal disease. Because kidneys may enlarge during an episode of acute pyelonephritis, concomitant renal length measurements cannot be used as baselines for growth assessment. This study was designed to determine the degree of renal enlargement in children with acute pyelonephritis and the time the enlargement takes to resolve after treatment is started to find the optimum time for obtaining baseline measurements.

SUBJECTS AND METHODS

In a cohort study, 180 children younger than 5 years old with their first proven acute urinary tract infection, with or without pyelonephritis, had renal scintigraphy and sonography within 15 days of starting treatment. The presence of cortical defects on scintigrams indicated pyelonephritis. The lengths of kidneys with and without scintigraphic defects (i.e., with and without pyelonephritis) were compared, adjusting for age and sex, and the length of kidneys with defects was related to time elapsed between the start of treatment and sonography.

RESULTS

Ninety-nine kidneys (28%) in 77 children (43%) had scintigraphic defects. Kidneys with defects were an average of 3.2 mm longer than kidneys without defects. Length and time interval between treatment and sonography in kidneys with defects correlated negatively, with mean length approaching that of kidneys without defects by 10-11 days.

CONCLUSION

Kidneys with acute pyelonephritis initially increase in length but return to normal on average by the 11th day of treatment. If poor renal growth is used as an indication of renal disease, sonography should be delayed or repeated at least 2 weeks after the start of treatment to determine the length of the uninflamed kidney.

Interaction of NSAIDs and Helicobacter pylori on gastrointestinal injury and prostaglandin production: a controlled double-blind trial

BACKGROUND

H. pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) are major causes of gastroduodenal injury in man. We assessed the effect of daily NSAID ingestion on gastric histology and the interaction of H. pylori infection and NSAID ingestion on gross and histological injury and prostaglandin production.

METHODS

Fifty-two healthy volunteers with normal baseline endoscopy were randomly assigned to receive identical-appearing naproxen 500 mg b.d., etodolac 400 mg b.d., or placebo b.d. for 4 weeks. The number and size of all erosions and ulcers were recorded by endoscopy at weeks 1 and 4. Biopsies taken at baseline, week 1 and week 4 were assessed for H. pylori, histology and gastric prostaglandin E2 production.

RESULTS

No significant changes occurred with treatment in any histological feature in the three study groups or in H. pylori positive or negative subsets. Antral inflammation scores (scale, 0-6) for the NSAID group were: week 0--1.2 +/- 0.3; week 1--1.1 +/- 0.3; week 4--1.3 +/- 0.3; findings of 'chemical gastritis' were not seen. No significant difference in gross gastroduodenal injury (number or total surface area of ulcers or erosions) was seen between H. pylori positive and negative subjects in the three groups at week 1 or 4. Baseline prostaglandin E2 production was significantly higher in H. pylori positive subjects (2398 +/- 400 vs. 1064 +/- 255 pg/mg protein) and decreased significantly with 1 week of naproxen in H. pylori positive and negative subjects.

CONCLUSIONS

NSAID ingestion does not cause diffuse histological injury. Any diffuse histological injury in the gastric mucosa is related to the presence of H. pylori, and this H. pylori-associated gastritis is not altered by NSAID ingestion. Furthermore, the development of gross gastroduodenal damage with 4 weeks of NSAID use is not influenced by underlying H. pylori infection.

Risk factors in the development of early renal cortical defects in children with urinary tract infection

OBJECTIVE

Defects seen on early cortical scintigrams of the renal cortex in children with urinary tract infection may represent acute inflammatory change or established scar. The purpose of this study was to determine the relationship between these defects and age, sex, the presence and grade of vesicoureteral reflux, and infective organism in a cohort of children examined after their first proved urinary tract infection.

SUBJECTS AND METHODS

We prospectively examined 193 consecutive patients less than 5 years old who were seen at the ambulatory pediatric department during a 3-year period and had a first proved urinary tract infection. Children with obstructed or solitary kidneys were excluded. All patients were imaged with scintigraphy of the renal cortex and radiographic voiding cystourethrography within 15 days of diagnosis. The association of age, sex, the presence and grade of vesicoureteral reflux, and infective organism with a defect (acute pyelonephritis or a renal scar) seen on a cortical renal scan was studied.

RESULTS

The prevalence of cortical defects was greater in the kidneys of patients less than 2 years old (96/290, 33%) than in older children (16/96, 17%) and greater in those with vesicoureteral reflux (41/92, 45%) than in those without it (71/294, 24%). Vesicoureteral reflux was absent in 63% (71/112) of kidneys with a cortical defect. No association with sex or infective organism was established. As well as having a greater prevalence of cortical defects, 145 (75%) of the 193 urinary tract infections included in the study were in children less than 2 years old. The kidneys of these younger patients also had a greater severity and prevalence of vesicoureteral reflux (74/290, 26%) than did those of older children (18/96, 19%).

CONCLUSION

Early cortical defects are associated with an age less than 2 years and vesicoureteral reflux. However, the association of early defects with the presence and grade of vesicoureteral reflux is confounded by the declining prevalence and severity of reflux with age. A significant proportion of cortical defects occur in the absence of vesicoureteral reflux, and the contribution of reflux to scar formation might be less than previously considered.

Vesicoureteral reflux: an accurate predictor of acute pyelonephritis in childhood urinary tract infection?

PURPOSE

To determine the association between vesicoureteral reflux (VUR) and the presence of acute pyelonephritis in children with urinary tract infections.

MATERIALS AND METHODS

The authors studied 150 consecutive patients less than 5 years of age with their first proved urinary tract infection. All patients underwent renal cortical scintigraphy (with technetium-99m dimercaptosuccinic acid or Tc-99m gluconate) and voiding cystourethrography (VCUG) to identify the presence of cortical defects and VUR, respectively.

RESULTS

Of 300 kidneys, 88 (29.3%) had a cortical defect at scintigraphy. Fifty-four of the 88 patients (61%) did not have VUR demonstrated at VCUG. Conversely, 72 of the 300 kidneys (24%) had VUR; of these, 38 (53%) had no cortical defect. The sensitivity of VCUG in helping predict a defect was 38.6%, and the specificity was 82.1%.

CONCLUSION

VUR (as shown by VCUG) and renal cortical scintigraphic defects frequently occur independently of each other. Renal cortical scintigraphy may be a more accurate predictor of patients at risk for scarring.

Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices

OBJECTIVE

Comparison of the safety and efficacy of endoscopic sclerotherapy and ligation for the treatment of bleeding esophageal varices.

DESIGN

Randomized, controlled trial.

SETTING

An urban county hospital.

PATIENTS

Patients with clinically severe bleeding from esophageal varices.

INTERVENTION

A total of 77 patients were randomly assigned to receive sclerotherapy or ligation at the initial endoscopic examination. Treatment was repeated weekly until variceal obliteration was achieved. After eradication, patients had endoscopic examinations every 3 months or for any episode of rebleeding. Recurrent varices were treated with the originally assigned form of endoscopic therapy.

MEASUREMENTS

Patients were assessed for further bleeding, for transfusion requirements, for time in hospital, for variceal eradication, for number of treatment sessions required, for complications, for treatment failure, and for risk of death.

RESULTS

Rebleeding tended to be less frequent with ligation than with sclerotherapy: 10 of 38 (26%) compared with 17 of 39 (44%) (difference, 17% [95 CI, -4% to 38%]), but results in the two groups were comparable for blood transfusions, for length of hospital stay, and for risk of death. Comparison of Kaplan-Meier estimates of time to rebleeding and death showed no statistical differences between treatments. Complications were less common in the ligation group: fewer patients in the ligation group had esophageal strictures (0 of 38 compared with 13 of 39 [33%]; P < 0.001) and had complicated esophageal ulcers (1 of 38 [2.6%] compared with 6 of 39 [15%]; P = 0.11). In addition, fewer ligation treatments were required to achieve variceal eradication (4.1 +/- 0.3 compared with 6.2 +/- 0.4; P < 0.001).

CONCLUSION

Endoscopic ligation causes statistically fewer local complications than sclerotherapy and achieves variceal eradication more rapidly. Ligation is a viable alternative to sclerotherapy and may have some advantages as a treatment for bleeding esophageal varices.

Common-sense management of Helicobacter pylori-associated gastroduodenal disease. Personal views

We have tried to present a rational approach to the medical treatment of peptic ulcer disease and nonulcer dyspepsia in the era of H. pylori. We are aware that the natural history of peptic ulcer disease is still debated. Some clinicians believe that peptic ulcer disease may "burn out" over a 10- to 15-year period, and in light of this, the emphasis toward a nonsurgical "cure" for peptic ulcer disease may seem misguided. Yet, all factors must be taken into account. Current medical therapy has demonstrated inadequacies. H. pylori is unequivocally (in our view) associated with peptic ulcer disease. Anti-H. pylori therapy has proven efficacy in the long-term prevention of peptic ulcer recurrence. Despite our enthusiasm for treatment of H. pylori in select circumstances, we encourage further controlled clinical trials to better delineate the role of H. pylori in the natural history and treatment of peptic ulcers. The association between H. pylori and nonulcer dyspepsia is tenuous at best. Treatment directed at eradicating H. pylori in nonulcer dyspepsia does not impress us favorably. We are intrigued by preliminary data that, despite a lack of improvement in the short term, H. pylori eradication in nonulcer dyspepsia patients may reduce symptoms over the long term. Unfortunately, this study suffers methodologic difficulties. If other studies were to confirm these findings, this would provide a cogent reason for us to reassess our views on the treatment of H. pylori in nonulcer dyspepsia. At present, the costs, benefits, and risks of anti-H. pylori therapy in nonulcer dyspepsia are not sufficient to warrant its use outside of therapeutic trials.

A toxic shock syndrome toxin mutant of Staphylococcus aureus isolated by allelic replacement lacks virulence in a rabbit uterine model

The gene coding for toxic shock syndrome toxin-1 in S. aureus was inactivated by allelic replacement in two TSS-associated strains. One mutant derived from FRI1169 (a non-enterotoxigenic strain) lacked virulence in the rabbit uterine chamber infection model. This suggests that TSST-1 is the only determinant produced by this strain that can induce the symptoms of shock in rabbits. A novel method for allelic replacement involving transduction of plasmid integrants is described.

Methyl isocyanate: reproductive and developmental toxicology studies in Swiss mice

Studies were conducted in Swiss (CD-1) mice to evaluate the potential of inhaled vapors of methyl isocyanate (MIC) to affect reproduction and development. Inhaled MIC at concentrations of 0, 1, or 3 ppm, 6 hr per day during days 14 through 17 of gestation caused a significant increase in the number of dead fetuses at birth and caused a significant decrease in neonatal survival during lactation. In contrast, exposure of male and female mice to 1 or 3 ppm given 6 hr per day for 4 consecutive days had no effect on reproduction during mating trials conducted 1, 8, and 17 weeks after the exposure period. Similarly, there was no evidence of a dominant lethal effect in exposed male mice.

Distillation Method for Determination of Moisture in Spices: Collaborative Study

AOAC method 30.005 for determination of moisture in spices by distillation was collaboratively studied to revalidate its reliability. Using toluene as the solvent system, repeatability and reproducibility were acceptable for basil. Using hexane as the solvent for red pepper produced less satisfactory results. The method has been adopted official first action.