A systematic analysis of experimental immunotherapies on tumors differing in size and duration of growth

We conducted a systematic analysis to determine the reason for the apparent disparity of success of immunotherapy between clinical and experimental cancers. To do this, we performed a search of PubMed using the keywords “immunotherapy” AND “cancer” for the years of 1980 and 2010. The midspread of experimental tumors used in all the relevant literature published in 2010 were between 0.5–121 mm³ in volume or had grown for four to eight days. Few studies reported large tumors that could be considered representative of clinical tumors, in terms of size and duration of growth. The predominant effect of cancer immunotherapies was slowed or delayed outgrowth. Regression of tumors larger than 200 mm³ was observed only after passive antibody or adoptive T cell therapy. The effectiveness of other types of immunotherapy was generally scattered. By comparison, very few publications retrieved by the 1980 search could meet our selection criteria; all of these used tumors smaller than 100 mm³, and none reported regression. In the entire year of 2010, only 13 used tumors larger than 400 mm³, and nine of these reported tumor regression. Together, these results indicate that most recent studies, using many diverse approaches, still treat small tumors only to report slowed or delayed growth. Nevertheless, a few recent studies indicate effective therapy against large tumors when using passive antibody or adoptive T cell therapy. For the future, we aspire to witness the increased use of experimental studies treating tumors that model clinical cancers in terms of size and duration of growth.

Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients

Pseudobulbar affect (PBA) or pathological laughing and crying (PLC) is a disorder of affect that occurs in about 10% of multiple sclerosis (MS) patients. The objective of this study was to validate the CNS Emotional Lability Scale (CNS-LS) in MS patients and to correlate the results with the frequency and intensity of episodes of PLC. Physicians at seven private practice referral centers in the United States made a diagnosis concerning PLC based on patient interviews. Clinical coordinators separately administered the CNS-LS, a self-report measure of PLC with seven questions, to MS patients, including patients known to exhibit PLC, patients thought to be free of PLC, and newly diagnosed patients where PLC status was unknown, and the physician was blinded as to the results. A receiver operating characteristic (ROC) curve analysis was performed to define a cut-off best correlating with the physician’s diagnosis. Of 90 MS patients selected to complete the survey, 50 were physician diagnosed with PLC; 40 were without PLC, and 15 of these 90 patients were newly diagnosed with MS (B-6 months). Scores of 17 or higher corresponded to a sensitivity of 0.94 and a specificity of 0.83 (LR -/5.5, LR -/0.07); 89% of patients were correctly diagnosed. The area under the ROC curve was 0.95. Symptoms were greater in patients diagnosed as PLC than in non-PLC patients as evidenced by mean number of episodes/week, number of days/week with episodes, duration of an episode and total time in an episode. Similar results were observed if patients were classified as PLC or non-PLC according to CNS-LS score]-17, suggesting that the CNS-LS is a valid measure for the assessment of PLC in MS patients and could be a useful instrument for clinical and research purposes.

Sleep duration and health among older adults: associations vary by how sleep is measured

BACKGROUND

Cohort studies have found that short and long sleep are both associated with worse outcomes, compared with intermediate sleep times. While demonstrated biological mechanisms could explain health effects for short sleep, long-sleep risk is puzzling. Most studies reporting the U shape use a single question about sleep duration, a measurement method that does not correlate highly with objectively measured sleep. We hypothesised that the U shape, especially the poor outcomes for long sleepers, may be an artefact of how sleep is measured.

METHODS

We examined the cross-sectional prevalence of fair/poor health by sleep hour categories (≤ 6, ≤ 7, ≤ 8, ≤ 9, > 9 h) in a national US sample of adults aged 62-90 that included several types of sleep measures (n = 727). Survey measures were: a single question; usual bedtimes and waking times; and a 3-day sleep log. Actigraphy measures were the sleep interval and total sleep time. Fair/poor health was regressed on sleep hour categories adjusted for demographics, with tests for both linear trend and U shape.

RESULTS

Adjusted OR of fair/poor health across sleep hour categories from the single question were 4.6, 2.2, referent (8 h), 1.8 and 6.9. There was high prevalence of fair/poor health for ≤ 6 h for all sleep measures, but the long-sleep effect was absent for sleep logs and actigraphy measures.

CONCLUSIONS

Associations between long sleep and poor health may be specific to studies measuring sleep with survey questions. As cohorts with actigraphy mature, our understanding of how sleep affects health may change.

Predicting the EQ-5D-3L Preference Index from the SF-12 Health Survey in a National US Sample: A Finite Mixture Approach

BACKGROUND

. When data on preferences are not available, analysts rely on condition-specific or generic measures of health status like the SF-12 for predicting or mapping preferences. Such prediction is challenging because of the characteristics of preference data, which are bounded, have multiple modes, and have a large proportion of observations clustered at values of 1.

METHODS

. We developed a finite mixture model for cross-sectional data that maps the SF-12 to the EQ-5D-3L preference index. Our model characterizes the observed EQ-5D-3L index as a mixture of 3 distributions: a degenerate distribution with mass at values indicating perfect health and 2 censored (Tobit) normal distributions. Using estimation and validation samples derived from the Medical Expenditure Panel Survey 2000 dataset, we compared the prediction performance of these mixture models to that of 2 previously proposed methods: ordinary least squares regression (OLS) and two-part models.

RESULTS

. Finite mixture models in which predictions are based on classification outperform two-part models and OLS regression based on mean absolute error, with substantial improvement for samples with fewer respondents in good health. The potential for misclassification is reflected on larger root mean square errors. Moreover, mixture models underperform around the center of the observed distribution.

CONCLUSIONS

. Finite mixtures offer a flexible modeling approach that can take into account idiosyncratic characteristics of the distribution of preferences. The use of mixture models allows researchers to obtain estimates of health utilities when only summary scores from the SF-12 and a limited number of demographic characteristics are available. Mixture models are particularly useful when the target sample does not have a large proportion of individuals in good health.

Assessment of sleep in the National Social Life, Health, and Aging Project

OBJECTIVES

The relationship of sleep to health has been an active area of research in recent years, and the National Social Life, Health, and Aging Project (NSHAP) expanded sleep data collection in Wave 2 with enhanced core questions and a novel sleep module that included an objective measure of sleep duration and quality.

METHOD

A randomly selected one-third of Wave 2 participants and their spouses or coresident partners were invited to participate in the sleep module. Objective sleep data were collected using wrist actigraphy, an accelerometer that records an integrated measure of motion over short epochs (15 s each). This information is stored and subsequently analyzed to determine sleep and wake periods by epoch. Individuals were instructed to wear the actiwatches for 72 hr. Several sleep parameters were derived from the accelerometer. Individuals concurrently kept a sleep diary.

RESULTS

Sleep actigraphy data were successfully collected from 780 individuals. Many of the survey-based and the actigraph-estimated sleep parameters varied by age and gender. However, age and gender patterns often differed for sleep characteristics that were both asked and measured, such as sleep duration.

DISCUSSION

The survey and actigraphy data provide different information about sleep characteristics. The opportunity to examine actigraph-estimated sleep characteristics in a nationally representative sample of older adults allows novel analyses of the associations of sleep parameters with social and health data.

Insomnia symptoms and actigraph-estimated sleep characteristics in a nationally representative sample of older adults

BACKGROUND

Reports of insomnia symptoms are common among the elderly. However, little is known about the relationship between insomnia symptoms and objective assessments of sleep in the general population of older adults. We assessed concordance between insomnia symptoms and actigraphic sleep characteristics in a nationally representative sample of older Americans.

METHODS

In a national probability sample of 727 adults aged 62-91 years in 2010-2011 from the National Social Life, Health, and Aging Project, respondents were asked how often they (a) feel rested when they wake up, (b) have trouble falling asleep, (c) have trouble with waking up during the night, and (d) have trouble waking up too early and not being able to fall asleep again. Responses to these questions were compared to sleep characteristics estimated from three nights of actigraphy for the same individuals. Statistical analyses were adjusted for age, gender, race and ethnicity, income, assets, and education.

RESULTS

Feeling rested (Question (a), above) was not correlated with any actigraphy-estimated sleep characteristics. Questions (b)-(d) each had several significant correlations with the actigraphy metrics, but generally not with the specific objective sleep characteristics that each question intended to reference. In some cases, the associations were not in the expected direction.

CONCLUSIONS

Although three of four questions about insomnia symptoms were significantly associated with objectively estimated sleep characteristics, responses seem to be general indicators of sleep quality rather than reports of specific sleep characteristics.

Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial

BACKGROUND AND PURPOSE

Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST) was a randomized pilot study to obtain information necessary to design a Phase III trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction.

METHODS

All patients with stroke were screened for eligibility (age 18-75 years, National Institutes of Health Stroke Scale≥18 with Item 1a<2 [responsive to minor stimulation], and CT demonstrating unilateral, complete middle cerebral artery territory infarction by specific imaging criteria). All enrolled patients were treated using a standardized medical treatment protocol. Those with both≥4 mm of pineal shift and deterioration in level of arousal or ≥7.5 mm of anteroseptal shift within 96 hours of stroke onset were randomized to continued medical treatment only or medical treatment plus surgery. Death at 21 days was the primary outcome measure.

RESULTS

Among 4909 screened patients, only 66 (1.3%) patients were eligible for HeADDFIRST. Forty patients were enrolled, and 26 patients developed the requisite brain swelling for randomization. All who failed to meet randomization criteria were alive at 21 days. Mortality at 21 and 180 days was 40% (4/10) in the medical treatment only and 21% (3/14) and 36% (5/14) in the medical treatment plus surgery arms, respectively.

CONCLUSIONS

HeADDFIRST randomization criteria effectively distinguished low from high risk of death from large supratentorial cerebral hemispheric infarction. Lower mortality in the medical treatment only group than in other published trials suggests a possible benefit to standardizing medical management. These results can inform the interpretation of recently completed European trials concerning patient selection and medical management.

CLINICAL TRIAL REGISTRATION

This trial was not registered because enrollment began before July 1, 2005.

Sleep duration and all-cause mortality: a critical review of measurement and associations

PURPOSE

Variation in sleep duration has been linked with mortality risk. The purpose of this review is to provide an updated evaluation of the literature on sleep duration and mortality, including a critical examination of sleep duration measurement and an examination of correlates of self-reported sleep duration.

METHODS

We conducted a systematic search of studies reporting associations between sleep duration and all-cause mortality and extracted the sleep duration measure and the measure(s) of association.

RESULTS

We identified 42 prospective studies of sleep duration and mortality drawing on 35 distinct study populations worldwide. Unlike previous reviews, we find that the published literature does not support a consistent finding of an association between self-reported sleep duration and mortality. Most studies have employed survey measures of sleep duration, which are not highly correlated with estimates based on physiologic measures.

CONCLUSIONS

Despite a large body of literature, it is premature to conclude, as previous reviews have, that a robust, U-shaped association between sleep duration and mortality risk exists across populations. Careful attention must be paid to measurement, response bias, confounding, and reverse causation in the interpretation of associations between sleep duration and mortality.

QTc prolongation is associated with impaired right ventricular function and predicts mortality in pulmonary hypertension

BACKGROUND

In rodent models of pulmonary hypertension (PH) and right ventricular hypertrophy (RVH), the QTc interval is prolonged, reflecting downregulation of repolarizing Kv channels in RV myocytes. The significance of QTc prolongation in human PH is unknown. We hypothesized that QTc prolongation occurs in human PH, is associated with RVH and decreased RV function, and predicts adverse prognosis.

METHODS

Patients receiving a PAH-specific therapy (a prostanoid, endothelin-receptor antagonist and/or a phosphodiesterase-5 inhibitor), who had a 12-lead electrocardiogram (ECG) (n=202) were compared to age- and sex-matched controls (n=100). The duration of QTc on ECG was correlated with invasive hemodynamics (n=156) and with the status of the RV, as measured by Brain Natriuretic Peptide (NT-proBNP, n=145) and magnetic resonance imaging (n=24). Survival of the entire PH cohort and a subgroup with WHO Groups 1 and 4 PAH was prospectively determined from the Social Security Death Index.

RESULTS

QTc intervals were longer in PH vs. controls (454.8 ± 29 ms vs. 429.8 ± 18 ms, p<0.001) and did not differ based on PAH-specific therapy. NT-proBNP increased proportionately with QTc and was higher for those in the upper quintile (QTc ≥ 480 ms) vs. those with QTc<480 ms (4004 ± 6682 pg/mL vs. 1501 ± 1822 pg/mL, p<0.001). The QTc interval also correlated directly with increasing RV end-diastolic volume (r=.67, p<0.001) and mass (r=.0.51, p<0.05), and inversely with RV ejection fraction (r=-.49, p<0.05). In the entire PH cohort and WHO Groups 1 and 4 subgroup, QTc ≥ 480 ms and cardiac index were independent predictors of mortality.

CONCLUSIONS

QTc prolongation in PH patients reflects the status of the RV and is an independent predictor of mortality.

A marginal structural model analysis for loneliness: implications for intervention trials and clinical practice

OBJECTIVE

Clinical scientists, policymakers, and individuals must make decisions concerning effective interventions that address health-related issues. We use longitudinal data on loneliness and depressive symptoms and a new class of causal models to illustrate how empirical evidence can be used to inform intervention trial design and clinical practice.

METHOD

Data were obtained from a population-based study of non-Hispanic Caucasians, African Americans, and Latino Americans (N = 229) born between 1935 and 1952. Loneliness and depressive symptoms were measured with the UCLA Loneliness Scale-Revised and Center for Epidemiologic Studies Depression Scale, respectively. Marginal structural causal models were employed to evaluate the extent to which depressive symptoms depend not only on loneliness measured at a single point in time (as in prior studies of the effect of loneliness) but also on an individual's entire loneliness history.

RESULTS

Our results indicate that if interventions to reduce loneliness by 1 standard deviation were made 1 and 2 years prior to assessing depressive symptoms, both would have an effect; together, they would result in an average reduction in depressive symptoms of 0.33 standard deviations, 95% CI [0.21, 0.44], p < .0001.

CONCLUSIONS

The magnitude and persistence of these effects suggest that greater effort should be devoted to developing practical interventions on alleviating loneliness and that doing so could be useful in the treatment and prevention of depressive symptoms. In light of the persistence of the effects of loneliness, our results also suggest that, in the evaluation of interventions on loneliness, it may be important to allow for a considerable follow-up period in assessing outcomes.

Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect

OBJECTIVE

To evaluate dextromethorphan combined with ultra low-dose quinidine (DMq) for treating pseudobulbar affect (PBA) in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS).

METHODS

In a 12-week randomized, double-blind trial, ALS and MS patients with clinically significant PBA (a baseline score ≥13 on the Center for Neurologic Studies-Lability Scale [CNS-LS]) were maintained, twice daily, on placebo, DMq at 30/10mg (DMq-30), or DMq at 20/10mg (DMq-20).

RESULTS

In 326 randomized patients (of whom 283, or 86.8%, completed the study), the PBA-episode daily rate was 46.9% (p < 0.0001) lower for DMq-30 than for placebo and 49.0% (p < 0.0001) lower for DMq-20 than for placebo by longitudinal negative binomial regression, the prespecified primary analysis. Mean CNS-LS scores decreased by 8.2 points for DMq-30 and 8.2 for DMq-20, vs 5.7 for placebo (p= 0.0002 and p= 0.0113, respectively). Other endpoints showing statistically significant DMq benefit included, for both dosage levels, the likelihood of PBA remission during the final 14 days and, for the higher dosage, improvement on measures of social functioning and mental health. Both dosages were safe and well tolerated.

INTERPRETATION

DMq markedly reduced PBA frequency and severity, decreasing the condition's detrimental impact on a patient's life, with satisfactory safety and high tolerability. The findings expand the clinical evidence that DMq may be an important treatment for patients suffering from the socially debilitating symptoms of PBA.

Perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study

We present evidence from a 5-year longitudinal study for the prospective associations between loneliness and depressive symptoms in a population-based, ethnically diverse sample of 229 men and women who were 50-68 years old at study onset. Cross-lagged panel models were used in which the criterion variables were loneliness and depressive symptoms, considered simultaneously. We used variations on this model to evaluate the possible effects of gender, ethnicity, education, physical functioning, medications, social network size, neuroticism, stressful life events, perceived stress, and social support on the observed associations between loneliness and depressive symptoms. Cross-lagged analyses indicated that loneliness predicted subsequent changes in depressive symptomatology, but not vice versa, and that this temporal association was not attributable to demographic variables, objective social isolation, dispositional negativity, stress, or social support. The importance of distinguishing between loneliness and depressive symptoms and the implications for loneliness and depressive symptomatology in older adults are discussed.

Heart Rate Response to Exercise Stress Testing in Asymptomatic Women

Background— The definition of a normal heart rate (HR) response to exercise stress testing in women is poorly understood, given that most studies describing a normative response were predominately based on male data. Measures of an attenuated HR response (chronotropic incompetence) and age-predicted HR have not been validated in asymptomatic women. We investigated the association between HR response to exercise testing and age with prognosis in 5437 asymptomatic women.

Methods and Results— Participants underwent a symptom-limited maximal stress test in 1992. HR reserve (change in HR from rest to peak), chronotropic index, and age-predicted peak HR were calculated. Deaths were identified to December 31, 2008. Mean age at baseline was 52±11 years, with 549 deaths (10%) over 15.9±2.2 years. Mean peak HR was inversely associated with age; mean peak HR=206–0.88(age). After adjusting for exercise capacity and traditional cardiac risk factors, risk of death was reduced by 3% for every 1–beat-per-minute increase in peak HR, and by 2% for every 1–beat-per-minute increase in HR reserve ( P <0.001). Inability to achieve 85% age-predicted HR was not an independent predictor of mortality, but being ≥1 SD below the mean predicted HR or a chronotropic index <0.80 based on the prediction model established by this cohort were independent predictors of mortality ( P <0.001 and P =0.023, respectively).

Conclusions— Chronotropic incompetence is associated with an increased risk of death in asymptomatic women; however, the traditional male-based calculation overestimates the maximum HR for age in women. Sex-specific parameters of physiological HR response to exercise should be incorporated into clinical practice.

Loneliness predicts increased blood pressure: 5-year cross-lagged analyses in middle-aged and older adults

Loneliness is a prevalent social problem with serious physiological and health implications. However, much of the research to date is based on cross-sectional data, including our own earlier finding that loneliness was associated with elevated blood pressure (Hawkley, Masi, Berry & Cacioppo, 2006). In this study, we tested the hypothesis that the effect of loneliness accumulates to produce greater increases in systolic blood pressure (SBP) over a 4-year period than are observed in less lonely individuals. A population-based sample of 229 50- to 68-year-old White, Black, and Hispanic men and women in the Chicago Health, Aging, and Social Relations Study was tested annually for each of 5 consecutive years. Cross-lagged panel analyses revealed that loneliness at study onset predicted increases in SBP 2, 3, and 4 years later (B = 0.152, SE = 0.091, p < .05, one-tailed). These increases were cumulative such that higher initial levels of loneliness were associated with greater increases in SBP over a 4-year period. The effect of loneliness on SBP was independent of age, gender, race or ethnicity, cardiovascular risk factors, medications, health conditions, and the effects of depressive symptoms, social support, perceived stress, and hostility.

Loneliness predicts reduced physical activity: cross-sectional & longitudinal analyses

OBJECTIVE

To determine cross-sectional and prospective associations between loneliness and physical activity, and to evaluate the roles of social control and emotion regulation as mediators of these associations.

DESIGN

A population-based sample of 229 White, Black, and Hispanic men and women, age 50 to 68 years at study onset, were tested annually for each of 3 years.

MAIN OUTCOME MEASURES

Physical activity probability, and changes in physical activity probability over a 3-year period.

RESULTS

Replicating and extending prior cross-sectional research, loneliness was associated with a significantly reduced odds of physical activity (OR = 0.65 per SD of loneliness) net of sociodemographic variables (age, gender, ethnicity, education, income), psychosocial variables (depressive symptoms, perceived stress, hostility, social support), and self-rated health. This association was mediated by hedonic emotion regulation, but not by social control as indexed by measures of social network size, marital status, contact with close ties, group membership, or religious group affiliation. Longitudinal analyses revealed that loneliness predicted diminished odds of physical activity in the next two years (OR = 0.61), and greater likelihood of transitioning from physical activity to inactivity (OR = 1.58).

CONCLUSION

Loneliness among middle and older age adults is an independent risk factor for physical inactivity and increases the likelihood that physical activity will be discontinued over time.

From social structural factors to perceptions of relationship quality and loneliness: the Chicago health, aging, and social relations study

OBJECTIVE

The objective of this study was to test a conceptual model of loneliness in which social structural factors are posited to operate through proximal factors to influence perceptions of relationship quality and loneliness.

METHODS

We used a population-based sample of 225 White, Black, and Hispanic men and women aged 50 through 68 from the Chicago Health, Aging, and Social Relations Study to examine the extent to which associations between sociodemographic factors and loneliness were explained by socioeconomic status, physical health, social roles, stress exposure, and, ultimately, by network size and subjective relationship quality.

RESULT

Education and income were negatively associated with loneliness and explained racial/ethnic differences in loneliness. Being married largely explained the association between income and loneliness, with positive marital relationships offering the greatest degree of protection against loneliness. Independent risk factors for loneliness included male gender, physical health symptoms, chronic work and/or social stress, small social network, lack of a spousal confidant, and poor-quality social relationships.

DISCUSSION

Longitudinal research is needed to evaluate the causal role of social structural and proximal factors in explaining changes in loneliness.

VLDL best predicts aortic root atherosclerosis in LDL receptor deficient mice

Hyperlipidemia is a major risk factor for developing atherosclerosis in humans, and epidemiological studies have correlated specific lipoprotein levels with cardiovascular disease risk. Murine models of atherosclerosis rely on the induction of hyperlipidemia for vascular lesions to form, but the pathogenic contributions attributed to different lipoprotein populations are not well defined. To address this issue, we analyzed over 300 LDL receptor (LDLR) deficient mice that have been fed a high-fat diet and for which a full lipoprotein profile and aortic root atherosclerosis values were assessed. Overall, aortic root atherosclerosis is best predicted by plasma VLDL cholesterol levels with less predictive value derived from either LDL or HDL cholesterol. Triglyceride levels are more atherogenic in female mice, especially immune competent females, and depletion of the adaptive immune system leads to a global reduction in plasma lipid levels and aortic root lesion size yet does not appear to alter the atherogenic potential of individual lipoprotein subspecies. In contrast, HDL-cholesterol is a better predictor of aortic root atherosclerosis in apoE-deficient mice. In summary, this large scale analysis of high-fat diet fed LDLR deficient mice highlight the relationship between different plasma lipid components, especially VLDL-cholesterol, and aortic root atherosclerosis.

Dextromethorphan and quinidine in adult patients with uncontrolled painful diabetic peripheral neuropathy: a 29-day, multicenter, open-label, dose-escalation study

BACKGROUND

Pain associated with diabetic peripheral neuropathy (DPN) has a substantial negative impact on patients' quality of life.

OBJECTIVES

The primary objective of this study was to evaluate the tolerability of capsules containing dextromethorphan (DM) and quinidine (Q) in patients with painful DPN. A secondary objective was to perform a preliminary assessment of the efficacy of DM/Q in this patient population.

METHODS

This was a multicenter, open-label, dose-escalation study. Eligible patients were aged between 18 and 80 years, had a confirmed diagnosis of diabetes with acceptable glycemic control, had been receiving established diabetic therapy for at least 3 months, and had a clinical diagnosis of distal symmetric sensory neuropathy with daily DPN-associated pain for the previous 3 months. On study entry, patient-rated diabetic pain had to be moderate or greater. Patients who met the inclusion criteria underwent a 2-week washout period during which all analgesics were discontinued, followed by 29 days of treatment with capsules containing DM 30 mg and Q 30 mg (DM30/Q30), beginning with 1 capsule/d and escalating at approximately 1-week intervals, as tolerated, to a maximum dose of 4 capsules/d (DM120/Q120). Tolerability was assessed based on adverse events and changes in clinical and laboratory parameters and nerve conduction velocity. Preliminary efficacy assessments included changes from baseline in scores on the pain intensity rating scale (PIRS), pain relief rating scale (PRRS), peripheral neuropathy quality-of-life instrument, and patients' diary assessments of sleep, present pain intensity, pain, and activity.

RESULTS

The study included 36 men and women (mean age, 58 years; mean body mass index, 32.8 kg/m(2)). Of the 33 subjects who completed the study, 23 (69.7%) did so at the highest permitted dose (DM120/Q120). The most commonly reported adverse events (occurring in > or =5% of subjects) were nausea (27.8%), dizziness (25.0%), and headache (25.0%). Three patients experienced 5 serious adverse events, only 1 of which was considered possibly related to study drug. The most commonly occurring laboratory abnormalities (involving glycosylated hemoglobin, serum glucose, triglycerides, and cholesterol) were considered typical of a population with diabetes. Improvements from baseline in scores on the PIRS, PRRS, and other exploratory efficacy measures were noted (P < 0.001).

CONCLUSIONS

The results of this open-label study indicated that the combination of DMIQ (dose range, DM30/Q30-DM120/Q120) was well tolerated in patients with pain associated with DPN. Based on the preliminary efficacy results, a randomized, controlled, double-blind trial is warranted to assess the tolerability and efficacy of this combination in patients with DPN.

Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses

The extent to which loneliness is a unique risk factor for depressive symptoms was determined in 2 population-based studies of middle-aged to older adults, and the possible causal influences between loneliness and depressive symptoms were examined longitudinally in the 2nd study. In Study 1, a nationally representative sample of persons aged 54 and older completed a telephone interview as part of a study of health and aging. Higher levels of loneliness were associated with more depressive symptoms, net of the effects of age, gender, ethnicity, education, income, marital status, social support, and perceived stress. In Study 2, detailed measures of loneliness, social support, perceived stress, hostility, and demographic characteristics were collected over a 3-year period from a population-based sample of adults ages 50-67 years from Cook County, Illinois. Loneliness was again associated with more depressive symptoms, net of demographic covariates, marital status, social support, hostility, and perceived stress. Latent variable growth models revealed reciprocal influences over time between loneliness and depressive symptomatology. These data suggest that loneliness and depressive symptomatology can act in a synergistic effect to diminish well-being in middle-aged and older adults.

Randomized, controlled trial of dextromethorphan/quinidine for pseudobulbar affect in multiple sclerosis

OBJECTIVE

To evaluate the efficacy and safety of DM/Q (capsules containing dextromethorphan [DM] and quinidine [Q]) compared with placebo, taken twice daily, for the treatment of pseudobulbar affect over a 12-week period in multiple sclerosis patients.

METHODS

A total of 150 patients were randomized in a double-blind, placebo-controlled study to assess pseudobulbar affect with the validated Center for Neurologic Study-Lability Scale. Each patient also recorded the number of episodes experienced between visits, estimated quality of life and quality of relationships on visual analog scales, and completed a pain rating scale.

RESULTS

Patients receiving DM/Q had greater reductions in Center for Neurologic Study-Lability Scale scores than those receiving placebo (p < 0.0001) at all clinic visits (days 15, 29, 57, and 85). All secondary end points also favored DM/Q, including the number of crying or laughing episodes (p <or= 0.0077), quality of life (p < 0.0001), quality of relationships (p = 0.0001), and pain intensity score (p = 0.0271). DM/Q was well tolerated; only dizziness occurred with greater frequency than with placebo.

INTERPRETATION

Results in multiple sclerosis patients were similar to those of a previous study in amyotrophic lateral sclerosis, demonstrating that DM/Q may be beneficial in treating potentially disabling pseudobulbar affect in a variety of neurological disorders.

The prognostic value of a nomogram for exercise capacity in women

BACKGROUND

Recent studies have demonstrated that exercise capacity is an independent predictor of mortality in women. Normative values of exercise capacity for age in women have not been well established. Our objectives were to construct a nomogram to permit determination of predicted exercise capacity for age in women and to assess the predictive value of the nomogram with respect to survival.

METHODS

A total of 5721 asymptomatic women underwent a symptom-limited, maximal stress test. Exercise capacity was measured in metabolic equivalents (MET). Linear regression was used to estimate the mean MET achieved for age. A nomogram was established to allow the percentage of predicted exercise capacity to be estimated on the basis of age and the exercise capacity achieved. The nomogram was then used to determine the percentage of predicted exercise capacity for both the original cohort and a referral population of 4471 women with cardiovascular symptoms who underwent a symptom-limited stress test. Survival data were obtained for both cohorts, and Cox survival analysis was used to estimate the rates of death from any cause and from cardiac causes in each group.

RESULTS

The linear regression equation for predicted exercise capacity (in MET) on the basis of age in the cohort of asymptomatic women was as follows: predicted MET = 14.7 - (0.13 x age). The risk of death among asymptomatic women whose exercise capacity was less than 85 percent of the predicted value for age was twice that among women whose exercise capacity was at least 85 percent of the age-predicted value (P<0.001). Results were similar in the cohort of symptomatic women.

CONCLUSIONS

We have established a nomogram for predicted exercise capacity on the basis of age that is predictive of survival among both asymptomatic and symptomatic women. These findings could be incorporated into the interpretation of exercise stress tests, providing additional prognostic information for risk stratification.

Prognostic value of the duke treadmill score in asymptomatic women

The Duke Treadmill Score (DTS) has been shown to predict mortality in women who have symptomatic heart disease, but its ability to do so in asymptomatic women is unknown, as is its comparative advantage to exercise capacity. We investigated whether a decreased DTS is associated with increased mortality in a prospective cohort of 5,636 asymptomatic women. A symptom-limited exercise treadmill test using Bruce's protocol was performed at baseline. DTS was calculated using exercise time, exercise-induced angina, and ST-segment depression. Exercise capacity was measured in METs. Deaths and cause of death were identified from 1992 to 2000. After adjusting for the Framingham Risk Score, the risk of death decreased by 9% for each unit increase in DTS and by 17% for every 1-MET increase (p <0.001). Those who had a DTS <5 (moderate or high risk) had hazard ratios for death and cardiac death that were 2.2 and 2.5 times greater, respectively, than did those who had a DTS > or =5 (low risk), after adjusting for Framingham Risk Score (p <0.001). Receiver-operating characteristic curves for the DTS model and the exercise capacity model were not significantly different. In conclusion, we have demonstrated that, although the DTS is an independent predictor of mortality and cardiac mortality in asymptomatic women, it does not appear to be a better predictor than exercise capacity alone. The role of ST-segment changes and symptoms with stress testing in asymptomatic women does not provide additional prognostic information.

Distinct temporal phases in the behavioral pharmacology of LSD: dopamine D2 receptor-mediated effects in the rat and implications for psychosis

RATIONALE

The effect of LSD in humans has been described as occurring in two temporal phases. The behavioral effects in rats also occur in two temporal phases: an initial suppression of exploration followed by increased locomotor activity.

OBJECTIVES

We decided to investigate this phenomenon from the perspective that the pharmacology might have relevance to the neurochemical mechanisms underlying psychosis.

METHODS

Twenty-five male Sprague-Dawley rats were trained to discriminate LSD (186 nmol/kg, 0.08 mg/kg, i.p.) with a 30-min preinjection time (LSD-30, N=12) and LSD (372 nmol/kg, 0.16 mg/kg, i.p.) with a 90-min preinjection time (LSD-90, N=13) from saline, using a two-lever, food-reinforced operant conditioning task.

RESULTS

LSD (186 or 372 nmol/kg, 0.08 or 0.16 mg/kg) given 30 min prior to training produced a cue that was completely antagonized by 5-HT2A antagonists and lasted no longer than 1 h. LSD (372 nmol/kg, 0.16 mg/kg) injected 90 min before training produced a cue that was not fully blocked by 5-HT2A antagonists, but instead was significantly inhibited by haloperidol. In these rats, substitution no longer occurred with the 5-HT2 agonists DOI or LSD (30 min preinjection), but full substitution was obtained with the D2 agonists apomorphine, N-propyldihydrexidine, and quinelorane.

CONCLUSION

The discriminative stimulus effect of LSD in rats occurs in two phases, and these studies provide evidence that the later temporal phase is mediated by D2 dopamine receptor stimulation. A second temporal phase that involves dopaminergic pathways would be consistent with the widespread belief that excessive dopaminergic activity may be an underlying cause of paranoid psychosis.

Not all patients want to participate in decision making. A national study of public preferences

BACKGROUND

The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.

OBJECTIVES

1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.

DESIGN AND PARTICIPANTS

A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.

MAIN RESULTS

Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.

CONCLUSION

This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

Not all patients want to participate in decision making. A national study of public preferences

BACKGROUND

The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.

OBJECTIVES

1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.

DESIGN AND PARTICIPANTS

A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.

MAIN RESULTS

Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.

CONCLUSION

This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

The effect of physician disclosure of financial incentives on trust

BACKGROUND

Many physicians receive financial incentives to limit their ordering of expensive tests and procedures. While Medicare mandates disclosure of incentives, it is not clear how to inform patients without undermining trust.

METHODS

Our objective was to determine public opinion about physician disclosure of financial incentives and how this might be best communicated to patients. The 2002 General Social Survey included 2765 interviews from a probability sample of English-speaking US households. The interview included questions about financial incentives and an audiotaped scenario of a physician discussing the impact of financial incentives on ordering a magnetic resonance image. Respondents heard 1 of 6 randomly selected disclosure strategies. The measurements included ratings of trust, satisfaction, agreement with the physician's decision, and likelihood of remaining with the physician/health plan or seeking a second opinion.

RESULTS

Nearly half (48.8%) of respondents had previously heard of financial incentives to limit test ordering. Of the respondents, 94.8% wanted to be told about incentives, at the time of enrollment in a health plan (80.5%), by a health plan representative (44.8%), their physician (17.1%), or both (38.1%). Of the 6 different disclosure strategies, "addressing emotions" and "negotiation" were associated with the best outcomes, while "common enemy" and "denying influences" were most negatively perceived. Black and Hispanic subjects were less likely to express satisfaction or trust and more likely to disenroll or seek a second opinion.

CONCLUSIONS

The public wants information about physician financial incentives. Specific communication styles enhance how this information is conveyed to patients, increasing trust and supporting the physician-patient relationship.

Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: A randomized trial

BACKGROUND

Patients with ALS commonly exhibit pseudobulbar affect.

METHODS

The authors conducted a multicenter, randomized, double-blind, controlled, parallel, three-arm study to test a defined combination of dextromethorphan hydrobromide (DM) and quinidine sulfate (Q) (AVP-923) for the treatment of pseudobulbar affect in ALS. Q inhibits the rapid first-pass metabolism of DM. The effects of AVP-923 (30 mg of DM plus 30 mg of Q) given twice daily for 28 days were compared with those of its components. Patients were evaluated on days 1, 15, and 29. The primary efficacy variable was the change from baseline in the Center for Neurologic Study Lability Scale (CNS-LS) score. Secondary efficacy variables were laughing/crying episode rates and changes in Visual Analog Scales for Quality of Life (QOL) and Relationships (QOR). Efficacy was evaluated in intention-to-treat subjects who were not poor metabolizers of DM (n = 65 for AVP-923, n = 30 for DM, and n = 34 for Q). Safety was assessed in all randomized subjects (n = 140).

RESULTS

AVP-923 patients experienced 3.3-point greater improvements in CNS-LS than DM patients (p = 0.001) and 3.7-point greater improvements than Q patients (p < 0.001). AVP-923 patients exhibited lower overall episode rates, improved QOL scores, and improved QOR scores (p < 0.01 for all endpoints). Adverse effects were mostly mild or moderate; treatment-related discontinuation was 24% for AVP-923, 6% for DM, and 8% for Q.

CONCLUSIONS

AVP-923 palliates pseudobulbar affect in ALS. Overall benefits of treatment are reflected in fewer episodes of crying and laughing and improvements in overall quality of life and quality of relationships.

Postoperative maintenance of Crohn's disease remission with 6-mercaptopurine, mesalamine, or placebo: a 2-year trial

BACKGROUND & AIMS

No therapy has been shown to reliably prevent the evolution of postoperative recurrence of Crohn's disease. The aim of the current trial was to compare 6-mercaptopurine (6-MP) and mesalamine with placebo for the prevention of clinical, endoscopic, and radiographic recurrence of Crohn's disease after resection and ileocolic anastomosis.

METHODS

Five centers randomized 131 patients to receive 6-MP (50 mg), mesalamine (3 g), or placebo daily in a double-blind, double-dummy trial. Patients had clinical assessments at 7 weeks and then every 3 months; colonoscopy at 6, 12, and 24 months; and small bowel series at 12 and 24 months. End points were clinical, endoscopic, and radiographic recurrence rates at 24 months.

RESULTS

Clinical recurrence rates (intent to treat) by life-table analysis at 24 months were 50% (95% confidence interval [CI], 34%-68%), 58% (95% CI, 41%-75%), and 77% (95% CI, 61%-91%) in patients receiving 6-MP, mesalamine, and placebo, respectively. Endoscopic recurrence rates were 43% (95% CI, 28%-63%), 63% (95% CI, 47%-79%), and 64% (95% CI, 46%-81%), and radiographic recurrence rates were 33% (95% CI, 19%-54%), 46% (95% CI, 29%-66%), and 49% (95% CI, 30%-72%), respectively. 6-MP was more effective than placebo ( P < 0.05) at preventing clinical and endoscopic recurrence over 2 years. Patient withdrawals resulted in 69% of the study population evaluable for the clinical recurrence end point.

CONCLUSIONS

6-MP, 50 mg daily, was more effective than placebo at preventing postoperative recurrence of Crohn's disease and should be considered as a maintenance therapy after ileocolic resection.

Causes and consequences of kidney loss in patients with nephrolithiasis

BACKGROUND

It is unknown whether stone formers may safely donate a kidney. Nephrectomy could accelerate stone formation, or loss of filtration with age. We contrast, here, the course of stone patients with two versus one kidney.

METHODS

One hundred fifteen patients with a single functioning kidney were compared with 3151 patients with two kidneys. Cause of kidney loss was determined, along with stone types, rates of stone formation, urine stone risk factors, and creatinine clearance.

RESULTS

Women were 49.6% of the patients with kidney loss, compared to 33.6% of ordinary stone formers. Obstruction, stone burden, and infection were the most common reasons for kidney loss. We found an increased number of struvite and calcium phosphate stones among single kidney patients. Before and during treatment, single kidney patients had fewer stones than ordinary stone formers. Creatinine clearance was lower in the single kidney patients; rate of loss of kidney function with age was higher among single kidney males versus two kidney males if all patients are considered. Among males >age 45 years, the difference disappears. Females with one and two kidneys lost function with age at equivalent rates. Compared with nonstone formers, male stone formers lose kidney function with age at an accelerated rate.

CONCLUSION

Nephrectomy does not worsen stone disease. It may increase loss of renal function among younger males. The pattern of renal function loss with age differs between stone formers and nonstone formers.

Exercise capacity and the risk of death in women: the St James Women Take Heart Project

BACKGROUND

Cardiovascular disease is the leading cause of death among women and accounts for more than half of their deaths. Women have been underrepresented in most studies of cardiovascular disease. Reduced physical fitness has been shown to increase the risk of death in men. Exercise capacity measured by exercise stress test is an objective measure of physical fitness. The hypothesis that reduced exercise capacity is associated with an increased risk of death was investigated in a cohort of 5721 asymptomatic women who underwent baseline examinations in 1992.

METHODS AND RESULTS

Information collected at baseline included medical and family history, demographic characteristics, physical examination, and symptom-limited stress ECG, using the Bruce protocol. Exercise capacity was measured in metabolic equivalents (MET). Nonfasting blood was analyzed at baseline. A National Death Index search was performed to identify all-cause death and date of death up to the end of 2000. The mean age of participants at baseline was 52+/-11 years. Framingham Risk Score-adjusted hazards ratios (with 95% CI) of death associated with MET levels of <5, 5 to 8, and >8 were 3.1 (2.0 to 4.7), 1.9 (1.3 to 2.9), and 1.00, respectively. The Framingham Risk Score-adjusted mortality risk decreased by 17% for every 1-MET increase.

CONCLUSIONS

This is the largest cohort of asymptomatic women studied in this context over the longest period of follow-up. This study confirms that exercise capacity is an independent predictor of death in asymptomatic women, greater than what has been previously established among men. The implications for clinical practice and health care policy are far reaching.

Are there social determinants of health and disease?

The concept of a determinant is tied to the idea of a mechanism for action. Ideas from epidemiology, particularly the epidemiologic triad of agent, host, and environment, can help to make sense of factors that affect the absence of disease or that interfere with a mechanism that alters health. However, assembling convincing evidence for the existence of social determinants of health is a challenge, in part because of the difficulties of bridging the social and biological realms. While social contexts are measured using aggregates of individuals, disease and dysfunction occur at the individual level, leading to difficult problems of ecological inference. Although social factors have been shown to be associated with differences in mortality from specific causes, these factors account for only a small portion of the mortality from any individual cause. This suggests that the pathways through which social factors influence health are affected by their interactions with other factors.

The effects of morphine on human articular cartilage of the knee: an in vitro study

PURPOSE

The purpose of this study was to determine the metabolic, histologic, and ultrastructural effects of morphine and its combination with saline and bupivacaine on human articular cartilage.

TYPE OF STUDY

In vitro study.

METHODS

Nonfibrillated human articular cartilage was harvested and transferred into an experimental culture consisting of a control medium, saline, or a combination of morphine/saline or morphine/saline/bupivacaine for 12, 24, or 72 hours. Each sample was radiolabeled to assess proteoglycan synthesis. Histologic and ultrastructural effects were also examined.

RESULTS

We found a significant, dose-related, transient decrease in 35SO4 incorporation in the morphine/saline samples at 12 hours, and in the saline only samples at 24 hours. We found no evidence of histologic or ultrastructural damage to the cartilage.

CONCLUSIONS

Morphine and saline can both produce a transient decrease in 35SO4 incorporation that normalizes by 72 hours. This study does not suggest any contraindication to the use of intra-articular morphine as a postoperative analgesic.

Bone mineral density and fracture among prevalent kidney stone cases in the Third National Health and Nutrition Examination Survey

Concern that people who form kidney stones may have reduced bone mineral density (BMD) and increased fracture risk has motivated clinical and population-based studies, but findings are inconsistent. In this cross-sectional study, we use the Third National Health and Nutrition Examination Survey (NHANES III) to determine whether a history of kidney stones (n = 793) is associated with lower femoral neck BMD and whether the association is similar for men and women. We further ask whether dietary calcium modifies the association between kidney stone history and BMD and whether there is an association between kidney stone history and prevalent spine or wrist fracture. We find that men with kidney stone history have lower femoral neck BMD than men without kidney stone history after adjusting for age, body mass index (BMI), race/ethnicity, and other potential confounders. The effect of kidney stone history on BMD is weaker for women. Men with kidney stone history also are more likely to report prevalent wrist and spine fractures. Dietary calcium, represented by usual milk consumption, is associated positively with BMD for both men and women and modifies the effect of kidney stone history on BMD for men. For men who form kidney stones, milk consumption is associated more strongly with femoral neck BMD than for men without such a history. The effect modification is such that the difference in BMD between men with and without kidney stone history is observed only at lower levels of milk consumption.

Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial

BACKGROUND

Recurrent herpes simplex labialis (HSL) occurs in 20% to 40% of the US population. Although the disease is self-limiting in persons with a healthy immune response, patients seek treatment because of the discomfort and visibility of a recurrent lesion.

OBJECTIVE

Our purpose was to determine whether docosanol 10% cream (docosanol) is efficacious compared with placebo for the topical treatment of episodes of acute HSL.

METHODS

Two identical double-blind, placebo-controlled studies were conducted at a total of 21 sites. Otherwise healthy adults, with documented histories of HSL, were randomized to receive either docosanol or polyethylene glycol placebo and initiated therapy in the prodrome or erythema stage of an episode. Treatment was administered 5 times daily until healing occurred (ie, the crust fell off spontaneously or there was no longer evidence of an active lesion) with twice-daily visits.

RESULTS

The median time to healing in the 370 docosanol-treated patients was 4.1 days, 18 hours shorter than observed in the 367 placebo-treated patients (P =.008; 95% confidence interval [CI]: 2, 22). The docosanol group also exhibited reduced times from treatment initiation to (1) cessation of pain and all other symptoms (itching, burning, and/or tingling; P =.002; 95% CI: 3, 16.5); (2) complete healing of classic lesions (P =.023; 95% CI: 1, 24.5); and (3) cessation of the ulcer or soft crust stage of classic lesions (P <.001; 95% CI: 8, 25). Aborted episodes were experienced by 40% of the docosanol recipients versus 34% of placebo recipients (P =.109; 95% CI for odds ratio: 0.95, 1.73). Adverse experiences with docosanol were mild and similar to those with placebo.

CONCLUSION

Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

Impact of interpreter services on delivery of health care to limited-English-proficient patients

OBJECTIVE

To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients.

DESIGN

Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records.

SETTING

A large HMO in New England.

PARTICIPANTS

A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N = 327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N = 4,053).

MEASUREMENTS AND MAIN RESULTS

The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs. 0.70; P <.01), prescriptions written (1.76 vs 0.53; P <.01), and prescriptions filled (2.33 vs. 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs. 0.02; P =.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services.

CONCLUSION

Professional interpreter services can increase delivery of health care to limited-English-speaking patients.

Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis

OBJECTIVE

We investigated the disease-specific and metastasis-free survival rates in men with locally advanced (clinical stage T3) prostate cancer who were treated surgically.

METHODS

A retrospective, multi-institutional pooled analysis of the results of surgical treatment in 345 men with clinical stage T3 disease was performed. Survival curves were generated using the Kaplan-Meier method.

RESULTS

Among 298 evaluable patients, pelvic lymphadenectomy alone was performed in 56 men (19%), while 242 men (81%) underwent node dissection and radical prostatectomy. In total, 122 of 298 patients (41%) had nodal metastases and/or seminal vesicle tumor spread. Pathologically organ-confined disease was noted in 27 men (9%). The actuarial 10-year disease-specific and metastasis-free survival rates for all patients managed surgically were 57 and 32%, respectively. For patients with well, moderately and poorly differentiated tumors, cancer-specific survival rates at 10 years were 73, 67 and 29%, respectively.

CONCLUSIONS

A large number of men with clinical stage T3 prostate cancer have advanced disease and are unlikely to achieve improved long-term survival with surgery alone. Although there may be a role for radical prostatectomy in selected patients with low to intermediate grade tumors, such treatment appears unlikely to result in long-term survival in men with high grade disease. A prospective study is necessary to determine the optimal treatment approach in men with locally advanced prostate cancer.

The impact of contralateral breast cancer on the outcome of breast cancer patients treated by mastectomy

PURPOSE

To evaluate the clinical and pathological features of breast cancer patients who develop contralateral breast cancer (CBC) and assess the impact of the second breast cancer on their prognosis.

PATIENTS AND METHODS

This retrospective study includes 2136 women with stage I-III breast cancer treated between 1927 and 1987 at the University of Chicago Hospitals. A total of 132 (6.2%) developed CBC during a median follow-up period of 14.2 years; all of them were treated with mastectomy for both breast cancers. We compare the prognostic characteristics, treatments, and outcomes of patients who developed bilateral breast cancer with those who had only unilateral breast cancer (UBC). We also compare the features of the first and the second tumors among patients with bilateral breast cancer (BBC).

RESULTS

The annual incidence rate for CBC remained constant at an average rate of 0.23%, resulting in a cumulative incidence rate of 6.2%. Patients with BBC were significantly younger than those with UBC (median age, 51 years vs 54 years). No other significant differences were observed between BBC and UBC patients. Among BBC patients, the second cancer was smaller (2.0 cm vs 3.0 cm) and was associated with a lower incidence of axillary node involvement (29% vs 52%). The development of CBC was associated with worse survival (hazard ratio = 1.46 in comparison with patients who did not develop CBC, 95% CI of 1.09-1.95). On multivariate analysis, factors that decreased the disease-specific survival (DSS) in patients with BBC were a higher number of positive lymph nodes of the first and second cancers, a larger size of the second cancer, and a shorter interval between the two primaries.

DISCUSSION

At the time of diagnosis of first breast cancer, BBC patients were significantly younger than UBC patients. The second cancer among the BBC patients was at an earlier stage than the first one; however, no difference was noticed in the pathological feature between the cancer in the UBC patients and the first cancer of BBC patients. There is an indication that the longer the interval between the two cancers, the better the survival of the BBC patients.

A meta-analysis and overview of the literature on treatment options for left-sided ulcerative colitis and ulcerative proctitis

OBJECTIVES

Therapeutic trials in left-sided ulcerative colitis (L-UC) and ulcerative proctitis (UP) have lacked control for medication type, dose, delivery, and duration of therapy.

METHODS

All published therapeutic articles and abstracts in L-UC or UP from 1958-1997 were reviewed. Improvement, remission rates, and adverse events were recorded for all (ALL), placebo-controlled (PC) studies, and for PC studies passing quality assessment (QA) scoring. Meta-analysis was used where appropriate.

RESULTS

Left-sided UC: For active disease, 67 studies (17 PC; 10 QA) were identified. Mesalamine enemas achieved remission in a duration but not a dose response (QA), with higher remission rates than steroid enemas (ALL) and clinical improvement rates superior to oral therapies (QA, ALL). Remission maintenance: 17 (six PC, six QA) studies were identified. Mesalamine therapies had comparable remission rates at 6 months, with a possible dose but not delivery effect. Mesalamine enema dosing intervals between QHS to Q3 days maintained efficacy. Reported adverse events were most common with oral sulfasalazine and dose-independent for mesalamine. Withdrawals from therapy were less than placebo, or < or =3%. Ulcerative proctitis: For active disease, 18 (nine PC, three QA) studies were identified. Mesalamine suppositories achieved clinical improvement and remission in a duration but not dose response, with higher rates of remission than topical steroids (ALL). Remission maintenance: three (three PC, two QA) studies were identified. Remission ranged from 75% to 90% (6 months) and 61-90% (12 months) for mesalamine agents. Reported adverse events were most common for mesalamine foam (8%). Withdrawals from therapy were <2%.

CONCLUSIONS

In L-UC and UP, the efficacy and side-effect profile of topical mesalamine are dose independent and superior to oral therapies and topical steroids. Economic analysis suggests that use of these agents will also result in an overall decrease in patient costs.

New scoring system identifies kidney outcome with radiation therapy in acute renal allograft rejection

PURPOSE

To evaluate the role of radiation therapy for acute refractory renal rejection after failure of medical intervention, and to identify risk factors that influence graft survival following radiation therapy.

METHODS

Between June 1989 and December 1995, 53 renal transplant recipients (34 men and 19 women) were treated with localized radiation therapy for acute renal allograft rejection. Graft rejection was defined as an increase in serum creatinine with histologic evidence of rejection on renal biopsy. Ninety-one percent were cadaveric transplant recipients. The majority of patients who experienced acute graft rejection initially received corticosteroid therapy, except for 25% who were referred for radiation therapy and steroids for the first rejection. In more recent years, patients with moderate or severe steroid-resistant or recurrent rejection received OKT3, a polyclonal antilymphocyte antibody (ATGAM), tacrolimus (FK506), or mycophenolate mofetil (MMF). Patients who failed to respond to medical treatment were then referred for radiation therapy. Ultrasound was performed for kidney localization. Treatment consisted of a dose of 600 cGy given in 3 or 4 fractions using 6 MV photons, delivered AP or AP/PA.

RESULTS

The overall actuarial graft survival from the initiation of RT was 83% at 1 month, 60% at 1 year, and 36% at 5 years. The median follow-up from the date of transplant to the last follow-up was 22 months. The median time from the date of transplant to the initiation of radiotherapy was 3 months, and the median time from the initiation of radiotherapy to the last follow-up was 10 months. Variables evaluated were as follows: human leukocyte antigen matching on HLA-A, HLA-B, and HLA-DR, the transplant panel-reactive antibodies (PRA) at transplantation, number of acute rejection episodes, interval from the date of the transplant to the first rejection, serum creatinine levels at the time of the first radiation treatment, number of transplants, and concomitant immunosuppressive therapy. Independent factors examined by Cox regression modeling were: gender (p = 0.005), creatinine levels (p = 0.000), HLA-DR (p70% (p = 0.014). Each factor was scored using integral coefficients to generate four different groups. The Kaplan-Meier survival analyzed by group produces an interpretable separation of the risk factors for graft loss.

CONCLUSIONS

The outcome in patients treated with radiation therapy for acute renal graft rejection can be predicted by a novel scoring system. Patients with scores of three or less are able to achieve 100% renal graft salvage, while patients who have scores of 12 or higher are not able to be salvaged with the current radiation therapy regimen. Future studies should be directed toward identifying more effective treatment for patients who have a high score based on our criteria. The scoring system should be utilized to identify patients at risk who could benefit from radiation therapy. Further study with a randomized trial utilizing this scoring system is needed to confirm the validity of the scoring system in predicting graft survival and the efficacy of radiation in patients who receive radiation therapy for acute graft rejection.

Clinical trials in general surgical journals: are methods better reported?

BACKGROUND

Reports of clinical trials often lack adequate descriptions of their design and analysis. Thus readers cannot properly assess the strength of the findings and are limited in their ability to draw their own conclusions. A review of 6 surgical journals in 1984 revealed that the frequency of reporting 11 basic elements of design and analysis in clinical trials was only 59%. This study attempted to identify areas that still need improvement.

METHODS

Eligible studies published from July 1995 through June 1996 included all reports of comparative clinical trials on human subjects that were prospective and had at least 2 treatment arms. A total of 68 articles published in 6 general surgery journals were reviewed. The frequency that the previously identified 11 basic elements of design and analysis were reported was determined.

RESULTS

Seventy-four percent of all items were reported accurately (a 15% increase from the previous study), 4% were reported ambiguously, and 23% were not reported; improvement was seen in every journal. The reporting of eligibility criteria and statistical power improved the most. For 3 items, reporting was still not adequate; 32% of reports provided information about statistical power, 40% about the method of randomization, and 49% about whether the person assessing outcomes was blind to the treatment assignment.

CONCLUSIONS

Improvements have been made in reporting surgical clinical trials, but in general methodologic questions poorly answered in the 1980s continue to be answered poorly in the 1990s. Editors of surgical journals are urged to provide authors with guidelines on how to report clinical trial design and analysis.

Is geographic variation in hip fracture rates related to current or former region of residence?

This study examines geographic variation in male and female age-adjusted hip fracture rates in white elderly Medicare enrollees. We assembled a cohort of more than 2 million 1992 enrollees and followed them passively through record linkage for 2 years for a hospitalization containing a diagnostic code indicating hip fracture. We simultaneously estimated rate ratios by region of residence early (inferred from the Social Security number) and late in life. Residence region early in life is associated with substantial variation in hip fracture rates. Conversely, current region has little relation with hip fracture risk.

SPECT brain imaging in epilepsy: a meta-analysis

A meta-analysis of SPECT brain imaging in epilepsy was performed to derive the sensitivity and specificity of interictal, postictal or ictal rCBF patterns to identify a seizure focus in medically refractory patients.

METHODS

Papers were obtained by pooling all published articles identified by two independent literature searches: (a) Dialnet (EMBASE) or Radline by CD-ROM and (b) Current Contents searched manually. Literature inclusion criteria were: (a) patients had a localization-related epileptic syndrome; (b) more than six patients were reported; and (c) patients had at least an interictal EEG-documented epileptiform abnormality. Of 46 papers meeting these criteria, 30 contained extractable data. SPECT results were compared to localization by standard diagnostic evaluation and surgical outcome. Meta-analytic sensitivities for SPECT localization in patients with temporal lobe seizures relative to diagnostic evaluation were 0.44 (interictal), 0.75 (postictal) and 0.97 (ictal). Similar results were obtained relative to surgical outcome. False-positive rates were low relative to diagnostic evaluation (7.4% for interictal and 1.5% for postictal studies) and surgical outcome (4.4% for interictal and 0.0% for postictal studies).

RESULTS

The results were not dependent on tracer used (or dose), the presence of CT-identified structural abnormalities, blinding of image interpretation or camera quality (although data were more variable with low-resolution cameras). There were insufficient data for conclusions regarding extratemporal-seizure or pediatric epilepsy populations.

CONCLUSION

Insights gained from reviewing this literature yielded recommendations for minimal information that should be provided in future reports. Additional recommendations regarding the nature and focus of future studies also are provided. The most important of these is that institutions using SPECT imaging in epilepsy should perform ictal, preferably, or postictal scanning in combination with interictal scanning.

Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates

Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia (PCA) with meperidine is associated with significantly more neonatal neurobehavioral depression than PCA with morphine. A single dose of epidural morphine (4 mg) decreases postcesarean opioid analgesic requirements and may reduce or prevent neonatal neurobehavioral depression associated with PCA meperidine. Prospectively, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. After umbilical cord clamping, each patient received epidural morphine 4 mg and was randomly allocated to receive either PCA meperidine or PCA morphine. Initial neonatal characteristics, included gestational age, Apgar scores, weight, and umbilical cord gas partial pressures. Brazelton Neonatal Behavioral Assessment Scale (NBAS) examinations were performed on each of the first 4 days of life. Nursing infants (n = 47) were grouped according to maternal PCA opioid in breast milk (meperidine [n = 24] or morphine [n = 23]); bottle-fed infants (n = 56) served as the control group. The three infant groups were equivalent with respect to initial characteristics and NBAS scores on the first 2 days of life. On the third day of life, infants in the morphine group were significantly more alert and oriented to animate human cues compared with infants in the meperidine or control group. On the fourth day of life, infants in the morphine group remained significantly more alert and oriented to animate human auditory cues than infants in the meperidine group. Average PCA opioid consumption through 48 h postpartum was equivalent (0.54 mg/kg morphine and 4.7 mg/kg meperidine); however, even with these small doses, meperidine was associated with significantly poorer neonatal alertness and orientation than morphine. Morphine is the PCA opioid of choice for postcesarean analgesia among nursing parturients.

IMPLICATIONS

Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia with meperidine is associated with more neonatal neurobehavioral depression than patient-controlled analgesia with morphine. In this study, we found that nursing infants exposed to morphine were more alert and oriented to animate human cues than those exposed to meperidine.

Eye injuries after nonocular surgery. A study of 60,965 anesthetics from 1988 to 1992

BACKGROUND

Eye injuries after anesthesia, although infrequent, may result in visual impairment. Previous studies have not defined the risk factors associated with these injuries. To study the cause of these injuries and to determine incidence data, the authors reviewed the records from a 4.5-y period of patients who sustained eye injuries after anesthesia and nonocular surgery.

METHODS

The records were surveyed of 60,965 patients who underwent anesthesia for nonocular surgery at our institution from January 1988 to July 1992. Eye injuries were identified by examining several sources of information, including quality improvement data, postoperative visits or telephone calls, and examination of medical records of postoperative patients who required an ophthalmology consultation. Records were reviewed to determine the types and causes of eye injuries. Logistic regression, with univariate and multivariate analysis, was used to identify the importance of possible risk factors.

RESULTS

Of 34 patients who sustained eye injuries (0.056%), the most common was corneal abrasion (n = 21). Other injuries were conjunctivitis, blurred vision, red eye, chemical injury, direct trauma, and blindness. Independent factors associated with a higher relative risk of eye injury were long surgical procedures (odds ratio, 1.16 per hour of anesthetic care; CI, 1.1 to 1.3), lateral positioning during surgery (odds ratio, 4.7; CI, 2 to 11), operation on the head or neck (odds ratio, 4.4; CI, 2.2 to 9.0), general anesthesia (odds ratio, 3.0; CI, 2.2 to 38), and surgery on a Monday (odds ratio, 2.7; CI, 1.4 to 5.3). In only 21% of cases was a specific cause of injury identified.

CONCLUSIONS

For reasons not understood, eye injuries are more common in patients who are older or who undergo lengthier procedures. The cause of injury was usually not determined by the authors' methods. Until the mechanisms producing perioperative eye injuries are better understood, it is difficult to identify strategies to prevent this type of injury.

Eye injuries after nonocular surgery. A study of 60,965 anesthetics from 1988 to 1992

BACKGROUND

Eye injuries after anesthesia, although infrequent, may result in visual impairment. Previous studies have not defined the risk factors associated with these injuries. To study the cause of these injuries and to determine incidence data, the authors reviewed the records from a 4.5-y period of patients who sustained eye injuries after anesthesia and nonocular surgery.

METHODS

The records were surveyed of 60,965 patients who underwent anesthesia for nonocular surgery at our institution from January 1988 to July 1992. Eye injuries were identified by examining several sources of information, including quality improvement data, postoperative visits or telephone calls, and examination of medical records of postoperative patients who required an ophthalmology consultation. Records were reviewed to determine the types and causes of eye injuries. Logistic regression, with univariate and multivariate analysis, was used to identify the importance of possible risk factors.

RESULTS

Of 34 patients who sustained eye injuries (0.056%), the most common was corneal abrasion (n = 21). Other injuries were conjunctivitis, blurred vision, red eye, chemical injury, direct trauma, and blindness. Independent factors associated with a higher relative risk of eye injury were long surgical procedures (odds ratio, 1.16 per hour of anesthetic care; CI, 1.1 to 1.3), lateral positioning during surgery (odds ratio, 4.7; CI, 2 to 11), operation on the head or neck (odds ratio, 4.4; CI, 2.2 to 9.0), general anesthesia (odds ratio, 3.0; CI, 2.2 to 38), and surgery on a Monday (odds ratio, 2.7; CI, 1.4 to 5.3). In only 21% of cases was a specific cause of injury identified.

CONCLUSIONS

For reasons not understood, eye injuries are more common in patients who are older or who undergo lengthier procedures. The cause of injury was usually not determined by the authors' methods. Until the mechanisms producing perioperative eye injuries are better understood, it is difficult to identify strategies to prevent this type of injury.