Analysis of on-treatment cancer safety events with daprodustat versus conventional erythropoiesis-stimulating agents-post hoc analyses of the ASCEND-ND and ASCEND-D trials

BACKGROUND

The prespecified on-treatment analysis of ASCEND-ND (NCT02876835) raised concerns about a higher relative risk of cancer-related adverse events (AEs) with daprodustat vs darbepoetin in patients with anaemia of CKD. This concern was not observed in dialysis patients in ASCEND-D (NCT02879305).

METHODS

ASCEND-ND randomized 3872 patients to daprodustat or darbepoetin. ASCEND-D randomized 2964 patients to daprodustat or conventional erythropoiesis-stimulating agents (ESAs). In both studies ESA comparators used different dosing intervals (3/week, 1/week, every 2 or every 4 weeks). The prespecified on-treatment approach examined relative risks for cancer AEs up to the last dose date + 1 day. In these analyses, owing to different dosing intervals between arms, Cox models were used to estimate the daprodustat effect by various follow-up periods (censoring at last dose date, last dose date + dosing intervals, or end of study).

RESULTS

In ASCEND-ND, the safety of daprodustat vs darbepoetin on cancer-related AEs depended on the duration of follow-up after last dose date: hazard ratio (HR) 1.04 [95% confidence interval (CI) 0.77, 1.40] at end of study [HR 1.12 (95% CI 0.81, 1.56) for last dose date + dosing interval; HR 1.50 (95% CI 1.04, 2.15) for last dose date + 1 day]. In ASCEND-D, no excess risk of cancer-related AEs was observed with any model examined.

CONCLUSIONS

Prespecified on-treatment analyses for cancer-related AEs appeared to result in biased risk estimates in ASCEND-ND by preferentially under-counting events from patients assigned to darbepoetin. Analyses accounting for longer darbepoetin dosing intervals, or extending follow-up, resulted in attenuation of effect estimates towards neutrality, similar to ASCEND-D, where ESA comparator dosing intervals are closer to daprodustat.

TRIAL REGISTRATION

The ASCEND-ND trial is registered with ClinicalTrials.gov (NCT02876835); the ASCEND-D trial is registered with ClinicalTrials.gov (NCT02879305).

The role of cadaveric simulation in talus fracture research: A scoping review

BACKGROUND

Talus fractures are rare (<1% of all fractures), and their rarity limits the number of studies available to guide management. In instances such as this, cadaveric studies can play an important role. The purpose of this scoping review was to identify and describe the current body of literature on cadaveric studies of fractures of the talus.

METHODS

Through multiple electronic database searches (Medline, Embase, Scopus) we identified a broad body of cadaveric research into talus fractures, and these were classified into 4 main themes. Study characteristics were summarised along with any descriptive results and conclusions.

RESULTS

The search yielded 484 articles of which 19 met the inclusion criteria. They provide valuable insights into benefits and drawbacks of surgical approaches to the talus, particularly with regard to direct visualisation of anatomic reduction, and risks of neurovascular or tendon compromise. For talar neck fractures it is clear that cannulated screws offer superior fixation over plates, however, are inferior when considering anatomic reduction of the fracture. Direct visualisation of fracture reduction is far superior to intraoperative radiographic assessment, and mal-reduction leads to reduced subtalar joint range of motion, midfoot deformity, and increased joint contact pressures.

CONCLUSIONS

This study provides a summary of the existing literature surrounding the use of cadaver studies in fractures of the talus. We have identified gaps in the literature, particularly surrounding strength of fixation of new locking plate fixation techniques.

Urethro-venous fistula following straddle injury: A case report and image series

We present a case of a 49-year-old man with an acute traumatic urethral injury after a fall onto a fence post. Retrograde contrast study showed a contrast leak and suspicion of a traumatic urethro-venous fistula.

We successfully placed a urethral indwelling catheter (IDC) in the operating room and follow-up urethrocystoscopy showed healing of the injury. The patient remained asymptomatic during further follow-up visits.

MO530: Daprodustat is not Associated With an Increased Risk of Cancer: Results From the ASCEND-D and ASCEND-ND Trials

BACKGROUND AND AIMS

Increased HIF-1 levels are associated with mortality in some cancer patients, and levels of HIF-1 may also impact response to cancer treatments. Use of recombinant human erythropoietin or its analogs [erythropoiesis-stimulating agents (ESA)] in clinical trials in patients with cancer has been associated with increased risk of cancer-related morbidity and mortality, though the mechanism(s) for these effects is not clear. Daprodustat is an oral hypoxia-inducible factor (HIF)-prolyl hydroxylase inhibitor that increases the secretion of endogenous erythropoietin and the production of red cells. Cardiovascular outcome trials in patients with anemia of chronic kidney disease (CKD) requiring dialysis (ASCEND-D [1]; NCT02879305) and those not on dialysis (ASCEND-ND [2]; NCT028768355) have recently been published. Given the long latency with cancer events, we explored the effect of daprodustat as compared with ESA on the risk of cancer development utilizing a post-hoc modified intention-to-treat (mITT) approach, which includes events on and off treatment and provides greater protection to randomization than on-treatment approaches.

METHOD

Cancer-related adverse events (AEs) from the ASCEND studies were identified based on a predefined list of terms that included new cancer events or tumor progression and recurrence for patients receiving at least one dose of daprodustat or ESA (Safety Population). Patients were included into these trials as long as they had no history of cancer within 2 years prior to screening, were not currently receiving treatment for cancer and did not have a complicated kidney cyst. In addition to reporting the number and percentage of patients with cancer AEs, overall and by types, the rate per 100 person-year (PY) is also provided given differential follow-up for patients in these trials.

RESULTS

A total of 2964 patients were randomized in ASCEND-D and 3872 in ASCEND-ND, with ∼14 200 PY of follow-up. At baseline, patients reported a past history of cancer in 5.0% and 4.9% of patients receiving daprodustat or ESA, respectively, in ASCEND-D; and in 5.2% and 4.4% of patients receiving daprodustat or darbepoetin alfa, respectively, in ASCEND-ND. In the Safety Population, both the rate of cancer-related AEs and the rate per 100 PY were balanced for each study, with no pattern emerging regarding location or type (Table 1).

Of the patients with overall cancer AEs in the Safety Population (Table 1), fatal AEs in ASCEND-D occurred in 11 patients receiving daprodustat and in 15 patients receiving ESA, which was &lt;1% and 1% of the Safety Population, respectively. In ASCEND-ND, fatal AEs occurred in 6 patients receiving daprodustat and 11 patients receiving darbepoetin alfa, which was &lt;1% of the Safety Population in both groups. Pooling of data from the D and ND studies also demonstrated balance in cancer events between the dapro and ESA arms.

Further analysis of the characteristics of patients with cancer AEs demonstrated that the number of patients with multiple events, the time to first onset and outcome of the event and event seriousness and severity were also similar between treatment groups for both trials.

CONCLUSION

In cardiovascular outcome trials comprised of patients requiring dialysis (ASCEND-D) and not requiring dialysis (ASCEND-ND) with anemia of CKD, daprodustat was not associated with an increased risk of cancer, or cancer mortality, relative to ESA. Collectively, across these trials, cancer AEs are balanced.

Anterior cervical osteophytes causing dysphagia and dyspnoea

A 75-year-old man presents to his general practitioner (GP) with dyspnoea, and dysphagia to liquids and solids, with regurgitation causing recurrent episodes of dyspnoea. He had a background of osteoarthritis, was an ex heavy smoker and had undergone coronary artery bypass graft five years previously. After several emergency admissions, initial investigation by the GP, and referral to ear, nose and throat specialists with no cause for dysphagia found, he underwent computed tomography imaging of the neck and thorax which demonstrated large cervical osteophytes at the level of C3-C4. He was referred to spinal orthopaedics and after multidisciplinary team discussion the cervical osteophytes were removed via an anterior approach, resulting in complete resolution of his symptoms.

Development and Interrogation of a Transcriptomic Resource for the Giant Triton Snail (Charonia tritonis)

Gastropod molluscs are among the most abundant species that inhabit coral reef ecosystems. Many are specialist predators, along with the giant triton snail Charonia tritonis (Linnaeus, 1758) whose diet consists of Acanthaster planci (crown-of-thorns starfish), a corallivore known to consume enormous quantities of reef-building coral. C. tritonis are considered vulnerable due to overexploitation, and a decline in their populations is believed to have contributed to recurring A. planci population outbreaks. Aquaculture is considered one approach that could help restore natural populations of C. tritonis and mitigate coral loss; however, numerous questions remain unanswered regarding their life cycle, including the molecular factors that regulate their reproduction and development. In this study, we have established a reference C. tritonis transcriptome derived from developmental stages (embryo and veliger) and adult tissues. This was used to identify genes associated with cell signalling, such as neuropeptides and G protein-coupled receptors (GPCRs), involved in endocrine and olfactory signalling. A comparison of developmental stages showed that several neuropeptide precursors are exclusively expressed in post-hatch veligers and functional analysis found that FFamide stimulated a significant (20.3%) increase in larval heart rate. GPCRs unique to veligers, and a diversity of rhodopsin-like GPCRs located within adult cephalic tentacles, all represent candidate olfactory receptors. In addition, the cytochrome P450 superfamily, which participates in the biosynthesis and degradation of steroid hormones and lipids, was also found to be expanded with at least 91 genes annotated, mostly in gill tissue. These findings further progress our understanding of C. tritonis with possible application in developing aquaculture methods.

Norwich COVID-19 testing initiative pilot: evaluating the feasibility of asymptomatic testing on a university campus

Background

There is a high prevalence of COVID-19 in university-age students, who are returning to campuses. There is little evidence regarding the feasibility of universal, asymptomatic testing to help control outbreaks in this population. This study aimed to pilot mass COVID-19 testing on a university research park, to assess the feasibility and acceptability of scaling up testing to all staff and students.

Methods

This was a cross-sectional feasibility study on a university research park in the East of England. All staff and students (5625) were eligible to participate. All participants were offered four PCR swabs, which they self-administered over two weeks. Outcome measures included uptake, drop-out rate, positivity rates, participant acceptability measures, laboratory processing measures, data collection and management measures.

Results

798 (76%) of 1053 who registered provided at least one swab; 687 (86%) provided all four; 792 (99%) of 798 who submitted at least one swab had all negative results and 6 participants had one inconclusive result. There were no positive results. 458 (57%) of 798 participants responded to a post-testing survey, demonstrating a mean acceptability score of 4.51/5, with five being the most positive.

Conclusions

Repeated self-testing for COVID-19 using PCR is feasible and acceptable to a university population.

Well-posed continuum equations for granular flow with compressibility and μ(I)-rheology

Continuum modelling of granular flow has been plagued with the issue of ill-posed dynamic equations for a long time. Equations for incompressible, two-dimensional flow based on the Coulomb friction law are ill-posed regardless of the deformation, whereas the rate-dependent μ(I)-rheology is ill-posed when the non-dimensional inertial number I is too high or too low. Here, incorporating ideas from critical-state soil mechanics, we derive conditions for well-posedness of partial differential equations that combine compressibility with I-dependent rheology. When the I-dependence comes from a specific friction coefficient μ(I), our results show that, with compressibility, the equations are well-posed for all deformation rates provided that μ(I) satisfies certain minimal, physically natural, inequalities.

The Reliability of a Pre-Loaded Treadmill Time-Trial in Moderate Normobaric Hypoxia

The purpose of this study was to assess the reliability of a pre-loaded 1 500-m treadmill time trial, conducted in moderate normobaric hypoxia. 8 trained runners/triathletes (24±3 years, 73.2±8.1 kg, 182.5±6.5 cm, altitude specific V˙O2max: 52.9±5.5 ml·kg(-1)·min(-1)) completed 3 trials (the first as a familiarisation), involving 2, 15-min running bouts at 45% and 65% V˙O2max, respectively, and a 1 500-m time trial in moderate normobaric hypoxia equivalent to a simulated altitude of 2 500 m (FiO2~15%). Heart rate, arterial oxygen saturation, skeletal muscle and cerebral tissue oxygenation (StO2), expired gas ( V˙O2 and V˙CO2), and ratings of perceived exertion were monitored. Running performance (Trial 1: 352.7±40; Trial 2: 353.9±38.2 s) demonstrated a low CV (0.9%) and high ICC (1). All physiological variables demonstrated a global CV≤4.2%, and ICC≥0.87, with the exception of muscle (CV 10.4%; ICC 0.70) and cerebral (CV 4.1%; ICC 0.82) StO2. These data demonstrate good reliability of the majority of physiological variables and indicate that a pre-loaded 1 500-m time trial conducted in moderate normobaric hypoxia is a highly reliable test of performance.

Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis

INTRODUCTION

Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies.

METHODS

Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.

RESULTS

26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay.

CONCLUSION

Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.

Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with low morbidity

AIM

To examine the short-term outcomes of perineal reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap following abdominoperineal excision (APE).

METHOD

Retrospective case note review of all patients undergoing APE and primary VRAM reconstruction between July 2001 and February 2012 in a district general hospital tertiary referral centre for APE. Complications were categorized using the Clavien-Dindo classification, which grades complications from I to V in order of increasing severity.

RESULTS

Fifty-five consecutive patients (31 men, median age 65, range 38-84 years) underwent APE with VRAM flap reconstruction, 15 for anal cancer and 40 for rectal cancer. Median length of stay was 11 days but was significantly shorter in the laparoscopic group compared with the open group (8 vs 12 days; P < 0.01) and in patients who did not experience any complications (P < 0.05). Four patients (7%) had major complications (Grade 3 and above) directly related to the flap or donor site.

CONCLUSION

VRAM reconstruction of the perineum can be safely performed following APE with results that compare favourably with other techniques. Most flap complications are minor, although these are still associated with an increase in the length of hospital stay.

Melanomacrophages in three species of free-ranging sharks from the northwestern Atlantic, the blue shark Prionacae glauca (L.), the shortfin mako, Isurus oxyrhinchus Rafinesque, and the thresher, Alopias vulpinus (Bonnaterre)

The melanomacrophage aggregates or cells (MMC) are commonly used as biomarkers of exposure to pollution in fish, albeit their numbers and morphological characteristics can be influenced not only by environmental toxins but also by a range of physiological parameters and pathological conditions. Accordingly, before we can use MMC as biomarkers in any fish species, their normal, 'background' characteristics have to be established in apparently healthy fish. The knowledge of MMC in sharks is minimal. The aim of this study was to characterize MMC from 51 free-ranging, large pelagic sharks from the northwestern Atlantic, including shortfin mako, Isurus oxyrhinchus, thresher, Alopias vulpinus and blue shark, Prionacae glauca. The rationale of this study was twofold. First, because, sharks have life histories predisposing them to the accumulation of environmental toxins they constitute good sentinel species of the health of the global marine ecosystem. Second, because many shark populations are in decline or threatened by extinction, we need to expand our understanding of their health status in order to develop appropriate protective measures. All sharks were collected by sports fishing gear between June and August in 2007. Their health condition was assessed by necropsy, morphometrics, and by microscopic examination of gonads, livers, spleens and kidneys. Routine, haematoxylin and eosin and/or Pearl's reagent-stained paraffin embedded sections were studied by light microscopy. Our results provide the first data on the morphometric and morphological characteristics of MMC in viscera of apparently healthy free-ranging sharks from the northwestern Atlantic.

Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis

The rate and mode of early failure in 463 Birmingham hip resurfacings in a two-centre, multisurgeon series were examined. Of the 463 patients two have died and three were lost to follow-up. The mean radiological and clinical follow-up was for 43 months (6 to 90).

We have revised 13 resurfacings (2.8%) including seven for pain, three for fracture, two for dislocation and another for sepsis. Of these, nine had macroscopic and histological evidence of metallosis. The survival at five years was 95.8% (95% confidence interval (CI) 94.1 to 96.8) for revision for all causes and 96.9% (95% CI 95.5 to 98.3) for metallosis.

The rate of metallosis related revision was 3.1% at five years. Risk factors for metallosis were female gender, a small femoral component, a high abduction angle and obesity. We do not advocate the use of the Birmingham Hip resurfacing procedure in patients with these risk factors.

Regional migratory osteoporosis: a review illustrated by five cases

Regional migratory osteoporosis is an uncommon self-limiting disease characterized by an arthralgia which migrates between the weight-bearing joints of the lower limb. The radiological features of the disease obtained by conventional radiography, CT, MRI and radionuclide scintigraphy are illustrated by means of five case reports. These range from the most common presentation of sequential, proximal to distal spread in the lower limb to the rare intra-articular form, and disease involving the axial skeleton is also recognized. Clinical and radiographical features often overlap with those of diseases such as transient osteoporosis of the hip and transient bone marrow oedema syndrome, which is reflected in confusing terminology. Histological sampling is usually unnecessary; the radiological features are characteristic and the histological findings are not specific. Regional migratory osteoporosis is associated with systemic osteoporosis. This association is probably under-recognized, and has implications for the pathophysiology of the disease and for treatment.

Walking and running inter-limb asymmetry for Paralympic trans-femoral amputees, a biomechanical analysis

The aim of this project was to further the research and understanding of the trans-femoral amputee's ability to walk and run by comparing the changes in walking and running inter-limb asymmetry. An objective biomechanical analysis was conducted on four male transfemoral amputees, all members of the Australian Paralympic training squad for the 1996 Atlanta Paralympic Games. The data was collected in the biomechanics laboratories at Queensland University of Technology and the Australian Institute of Sport. The main outcomes measure a synchronised 3D kinematic (200 Hz), kinetic (600 Hz) and temporal analysis of walking at self-selected (1.1-1.3 m/s), and at maximal running speed (2.5-4.3 m/s). The walking and running biomechanical data was summarised into 27 indices of symmetry. The results showed that for all subjects the inter-limb asymmetry was significantly different at running speed, when compared to the walking speed. Using indices of symmetry 79% of the kinematic, 67% of the kinetic, and 67% of the temporal measurements identified better inter-limb asymmetry when the subjects walked, compared to running. This study objectively identified that when Paralympic level amputees ran on their standard running prosthesis, the inter-limb asymmetry was exacerbated.

Optimising the trans-femoral prosthetic alignment for running, by lowering the knee joint

For amputees to perform an everyday task, or to participate in physical exercise, it is crucial that they have an appropriately designed functional prosthesis. The aim of this study was to investigate the optimal trans-femoral prosthetic alignment configuration for running. A case study design was implemented as the method to collect data on four male Paralympic level trans-femoral amputee runners. In total 28 synchronised 3D kinematic, kinetic, and temporal biomechanical measures were analysed. A new prosthetic alignment, in which the prosthetic knee axis was lowered longitudinally (moved distally), was evaluated for running. The performance of the symmetry indices and running time for a total of three new modified alignments were compared to the standard prosthetic alignment. The interlimb asymmetry was found to improve when the subjects ran on the modified prosthetic alignment, and most importantly a one way ANOVA found a statistically significant increase in running velocity. This study identified that for all four subjects, who used the same prosthetic components, lowering the prosthetic knee joint centre improved their interlimb symmetry, and subsequently their running velocity by an average of 26%.

Treatment of sialorrhea with glycopyrrolate: A double-blind, dose-ranging study

OBJECTIVE

To determine the safety and efficacy of glycopyrrolate in the treatment of developmentally disabled children with sialorrhea.

DESIGN

Placebo-controlled, double-blind, crossover dose-ranging study.

SETTING

Outpatient facilities in 2 pediatric hospitals.

PATIENTS

Thirty-nine children with both developmental disabilities and excessive and bothersome sialorrhea.

MAIN OUTCOME MEASURES

Parent and investigator evaluation of change in sialorrhea and adverse effects.

RESULTS

Glycopyrrolate in doses of 0.10 mg/kg per dose is effective at controlling sialorrhea. Even at low doses, 20% of children may exhibit adverse effects severe enough to require discontinuation.

CONCLUSIONS

Glycopyrrolate is effective in the control of excessive sialorrhea in children with developmental disabilities. Approximately 20% of children given glycopyrrolate may experience substantial adverse effects, enough to require discontinuation of medication. Arch Pediatr Adolesc Med. 2000;154:1214-1218.

Caries prediction and indicators using a pediatric risk assessment teaching tool

The goals of this study were to determine both predictability and risk indicators in a young pediatric population seen in a dental school clinic using a Caries Risk Assessment teaching tool. Assigned risk categories and factors for 140 patients were analyzed for relationships with future caries development using Logistic Regression (p < 0.01) and Chi-square analysis (p < 0.05). Among the group developing caries, variables and disease were analyzed using ANOVA Independent Samples Test (p < 0.05). Assigned-risk categories were significantly predictive with odds ratios (OR) of Moderate- and High-risk developing new caries being 5.41 and 28.64 respectively when compared with Low-risk. Significant risk indicators were diet, oral hygiene and the presence of caries and decalcifications. The risk assessment tool used in this study predicted future caries development. Through this method of assessment, caries risk indicators in the population studied were determined to be diet, oral hygiene and past caries experience.

Metaplastic carcinoma of the breast arising within complex sclerosing lesion: a report of five cases

AIMS

This study presents a series of five cases in which metaplastic carcinoma, predominantly low-grade adenosquamous carcinoma, of the breast is seen arising within a background of a complex sclerosing lesion. This association has been recognized previously but has not been documented in detail. This study describes the characteristics of the components present in each case and discusses the existing literature. This observation adds further evidence to support an association between some types of invasive breast carcinoma and sclerosing lesions of the breast.

METHODS AND RESULTS

Four of these cases were received as referral cases for opinion. The fifth was received as part of the routine surgical workload within our own institution. Two patients presented following mammographic screening and three symptomatically; their mean age was 62 years (range 49-68). The mean lesion size was 16 mm (range 7-24). All five lesions showed features of a complex sclerosing lesion/radial scar in the form of central sclerosis with elastosis and radiating benign entrapped tubules. One had associated benign papillary structures and two had focal benign squamous metaplasia. Four cases showed coexisting but distinct areas of low-grade adenosquamous carcinoma with glandular and squamous epithelial differentiation in a spindle cell background. One case had associated undifferentiated spindle cell carcinoma. Detailed immunophenotypic characteristics of two cases are presented.

CONCLUSIONS

This series illustrates a postulated but previously unconfirmed association between an unusual form of metaplastic breast carcinoma (adenosquamous carcinoma) and complex sclerosing lesions. The mechanisms of induction of breast carcinoma are poorly understood but these observations further emphasize the potential for sclerosing lesion of the breast to be associated with, and possibly give rise to, invasive carcinoma of different types. The precise nature of the interaction between the pathological processes remains unclear.

Patient motivation

This paper addresses the important issue of patient motivation. Research indicates that non-compliance is a major problem for healthcare professionals, with between a third and a half of all patients failing to comply with recommended healthcare instructions. The paper outlines some of the misconceptions associated with motivation and discusses six factors, together with some brief additional factors, which it is hoped will contribute to a deeper understanding of the subject and the improved dental health of patients.

Investigating the relationship between economic status and HIV risk

Although anecdotal information suggests that there is a relationship between socioeconomic status and HIV risk, there have been few investigations of that possible relationship. Understanding that relationship can have important implications for designing and implementing prevention programs. This study investigated the relationship between indicators of socioeconomic status and HIV prevalence in Massachusetts using seroprevalence data from publicly funded test sites. HIV seroprevalence was found to differ depending on demographic groups and the health care insurance/provider. Those who had no insurance or were Medicaid recipients had higher rates of HIV infection. Homeless individuals were also at higher risk. Further, low-income ZIP codes in Massachusetts were four times more likely to have high seroprevalence rates among residents voluntarily testing for HIV. Thus, HIV seroprevalence appears to be associated with socioeconomic status in this group of voluntarily tested individuals.

Sex, drugs and HIV counseling and testing: a prospective study of behavior-change among methadone-maintenance clients in New England

OBJECTIVES

To determine whether changes in injecting drug use and sexual behavior over a 12-month follow-up are associated with HIV counseling and testing (C and T) of injecting drug users in methadone maintenance treatment programs (MMTP) in Massachusetts and Connecticut.

METHODS

Clients were invited to participate in a longitudinal study involving five interviews. Data were also obtained by ethnographers and from clinical records. Behavioral outcomes of interest were number of drug injections, sharing of unclean 'works' (injecting equipment), number of unprotected sex partners, and number of unprotected sexual episodes. Data analyses included multiple regression, odds ratios, and quantitative analysis of text-based data.

RESULTS

Subjects reported reductions in both injecting drug use and sexual behavior Primary associations with reduced injecting drug use were remaining in the MMTP and attending HIV-positive support groups. A reduction in high-risk sexual behavior was associated with an HIV-positive test result and duration of HIV counseling in the MMTP. Increase in drug injecting use was associated with an HIV-positive test result. Inconsistent condom use was associated with enrollment in the MMTP where condoms were available only upon request and abstinence and monogamy between uninfected partners were promoted.

CONCLUSIONS

Injecting drug users who self-select to participate in MMTP and HIV C and T, two public health HIV-prevention interventions, reduce their HIV-risk behaviors. Clients should be encouraged to remain in MMTP and HIV-infected clients should attend support groups for HIV-positive persons. MMTP staff should promote a variety of safer sex behaviors and provide condoms without request.

Retention in methadone maintenance treatment programs, Connecticut and Massachusetts, 1990-1993

The goal of this study was to identify factors associated with six- and 12-month retention in methadone maintenance treatment programs (MMTPs) in Massachusetts and Connecticut. Data was obtained from 674 participants, clinic records, and clinic staff. Ethnographic and logistic regression analyses were conducted. Overall, 69% and 48% of the clients remained in treatment at six months and 12 months, respectively. The MMTPs were categorized as either a 12-Step, case management, or primary care model. Factors independently associated with retention in treatment at six months were each one-year increase in age of client (OR 1.05), injecting at three months (OR 0.47), and enrollment in the primary care model (OR 2.10). The same factors were associated with 12-month retention in treatment. To retain clients in MMTPs-which should, in turn, help reduce drug use and prevent HIV transmission among IDUs-younger IDUs and clients still injecting at three months after entering drug treatment may need additional services from the staff, or alternative treatment regimens. MMTP directors should consider differences between these programs and, if appropriate, make changes to increase retention in treatment.

Cytokine regulation of HIV replication induced by dendritic cell-CD4-positive T cell interactions

It has been established that human immunodeficiency virus (HIV) replication occurs throughout the course of disease in the lymphoid tissue. We have developed a model system to study the effect of cytokines and other agents on HIV replication using cocultures of DCs and T cells that reflect the cell-to-cell interactions that occur in the microenvironment of lymphoid tissue. Dendritic cells from peripheral blood, when pulsed with small amounts of HIV, induce infection in autologous, unstimulated CD4-positive T cells. Using this system, cytokines, anti-cytokine antibodies, and inhibitors of cellular activation were added to cultures and the effects on cellular proliferation and activation and HIV production were measured. Cytokines that increased T cell proliferation, such as IL-2 and IL-4, enhanced HIV replication, while the effect of IL-12 was more complex. HIV production was inhibited by blocking endogenously produced IL-2, as well as by adding IL-10, which blocks IL-2 secretion, antigen-presenting cell function, and T cell activation. Proinflammatory cytokines induced modest enhancement of viral replication in cocultures of HIV-pulsed DCs and CD4-positive T cells. Thus, using a model of HIV replication that more closely mimics the in vivo microenvironment of lymphoid tissue may allow a better analysis of the effect of cytokines and cytokine networks, as well as agents that modify immune activation on HIV replication.

Role of health beliefs in patient compliance with preventive dental advice

Lack of patient compliance with health recommendations is a well known fact. What is less well understood are the reasons why. This study used the Health Belief Model (HBM) to investigate the role of patients' health beliefs in patient compliance with preventive dental advice. A questionnaire was constructed to explore the four beliefs of "seriousness", "susceptibility", "benefits" and "self-efficacy" and this was administered to 43 adult patients attending the conservation department of a large teaching hospital for routine examination. Patients were seen twice, 1 month apart. At visit one, plaque was disclosed and plaque and bleeding scores were recorded. Patients were taught the modified Bass technique of plaque removal. Plaque and bleeding scores were repeated on visit two, 1 month later. Compliance was defined as any reduction in these scores at visit two. The health belief of "benefits" taken as a single variable showed a significant correlation with compliance and the combined beliefs of "susceptibility" and "benefits" were also found to be significantly related to compliance.

t(8;13) (p11;q12) translocation in a myeloproliferative disorder associated with a T-cell non-Hodgkin lymphoma

An unusual cytogenetic translocation, t(8;13) (p11;q12), is described in a patient presenting with a CML-like myeloproliferative disorder associated with a high-grade T-cell lymphoma. Evidence is presented suggesting that the breakpoint region in the translocation involves a site implicated in both the T cell malignancy and the abnormal granulocyte proliferation.

Public perceptions of the funding of NHS dental services

A survey was carried out of 102 members of the general public, asking for their views of the recent changes in the government funding of NHS dentistry. Approximately 80% of those surveyed had heard about the changes. The majority thought that the implications of the change would be a rise in costs to patients and a fall in the number of NHS dentists.