Patient-reported outcomes in multiple sclerosis: a systematic comparison of available measures

Multiple patient-reported outcomes (PROs) are currently being used in multiple sclerosis (MS) but their application is inconsistent and guidance on the appropriateness of each tool is lacking. The objective of our study was to identify MS-specific PROs and systematically to assess the development process and the reliability and validity of various instruments. A systematic literature search was conducted on multiple data sources, including MEDLINE, Embase (using the Ovid platform) and Google Scholar, from 1996 to March 2015. Search terms included combinations of MS, PROs and quality of life. Randomized controlled trials or observational studies conducted on patients with MS and published in English were included. In addition, the PROQOLID database was explored. The MS-specific PROs were systematically assessed using the Evaluating the Measurement of Patient-Reported Outcomes tool. In total, 8094 articles were screened and 405 PROs were identified from 1102 relevant articles. PROs were classified into MS-specific (n = 82) and non-MS-specific (n = 323). The results for the eight PROs that are most commonly used in MS clinical trials are presented here. For these eight PROs, the overall summary scores ranged between 50.1 and 68.7. The Multiple Sclerosis Impact Scale-29 had the best overall mean score (68.7), followed by the Leeds Multiple Sclerosis Quality of Life (67.0). This is the first study to provide a standardized assessment of all PROs for MS. There is a lack of data on content validity for PROs used in MS research, which indicates the need for a robust instrument in MS developed according to the US Food and Drug Administration guidelines.

Metals in commonly eaten groceries in Western Australia: a market basket survey and dietary assessment

Children's dietary exposure to metals has received limited attention in Australia. This study undertook a market basket survey and analysed 253 food and beverages for metals. These data were used in conjunction with recent average diet data for children in Western Australia to model dietary metals exposure, with mean metals intakes calculated for boys and girls aged 8, 12, 13 and 16 years. Results show that for some metals, including cadmium, nickel and manganese, dietary intake guidelines have been exceeded in younger children. The mean modelled cadmium intake in children aged 8 years was almost 60% of the World Health Organisation (WHO) guideline and exceeded the European Food Safety Authority (EFSA) guideline. Nickel and manganese intake was higher in younger children than reported in international studies. Modelling based on the 95% percentile of dietary consumption exceeded the respective guidelines or upper level of intake for several of the metals studied. The findings from this study support the need for further investigation into the exposure of children to metals from diet and the health implications of exposure.

Polybrominated diphenyl ether (PBDE) concentrations in plasma of pregnant women from Western Australia

PBDEs are a class of brominated flame retardants applied to consumer goods to reduce their flammability. These compounds are lipophilic, persistent and bioaccumulate through the food web. PBDEs have been detected in human blood, adipose tissue and breast milk. There are a small number of studies reporting concentrations of PBDEs in Australian populations. These indicate that concentrations are higher than in studies reporting concentrations from Europe but lower than those from Northern America. The aim of this paper was to determine the concentrations of PBDEs in the plasma of pregnant women participating in the Australian Maternal Exposure to Toxic Substances (AMETS) study in Western Australia. The samples comprised 164 pregnant women, aged 18 years and over, who were non-smokers and not occupationally exposed to persistent substances. Participants provided blood samples at 38 weeks gestation and these were analysed for five PBDE congeners. Maternal health and birth outcomes data were also obtained. The median for sum PBDE concentrations in plasma was 53.9 pg g(-1) (range 13.2 to 1390 pg g(-1)ww). Concentrations were adjusted for the estimated plasma lipid content. The concentrations of Σ5PBDE ranged from 2.44 to 258 ng g(-1) lipid with a median of 9.97 ng g(-1) lipid. BDE-47 was the dominant congener (median 21.4 pg g(-1), range <4.95 to 1030 pg g(-1)) followed by BDE-153 (median 12.2 pg g(-1), range <2.94 to 353 pg g(-1)). There were no significant associations between maternal, housing or dietary factors and concentrations of PBDEs in this study. Maternal PBDE concentrations were not associated with infant birth weight. This study builds upon previous Australian research and shows that concentrations in this sample of Western Australian women were higher than in parts of Europe.

Maternal exposure to organochlorine pesticides in Western Australia

BACKGROUND

Organochlorine pesticides (OCPs) persist over long periods of time. Little is known about levels of OCPs in the plasma of non smoking pregnant women in Western Australia. The aim of this study was to (1) determine exposure concentrations in a sample of pregnant women in Western Australia; (2) to determine the significant environmental, lifestyle and activity contributors to maternal exposure concentrations of OCPs and (3) to compare the measured maternal exposure concentrations with those measured in other countries.

METHODS

In a cross-sectional survey, 167 pregnant women located in rural and urban Western Australia provided plasma and answered questionnaires seeking information on lifestyle, demographics and the determinants of exposure to OCPs.

RESULTS

Of the 10 OCPs examined only HCB, β-HCH and p,p'DDE had concentrations above the limit of detection for more than 50% of samples. The mean level of HCB was 0.08 μg/L (range 0.005-2.0 μg/L), β-HCH 0.18 μg/L (range 0.04-3.16 μg/L) and p,p'DDE 1.05 μg/L, (range 0.03-17.04 μg/L). HCB concentrations were higher in women who ate seafood during pregnancy and who were older and lower among those with a history of breastfeeding. Concentrations of β-HCH were higher among women with a household income<$80,000 and lower among those with a history of breastfeeding. Concentrations of p,p'DDE were higher among women who lived within 1 km of industry and lower among those with a history of breastfeeding.

CONCLUSIONS

Concentrations of pesticides were low in Western Australian mothers compared with international studies.

Concentrations of polybrominated diphenyl ethers (PBDEs) in residential dust samples from Western Australia

Polybrominated diphenyl ethers (PBDEs) are one of the most common types of brominated flame retardants applied to foams, plastics and textiles to prevent fires. These flame retardants are now regulated and are either banned or being voluntarily phased. However, as these chemicals are persistent humans continue to be exposed. Dust has been identified as an important source of exposure and hence residential concentrations are of interest. The aim of this paper was to determine the concentrations of PBDEs in samples of residential dust from the homes of pregnant women in Western Australia. Thirty residential dust samples were analysed for concentrations of 32 PBDE congeners. Samples were collected from urban and rural areas. PBDEs were detected in all residential dust samples with the sum of the most common PBDEs (Σ(7) of BDEs 47, 99, 100, 153, 154, 183 and 209) ranging from 60.4 to 82400 ng g(-1) (median 571 ng g(-1)). DecaBDE makes up the highest proportion of PBDEs in residential dust, on average 66% of Σ(32)PBDEs. We did not find a relationship between housing characteristics nor the presence of appliances and PBDE concentrations. Dust from urban areas had significantly higher concentrations of BDE-209 and Σ(32)PBDEs than dust from rural areas of Western Australia (p values 0.01 and 0.03 respectively). PBDEs were present in residential dust in Western Australia at concentrations higher than reported previously in Australia. Further investigation of sources with a larger sample size is required to determine associations between PBDE concentrations and potential exposure sources and geographical regions.

Formaldehyde personal exposure measurements and time weighted exposure estimates in children

Residential concentrations of formaldehyde have been associated with poor respiratory health in children, where formaldehyde has been measured using stationary monitors inside homes. Although children spend most of their time indoors at home, there are few studies of children's personal exposure to formaldehyde. The aim of this study was to investigate the relationship between personal exposure formaldehyde concentrations, microenvironmental concentrations and time weighted exposure estimates in children. Forty-one primary school children (aged between 9 and 12 years) wore a personal passive sampler over two 24h periods in two seasons and completed 24h daily activity diaries and a questionnaire about lifestyle and behaviour. Samplers were co located indoors at home, outdoors at centralised locations and indoors at school for the corresponding period. Personal exposure formaldehyde concentrations in this group of children were generally low with a geometric mean concentration of 9.1 ppb (range <detection limit to 27.3 ppb). There were strong correlations between personal exposure concentrations and both domestic indoor (r(s)=.779, p<0.001) and time weighted estimated (r(s)=.802, p<0.001) concentrations. The time weighted model did not improve the estimate of personal exposure compared with stationary indoor concentrations. Indoor air concentration measured with a single stationary monitor was a suitable surrogate for personal exposure.

Patient satisfaction: ethnic origin or explanatory model?

Despite concern over their psychiatric treatment, little is known about black and ethnic minority patient satisfaction with psychiatric services and whether perceived 'ethnicity' or discrepant understanding of illness experience is most relevant. Twenty-one white British and 63 ethnic minority patients were interviewed for their opinions on psychiatric in-patient care, their treatment preferences and their explanatory models of their illness. The most significant association with satisfaction was not ethnic origin but the patient's explanatory model of their illness which showed little association with ethnicity whether patients were voluntary or involuntary. Satisfaction is most likely when there is concordance between the patient's and psychiatrist's explanatory model.

Plasma C19 steroid sulphate levels and indices of androgen bioavailability in female pattern androgenic alopecia

Female pattern androgenic alopecia (AA) is a relatively common endocrine abnormality in premenopausal women. However, unlike hirsutism, little is known about the androgen metabolism and plasma C19 steroid sulphate profiles in this disorder. We have therefore measured the plasma levels of dehydroepiandrosterone sulphate (DHEA-S), 5-androstene-3 beta,17 beta-diol sulphate (5-ADIOL-S), 5 alpha-androstane-3 alpha, 17 beta-diol sulphate (3 alpha-DIOL-S), androstenedione (AD), total testosterone (T), free testosterone (FT), sex hormone binding globulin (SHBG), non-SHBG bound T, luteinizing hormone (LH) and follicle stimulating hormone (FSH), and have calculated the free androgen index (FAI): 100 x T (nmol/l) divided by SHBG (nmol/l), in premenopausal women with AA (n = 25-45) and in normal premenopausal women (n = 17-73). While mean plasma concentrations of DHEA-S and T were not significantly different from controls, mean SHBG concentrations were significantly lower (47 +/- 3 vs 64 +/- 3 nmol/l) and the mean free androgen index (4.4 +/- 0.4 vs 2.4 +/- 0.2), and mean concentrations of free testosterone (45 +/- 5 vs 26 +/- 1.4 pmol/l), non-SHBG bound T (0.9 +/- 0.2 vs 0.6 +/- 0.1 nmol/l) and androstenedione (4.3 +/- 0.3 vs 3.4 +/- 0.2 nmol/l) were significantly elevated in women with AA. Furthermore, mean plasma concentrations of 5-ADIOL-S (512 +/- 42 nmol/l) and 3 alpha-DIOL-S (76 +/- 7 nmol/l) were significantly higher than levels found in normal women (272 +/- 12 nmol/l and 52 +/- 2 nmol/l respectively). The nature of the hyperandrogenism associated with AA may thus only be revealed by a comprehensive plasma androgen and androgen sulphate profile, which may explain apparently aberrant data for a given patient. In addition, 5-ADIOL-S and 3 alpha-DIOL-S may serve as excellent plasma markers of both the existence of the disorder and the efficacy of its treatment.

Serum C-19 steroid sulphates in females with clinical hyperandrogenism

Serum sulphates of 5-androstene-3 beta, 17 beta-diol (5-ADIOL-S), 5 alpha-androstane-3 alpha,17 beta-diol (3 alpha-DIOL-S) and dehydroepiandrosterone (DHEA-S), as well as unconjugated androstenedione (AD), testosterone (T) and 17 alpha-hydroxyprogesterone (17OHP), sex hormone binding globulin (SHBG) and the free androgen index (FAI) were measured by specific radioimmunoassay in girls with premature adrenarche (n = 9-16), and in hirsute women with (1) late onset 21 hydroxylase deficiency (n = 14), (2) polycystic ovarian disease (n = 28) and (3) idiopathic hirsutism (n = 74). Levels were also determined in females with androgenic alopecia (n = 35-45), in normal prepubertal girls (n = 9-14) and in normal adult women (n = 50-73). Mean serum concentrations of 5-ADIOL-S, 3 alpha-DIOL-S, DHEA-S, AD, T, and FAI were elevated and SHBG depressed, in all patient groups compared with controls, except for DHEA-S and T in patients with alopecia. We conclude that in addition to DHEA-S, 5-ADIOL-S may have a role as a pro-hormone in the synthesis of more potent androgens (T, DHT) in peripheral tissues such as skin; in addition, 3 alpha-DIOL-S may be a marker of peripheral androgen metabolism.

Institutionalizing social support through the church and into the community

The positive influence of social support on such health related outcomes as patient adherence to medical regimens and stress reduction at the worksite has captured the attention of public health researchers and practitioners alike. Yet, the broader social outcome of building community competency to undertake and sustain health related solutions without constant intervention from professionals still remains elusive. The difficulty may lie with the need to uncover on each occasion the various roles and functions of social support structures that may or may not exist in a given community. The intent would then be to graft an intervention onto these existing roles and functions in order to mirror the naturally occurring social support structures. A conceptual framework that has been used to institutionalize health related activities through the role and function of the black Church, as a social unit of identity and solution for rural black communities in North Carolina, is put forth for consideration.

Effects of joint lavage on knee synovitis in rheumatoid arthritis

Ten patients with rheumatoid arthritis and persistent knee synovitis had synovial fluid aspirated through a 14 gauge wide-bore needle followed by joint lavage and intra-articular triamcinolone. This resulted in the removal of variable quantities of intra-articular debris including rice bodies. When compared to a control group of patients, the addition of joint lavage to the standard procedure of aspiration and injection of corticosteroid resulted in more sustained resolution of synovitis after 12 weeks as judged by knee tenderness and circumference, recurrence of effusion, and synovial fluid leucocyte count. This study suggests that knee joint lavage may be a useful adjunct to therapy in rheumatoid arthritis patients having persistent knee synovitis.

The effects of benzodiazepines on hormones in women with idiopathic hirsutism

A single blind study was planned to investigate whether benzodiapines would reduce androgens in women with idiopathic hirsutism. Placebo was given for the first month followed by four months of a benzodiazepine (chlorazepate 15 mg nocte or diazepam 10 mg nocte ). Plasma samples were collected during the follicular and luteal phases of each therapy month. Hair growth was assessed monthly. Eighteen women concluded the five months of the trial of whom ten received chlorazepate and eight diazepam. Comparison of follicular plasma samples during the placebo phase and fourth month of benzodiazepine found a significant increase in sex hormone binding globulin and a significant decrease in dehydroepiandrosterone sulphate with benzodiazepine therapy. No significant effects on hair growth were observed. A longer therapy time may be needed to demonstrate effects of benzodiapines on hirsutism. Further studies are needed to determine whether benzodiazepines affect hormonal parameters in normal men and women.