Resident factors associated with American board of internal medicine certification exam failure

INTRODUCTION

Performance on the certifying examinations such as the American Board of Internal Medicine Certification Exam (ABIM-CE) is of great interest to residents and their residency programs. Identification of factors associated with certification exam result may allow residency programs to recognize and intervene for residents at risk of failing. Despite this, residency programs have few evidence-based predictors of certification exam outcome. The change to pass-or-fail score reporting of the USA Medical Licensing Exam (USMLE) Step 1 removes one such predictor.

MATERIALS AND METHODS

We performed a retrospective study of residents from a medium-sized internal medicine residency program who graduated from 1998 through 2017. We used univariate tests of associations between ABIM-CE result and various demographic and scholastic factors.

RESULTS

Of 166 graduates, 14 (8.4%) failed the ABIM-CE on the first attempt. Failing the first attempt of the ABIM-CE was associated with older median age on entering residency (29 vs 27 years; P = 0.01); lower percentile rank on the Internal Medicine In-Training Examination (IM-ITE) in each of the first, second, and third years of training (P < 0.001 for all); and lower scores on the USMLE Steps 1, 2 Clinical Knowledge, and 3 (P < 0.05 for all). No association was seen between a variety of other scholastic or demographic factors and first-attempt ABIM-CE result.

DISCUSSION

Although USMLE step 1 has changed to a pass-or-fail reporting structure, there are still other characteristics that allow residency programs to identify residents at risk of ABIM-CE first time failure and who may benefit from intervention.

Evaluation of a mental health service reform program, the Pathways to Community Living Initiative, for people with severe mental illness and complex needs

OBJECTIVE

The Pathways to Community Living Initiative (PCLI) aims to reform mental health care for people with severe and persistent mental illness (SPMI) and complex needs. This study reports independent evaluation findings on transitions from hospital and practice change in mental health services.

METHODS

Data for this mixed-methods evaluation were obtained from administrative collections and semi-structured interviews with PCLI program managers, teams and executive leads; aged care managers; and leaders in inpatient, community and older people's mental health services.

RESULTS

Between July 2015 and December 2020, 674 participants (67% of those eligible for the PCLI) were transitioned from hospital to community. Of those transitioned, 21 required subsequent long-stay admissions. The PCLI introduced resources, clearly defined processes, and state-wide networks to guide changes in practice which are becoming embedded in the operations and governance of mental health services across New South Wales.

CONCLUSIONS

Severe and persistent mental illness and complex needs can be managed in community settings with highly individualised planning and care, supported by specialised clinical teams in partnership with mental health, aged care and disability services. Evaluation findings highlight the importance of continued investment in rehabilitation psychiatry.

Experiences of transition from hospital to community living via the Pathways to Community Living Initiative: A qualitative evaluation study of service users and family members

OBJECTIVE

People with severe and persistent mental illness (SPMI) may be excluded from community-based care if their complex support needs cannot be met and are at risk of institutionalisation. The Pathways to Community Living Initiative (PCLI) aims to address barriers to community living. This study evaluated the PCLI from the perspective of service users and family members.

METHODS

Evaluation questions were explored in semi-structured interviews. Transcripts were coded inductively and deductively. This article adheres to relevant EQUATOR standards for qualitative research and reporting.

RESULTS

There were 37 interviews with 27 service users and 12 family members. Factors associated with positive experiences of transition from hospital included detailed planning, personalised care, and staged transitions which alleviated concerns around safety, support, and coping. Community living provided opportunities to exercise greater choice and control in everyday life and, for some, to reconnect with family. Poor physical health and social isolation were noted as potential risks.

CONCLUSIONS

Participants regarded community living as preferable to hospital settings, and highly valued their freedom. They reported that clinical, aged care and disability supports helped them. Additional support may be required to improve physical health and social connectedness, and families appear to have unmet needs for psychosocial support.

The impact of operational partnership on telemental health before, during, and after COVID-19

The coronavirus disease (COVID-19) pandemic significantly accelerated the growth of telehealth services within the Veterans Health Administration (VHA), as the use of video conferencing to meet with Veterans in their homes increased tenfold in a 3-month period. A substantial portion of telehealth in VHA has traditionally comprised mental health services, and both the scope and volume of such services were significantly broadened in response to COVID-19 to allow for social distancing. The current article is a review of this mobilization from the framework of the People, Process, Technology, and Information model, with a particular highlight on the critical operational partnership between individual facilities providing care and the governing VHA program offices. Lessons learned and future goals for the sustainment and integration of telemental health services are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Perceived Parenting Styles and Values Development: A Longitudinal Study of Adolescents and Emerging Adults

This study explored parenting styles and values internalization. Perceived parenting styles were measured in Grade 7 (n = 749) and Grade 12 (n = 468), and values were measured in Grade 12 (n = 271) and one year postschool (n = 291). We measured three aspects of valuing: priority (extrinsic, intrinsic importance); regulation (controlled, autonomous); and successful enactment of values (success). Mothers' authoritative parenting in Grade 7 predicted increased importance and autonomous regulation of values one year postschool. Fathers' authoritative parenting in Grade 7 predicted decreased importance of extrinsic values. Fathers' permissive parenting in Grade 7 predicted decreased importance of intrinsic values. Authoritarian parenting in Grade 12 predicted more controlled values regulation postschool, particularly for extrinsic values. Parenting in early and late adolescence predicts values internalization in emerging adulthood.

Initial results from the New Horizons exploration of 2014 MU69, a small Kuiper Belt object

The Kuiper Belt is a distant region of the outer Solar System. On 1 January 2019, the New Horizons spacecraft flew close to (486958) 2014 MU₆₉, a cold classical Kuiper Belt object approximately 30 kilometers in diameter. Such objects have never been substantially heated by the Sun and are therefore well preserved since their formation. We describe initial results from these encounter observations. MU₆₉ is a bilobed contact binary with a flattened shape, discrete geological units, and noticeable albedo heterogeneity. However, there is little surface color or compositional heterogeneity. No evidence for satellites, rings or other dust structures, a gas coma, or solar wind interactions was detected. MU₆₉'s origin appears consistent with pebble cloud collapse followed by a low-velocity merger of its two lobes.

The effects of snow and salt on ice table stability in University Valley, Antarctica

The Antarctic Dry Valleys represent a unique environment where it is possible to study dry permafrost overlaying an ice-rich permafrost. In this paper, two opposing mechanisms for ice table stability in University Valley are addressed: i) diffusive recharge via thin seasonal snow deposits andii) desiccation via salt deposits in the upper soil column. A high-resolution time-marching soil and snow model was constructed and applied to University Valley, driven by meteorological station atmospheric measurements. It was found that periodic thin surficial snow deposits (observed in University Valley) are capable of drastically slowing (if not completely eliminating) the underlying ice table ablation. The effects of NaCl, CaCl₂ and perchlorate deposits were then modelled. Unlike the snow cover, however, the presence of salt in the soil surface (but no periodic snow) results in a slight increase in the ice table recession rate, due to the hygroscopic effects of salt sequestering vapour from the ice table below. Near-surface pore ice frequently forms when large amounts of salt are present in the soil due to the suppression of the saturation vapour pressure. Implications for Mars high latitudes are discussed.

A Delphi study to develop indicators of cancer patient experience for quality improvement

PURPOSE

The purpose of this study was to develop prioritised indicators to measure cancer patient experience and thus guide quality improvement in the delivery of patient care.

METHODS

A Delphi study, consisting of two surveys and three workshops, was employed to gather expert opinions on the most important indicators to measure. Survey participants were 149 health professionals, academics/technical experts and consumers. The first survey was based on a literature review which identified 105 elements of care within 14 domains of patient experience. These were rated on a 7-point Likert scale, with '1' representing high importance. Elements with mean ratings between 1.0 and 2.0 were retained for the second survey. The 43 least-important elements were omitted, four elements were revised and nine new elements added. Consensus was defined as at least 70% of participants rating an element '1' or '2'. Multivariate and cluster analyses were used to develop 20 draft indicators, which were presented to 51 experts to refine and prioritise at the three workshops.

RESULTS

All elements in the second survey were rated '1' or '2' by 81% of participants. Workshop participants agreed strongly on the four most important indicators: coordinated care, access to care, timeliness of the first treatment, and communication. Other indicators considered highly important were follow-up care for survivors; timeliness of diagnosis; information relating to side effects, pain and medication; comprehensibility of information provided to patients; and needs assessment.

CONCLUSIONS

Experts identified priorities with a high level of consensus, providing a rigorous foundation for developing prioritised indicators of quality in cancer patient experience.

Participation of Australian Aboriginal and Torres Strait Islander families in a parent support programme: longitudinal associations between playgroup attendance and child, parent and community outcomes

BACKGROUND

Playgroups are a relatively unique form of family support programme that is common in Australia which has high community acceptance and significant government investment. However, limited evidence exists regarding the effectiveness of playgroups to achieve better outcomes for children and their parents. This study describes patterns of playgroup participation for Aboriginal and Torres Strait Islander families with young children and examines the extent to which participation from birth to three years is associated with subsequent child, parent and community outcomes.

METHODS

This study uses three years of longitudinal data for 622 Aboriginal and Torres Strait Islander children who were participants in the Longitudinal Study of Indigenous Children (LSIC). Longitudinal associations between playgroup attendance when children were age 2 and 3 years and outcome measures for child vocabulary, motor skills, behaviour problems, prosocial development, parent home learning engagement, resilience, advice-seeking and health service use, and community trustworthiness were examined using path analysis.

RESULTS

Rates of playgroup participation in this sample group were generally lower than for Australian children overall. Playgroup attendance when children were age 2 to 3 years was associated with higher parental engagement in home learning activities when children were aged 4 years which, in turn, was associated with stronger expressive vocabulary scores for children.

CONCLUSION

The findings from this study suggest that playgroup participation can enhance the home learning environments for Aboriginal and Torres Strait Islander children. Playgroups as a parent support programme hold strong potential to reach and engage families, particularly in areas of high geographic isolation, which can realize improved outcomes for children, parents and communities.

Primary contact physiotherapy services reduce waiting and treatment times for patients presenting with musculoskeletal conditions in Australian emergency departments: an observational study

QUESTION

Can primary contact physiotherapists reduce waiting and treatment times and facilitate faster discharge in Australian emergency departments?

DESIGN

Data on patients treated by primary contact physiotherapists were collected prospectively and compared with historical and concurrent cohorts of patients treated by other clinicians, using diagnosis and urgency.

PARTICIPANTS

Twenty-nine primary contact physiotherapists, working at 10 sites, treated a total of 14 452 patients with musculoskeletal conditions in triage categories 3, 4 and 5.

OUTCOME MEASURES

Data were analysed for two time periods: baseline (historical control) and implementation (12 to 15 months). A concurrent control cohort within the implementation period was selected using diagnosis (ICD-10-AM) and urgency of treatment (triage category). Waiting time, treatment time, and time to discharge from the emergency department were compared across periods and between cohorts.

RESULTS

Significant differences were found in waiting and treatment times. On average, patients treated by primary contact physiotherapists waited 31minutes less than those treated by other practitioners and had an average treatment time of 108minutes compared with 148minutes. Overall, 93% of patients treated by primary contact physiotherapists and 75% treated by other practitioners were discharged from the emergency department within a 4-hour time period. To address concerns that these results could be due to other differences between cohorts, multiple regression models were used and the results were still significantly in favour of the primary contact physiotherapists.

CONCLUSION

A primary contact physiotherapist model in hospital emergency departments can reduce waiting and treatment times for patients with musculoskeletal presentations, resulting in better performance in achieving discharge within the 4-hour national target. [Bird S, Thompson C, Williams KE (2016) Primary contact physiotherapy services reduce waiting and treatment times for patients presenting with musculoskeletal conditions in Australian emergency departments: an observational study.Journal of Physiotherapy62: 209-214].

Home-based clinical video teleconferencing care: Clinical considerations and future directions

Clinical video teleconferencing (CVT) is a treatment delivery modality that can be used to provide services to clinical populations that experience barriers to accessing mental health care. Recently, home-based CVT (HBCVT) has been developed in order to deliver treatment via CVT to patients in their homes. A number of clinical considerations, including the appropriate clinical population and individual patient factors, need to be taken into account when delivering CVT. Particular challenges can exist when setting up the home environment for HBCVT. Concerns about maintaining patient privacy while living in shared spaces, ensuring adequate CVT technology in the patient's home, and conducting risk management remotely are important to consider when delivering treatment via CVT. Since treatments delivered via CVT are often conducted across state lines, novel ethical and legal issues such as privacy laws, licensing of providers, prescribing practices, and insurance reimbursements need to be addressed when conducting services via these modalities. Future research on HBCVT will provide researchers and clinicians with information regarding which patients are most appropriate for treatment delivered via this modality and help further develop evidence for the cost-effectiveness of CVT and HBCVT clinical practice guidelines.

Focal adhesion kinase and Wnt signaling regulate human ductal carcinoma in situ stem cell activity and response to radiotherapy

Cancer stem cells (CSCs) can avoid or efficiently repair DNA damage from radio and chemotherapy, which suggests they play a role in disease recurrence. Twenty percentage of patients treated with surgery and radiotherapy for ductal carcinoma in situ (DCIS) of the breast recur and our previous data show that high grade DCIS have increased numbers of CSCs. Here, we investigate the role of focal adhesion kinase (FAK) and Wnt pathways in DCIS stem cells and their capacity to survive irradiation. Using DCIS cell lines and patient samples, we demonstrate that CSC-enriched populations are relatively radioresistant and possess high FAK activity. Immunohistochemical studies of active FAK in DCIS tissue show high expression was associated with a shorter median time to recurrence. Treatment with a FAK inhibitor or FAK siRNA in nonadherent and three-dimensional matrigel culture reduced mammosphere formation, and potentiated the effect of 2 Gy irradiation. Moreover, inhibition of FAK in vitro and in vivo decreased self-renewal capacity, levels of Wnt3a and B-Catenin revealing a novel FAK-Wnt axis regulating DCIS stem cell activity. Overall, these data establish that the FAK-Wnt axis is a promising target to eradicate self-renewal capacity and progression of human breast cancers.

Abstract 131: Shared Medical Appointments for Heart Failure Patients Improve Cardiac Health Status

Objective: Heart Failure Shared Medical Appointments (HF SMAs) are group visits in which several HF patients are treated by a clinician(s) at the same time. This intervention is a system redesign that addresses growing health system and patient care burdens in chronic HF management. Group visits have been associated with greater adherence to select HF medications and hospitalization-free survival during the intervention. However, there is little data on patient-reported outcomes such as HF-specific health status, an important outcome that quantifies the impact of the patient’s HF on his or her life. The objective of this pilot study is to determine whether HF SMA is associated with a change in HF-specific health status. The short version Kansas City Cardiomyopathy Questionnaire (KCCQ-12) measures HF-specific health status, including symptoms, physical and social function, and quality of life.

Methods: We retrospectively collected patient characteristics by review of medical records for all patients in a VA hospital that completed the full HF SMA intervention (4 visits across 8 weeks). Each patient completed the KCCQ-12 at the beginning of each clinic visit. The primary outcome was change in KCCQ Summary Score(range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change). The secondary outcome was change in KCCQ subscales.

Results: Twenty-eight patients (median age 64, median LVEF 35%) completed all four HF SMA visits. The mean KCCQ at baseline was 51. From pre- to post-SMA, the average change in KCCQ-12 Summary Score was +8 (p=0.001). The Quality of Life Subscale was associated with the greatest change (average change,+15, p=0.0003), followed by Symptom Scale (average change +10, p=0.002). There was no significant change in Social Limitation (average change +6, p=0.08) or Physical Function (average change +2, p=0.48).

Conclusions: Preliminary findings suggest that a novel group intervention in patients with HF is associated with mild to moderate clinically significant changes in HF-specific health status. Further, HF SMA appears to specifically improve quality of life and symptoms more than physical function. Future clinical trials will be required to determine how these improvements compare to usual care.

Pseudomembranous tracheobronchitis caused by Rhizopus sp. After allogeneic stem cell transplantation

Invasive fungal infections are a major cause of morbidity and mortality in allogeneic stem cell transplant recipients. They can occasionally involve the tracheobronchial tree with serious clinical consequences. Tracheobronchial involvement is often an unexpected finding during diagnostic bronchoscopy. Herein, we report a case of pseudomembranous tracheobronchitis caused by Rhizopus sp. in an allogeneic stem cell transplant recipient.

Abstract P5-03-01: Focal adhesion kinase inhibition abrogates ductal carcinoma in situ cancer stem cell activity and self-renewal capacity via down regulation of WNT3a and potentiates effects of radiation

Background - Ductal carcinoma in situ (DCIS) recurs in 20% of patients after conserving surgery and radiotherapy. Research shows cancer stem cells (CSCs) are tumour initiating, resistant to current therapies and therefore may play a role in cancer recurrence. Focal Adhesion Kinase (FAK) signalling plays an important role in breast cancer, metastasis and radioresistance. These studies investigate FAK signalling in the regulation of human DCIS CSCs.

Methods - Immunohistochemical (IHC) expression of active FAK was analysed in DCIS patients (n = 63) with known recurrence. DCIS cell lines (DCIS.com & SUM225) and human primary DCIS cells (n = 13) were cultured as primary and secondary mammospheres to assess CSC/progenitor activity and self-renewal after inhibition of FAK (PF573228 or siRNA) in combination with radiation (2Gy). Western Blotting and IHC staining were used to measure DNA-damage, FAK and Wnt signalling. Cell lines were cultured in 3D matrigel as DCIS acini and in vivo as DCIS xenografts to examine the effects of FAK inhibition.

Results - Mammosphere initiating cells from DCIS cell lines and human primary DCIS have increased FAK activity and are more radioresistant than the total population (TP) (TP-6Gy vs AR-6Gy; DCIS.com-0.51±0.01 vs 0.05±0.01 Survival fraction (SF), P&lt;0.001; SUM225-0.52±0.03 vs 0.03±0.01 SF, P&lt;0.001; patient-derived DCIS–67.61±6.4% vs 13.8±7% mammosphere formation efficiency (MFE), P = 0.0005). FAK inhibition using PF573228 and FAK siRNA in mammosphere or 3D matrigel culture reduced mammosphere formation alone (mammosphere culture-control vs PF573228 0.5μM; DCIS.com-1.2±0.09% vs 0.7±0.06% MFE, P&lt;0.001; SUM225-2.2±0.1% vs 1.4±0.06% MFE, P&lt;0.001; patient derived DCIS-100±2.6% vs 72.1±6.2% MFE compared to control, P&lt;0.001). Moreover, FAK inhibition in combination with 2Gy radiation abrogated mammosphere formation more than either treatment alone and increased DNA double strand breaks (2Gy vs 2Gy/0.5μM PF573228; DCIS.com-0.66±0.02% vs 0.39±0.01% MFE, P&lt;0.05; SUM225-1.59±0.06% vs 1.22±0.05% MFE, P&lt;0.01; patient derived DCIS-0.63±0.04 vs 0.39±0.03 fold change compared to control, P&lt;0.01). Expression of active FAK in DCIS (n = 63) was associated with a shorter time to recurrence after surgery (Univariate analysis Cox's regression model, p = 0.049). Further investigation revealed FAK inhibition also decreased self-renewal capacity (SR) in vitro and in vivo (control vs PF573228 0.5μM; DCIS.com-0.85±0.03 vs 0.4±0.08 SR, P&lt;0.001; SUM225-0.66±0.06 vs 0.28±0.03 SR, P&lt;0.001; patient-derived DCIS-1 vs 0.54±0.19 SR compared to control, P = 0.001; DCIS.com xenograft-vehicle vs PF562271 25mg/kg; 1.3±0.12% vs 0.65±0.05% MFE, P&lt;0.0001) and could be rescued through the addition of Wnt3a, showing for the first time FAK-Wnt signalling crosstalk in DCIS.

Conclusion - Targeting FAK reduced self-renewal of DCIS stem/progenitor cells via down regulation of Wnt3a and improves sensitivity to radiotherapy. These data would support further investigations through a peri-operative trial of short term FAK inhibition before radiotherapy on the recurrence rates of DCIS patients after breast conserving surgery.

Funding - Breast Cancer Campaign and The Royal College of Surgeons.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-03-01.

Lapatinib inhibits stem/progenitor proliferation in preclinical in vitro models of ductal carcinoma in situ (DCIS)

Breast-conserving surgery for ductal carcinoma in situ (DCIS) is often combined with irradiation, reducing recurrence rates to 20% within 10 years; however, there is no change in overall survival. Evidence in the invasive breast indicates that breast cancer stem cells (CSCs) are radiotherapy-resistant and are capable of re-initiating a tumor recurrence; hence, targeting CSCs in high risk DCIS patient may improve survival. HER2 is overexpressed in 20% of DCIS and is known to be highly active in breast CSCs; we therefore investigated the effect of Lapatinib on DCIS CSC activity using 2 in vitro culture systems. Two DCIS cell lines DCIS.com (HER2 normal) and SUM225 (HER2 overexpressed) as well as DCIS cells from patient samples (n = 18) were cultured as mammospheres to assess CSC activity and in differentiated 3D-matrigel culture to determine effects within the non-CSCs. Mammosphere formation was reduced regardless of HER2 status, although this was more marked within the HER2-positive samples. When grown as differentiated DCIS acini in 3D-matrigel culture, Lapatinib only reduced acini size in the HER2-positive samples via decreased proliferation. Further investigation revealed lapatinib did not reduce self-renewal activity in the CSC population, but their proliferation was decreased regardless of HER2 status. In conclusion we show Lapatinib can reduce DCIS CSC activity, suggesting that the use of Lapatinib in high-risk DCIS patients has the potential to reduce recurrence and the progression of DCIS to invasive disease.

Abstract PD04-06: Molecular Phenotypes of DCIS predict Invasive and DCIS recurrence

Introduction: Molecular phenotypes of invasive breast cancer predict early recurrence and survival. DCIS exhibits similar phenotypes but their frequency and clinical significance remain uncertain. To determine whether molecular phenotypes of DCIS predict recurrence, 273 women (median age 57 years) with primary DCIS who were screened for or entered DCIS trials (Iressa/Lapatinib/ERISAC) in one unit from 1990–2010 were studied.

Methods: HER2, oestrogen receptor (ER) and progesterone receptor (PR) expression within primary DCIS were established using immunohistochemistry within the trial protocols. HER2 was scored 0 (absent) to 3 (maximum). Scores ≥2 were taken as positive if amplified on FISH testing. ER and PR scored positive if ≥5% of cells stained. 64.2% patients were ER positive, 43.3% were HER2 positive and 31.8% were high-grade lesions. 94 underwent mastectomy whilst 185 had BCS.

Results: There was an overall recurrence rate of 20.14% after a median follow-up period of 74 months (range 12–240). Of these recurrences, 36.4% were invasive. Conservation surgery (BCS) was used in 185 women who suffered 47 recurrences. Molecular phenotype predicted local recurrence by Log Rank analysis (P &lt; 0.01) and invasive recurrences (P &lt; 0.016) overall and in the BCS group remained predictive of invasive recurrence (p &lt;0.005) and overall recurrence (p &lt; 0.001).

The management of preinvasive breast cancer

SUMMARY Ductal carcinoma in situ (DCIS) is a preinvasive breast cancer in which the proliferations of malignant ductal epithelial cells have not breached the ductal basement membrane. Currently there is controversy over the optimum management of DCIS, with suggestions that there may be an element of ‘overdiagnosis’ of some low-risk cases that may never progress to invasive cancer within a patient’s lifetime. This review discusses the biology and natural history of DCIS and current management strategies, addresses the risk factors for recurrence and how these can be minimized, highlights areas of controversy and suggest the possible direction of future research.

P1-04-04: Focal Adhesion Kinase Plays a Major Role in the Regulation of Human Ductal Carcinoma In Situ (DCIS) Stem Cell Activity

Focal Adhesion Kinase (FAK) is a non-receptor tyrosine kinase that has been implicated in the regulation of normal mammary stem cells and cancer stem cells (CSCs) within mouse models. FAK is frequently overexpressed in human breast cancers but its role in human CSCs is not known. We aimed to investigate the role of FAK in human ductal carcinoma in situ (DCIS) stem cells (SCs).

We have used PF573228 to inhibit FAK activity in SUM225 (HER2−overexpressing) and MCF10DCIS.com (HER2−normal) DCIS cell lines. PF573228 inhibits the autophosphorylation of FAK at tyrosine 397 causing inactivation. Western blot analysis confirmed PF573228 (0.1-5 μM) caused a dose dependent inhibition of FAK activity in both cell lines.

The in vitro mammosphere colony assay was used to measure CSC activity in both DCIS cell lines and primary DCIS samples (n=5) (LREC#01/012). Mammosphere-forming efficiency (MFE) was calculated as percentage colony formation (&gt;60μm) in the presence or absence of PF573228 (0.1-5μM).

MFE was reduced in both the SUM225 cell line (p=0.02) and in the MCF10DCIS.com cell line (p=0.04) by PF573228 at a dose concentration of ≥0.1 μM (see Table 1). PF573228 (1 μM) also reduced mammosphere formation in human primary DCIS cells (n=5) by 18.1±5.75% when compared to control (p=0.03).

Preclinical pharmacology of the alpha4beta2 nAChR partial agonist varenicline related to effects on reward, mood and cognition

The pharmacological properties and pharmacokinetic profile of the alpha4beta2 nicotinic acetylcholine receptor (nAChR) partial agonist varenicline provide an advantageous combination of free brain levels and functional potencies at the target receptor that for a large part explain its efficacy as a smoking cessation aid. Since alpha4beta2 and other nAChR subtypes play important roles in mediating central processes that control reward, mood, cognition and attention, there is interest in examining the effects of selective nAChR ligands such as varenicline in preclinical animal models that assess these behaviors. Here we describe results from studies on varenicline's effects in animal models of addiction, depression, cognition and attention and discuss these in the context of recently published preclinical and preliminary clinical studies that collected data on varenicline's effects on mood, cognition and alcohol abuse disorder. Taken together, the preclinical and the limited clinical data show beneficial effects of varenicline, but further clinical studies are needed to evaluate whether the preclinical effects observed in animal models are translatable to the clinic.

Cognitive effects of memantine in postmenopausal women at risk of dementia: a pilot study

BACKGROUND

To determine the effects of memantine on cognition in a normal population of postmenopausal women with putative risk factors for Alzheimer's disease (AD) using a built-in control for the genetic risk factor for AD (apoE-epsilon4 status).

METHODS

A prospective, open-label, 6-month pilot medication trial with memantine and follow-up after discontinuance conducted at the Center for Neuroscience in Women's Health, Stanford University School of Medicine. Neuropsychological data were collected on 22 community-dwelling postmenopausal women (11 apoE-epsilon4 carriers and 11 apoE-epsilon4 non-carriers) with at least one putative risk factor for AD.

RESULTS

ApoE-epsilon4 status was not a significant predictor of change in neuropsychological performance. Changes associated with memantine treatment for entire sample included significant declines in some variables associated with verbal learning and memory that improved upon medication withdrawal. A positive medication effect was noted with executive functions and possibly category fluency. Trend-level improvements were seen in motor dexterity of the non-dominant hand and maintained even after drug discontinuance.

CONCLUSIONS

Treatment with memantine appeared to have differential effects on cognitive performance in a population of women with putative risk factors for AD. ApoE-epsilon4 carrier status did not account for observed changes in cognition.

The efficacy and safety of varenicline for smoking cessation using a flexible dosing strategy in adult smokers: a randomized controlled trial

OBJECTIVE

To determine whether self-regulated flexible dosing with varenicline tartrate is safe and effective for smoking cessation.

RESEARCH DESIGN AND METHODS

320 healthy, motivated-to-quit smokers (> or =10 cigarettes/day) aged 18-65 years, entered a multicenter, randomized, double-blind, placebo-controlled study - conducted between December 26, 2001 and June 24, 2003 - with a 12-week treatment phase and 40-week, double-blind, non-treatment follow-up. Treatment consisted of varenicline or placebo in fixed doses (Week 1: titrated from 0.5 to 1.0 mg/day) followed by a self-regulated flexible schedule (Weeks 2-12: 0.5-2.0 mg/day).

MAIN OUTCOME MEASURES

Primary outcomes included carbon monoxide-confirmed continuous abstinence rate (CAR) from smoking for Weeks 4 through 7, 9 through 12, and 9 through 52. Secondary outcomes included CAR from Weeks 9 through 24, 7-day point prevalence of abstinence, safety assessments, and measures of craving, withdrawal, and smoking reward.

RESULTS

Superior CARs were observed in varenicline-treated (n = 157) versus placebo participants (n=155) for Weeks 4 through 7 (38.2 vs. 11.6%), 9 through 12 (40.1 vs. 11.6%), 9 through 24 (28.0 vs. 9.0%), and 9 through 52 (22.3 vs. 7.7%) (all p<0.001). Seven-day point prevalence was higher in varenicline-treated than placebo participants at Weeks 12 (46.5 vs. 14.2%; p<0.001), 24 (32.5 vs. 13.5%; p<0.001), and 52 (28.0 vs. 13.5%; p=0.001). Overall, medication compliance was high, although varenicline-treated, but not placebo, participants tended to taper down their dosage over time. Total treatment-emergent AEs were 77.1% (varenicline: 121/157) and 65.8% (placebo: 102/155). Few AEs led to treatment discontinuation (varenicline: 11/157, 7.0% and placebo: 7/155, 4.5%). Participants were primarily healthy Caucasians, so more research is necessary to determine how applicable these findings are to other populations.

CONCLUSIONS

A self-regulated, flexible dosing regimen of varenicline is well tolerated, with superior effectiveness versus placebo for smoking cessation.

Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial

Background:

Varenicline, a new treatment for smoking cessation, has demonstrated significantly greater efficacy over placebo and sustained release bupropion (bupropion SR). A study was undertaken to compare a 12-week standard regimen of varenicline with a 10-week standard regimen of transdermal nicotine replacement therapy (NRT) for smoking cessation.

Methods:

In this 52-week, open-label, randomised, multicentre, phase 3 trial conducted in Belgium, France, the Netherlands, UK and USA, participants were randomly assigned (1:1) to receive varenicline uptitrated to 1 mg twice daily for 12 weeks or transdermal NRT (21 mg/day reducing to 7 mg/day) for 10 weeks. Non-treatment follow-up continued to week 52. The primary outcome was the biochemically confirmed (exhaled carbon monoxide ⩽10 ppm) self-reported continuous abstinence rate (CAR) for the last 4 weeks of the treatment period in participants who had taken at least one dose of treatment. Secondary outcomes included CAR from the last 4 weeks of treatment through weeks 24 and 52, and measures of craving, withdrawal and smoking satisfaction.

Results:

A total of 376 and 370 participants assigned to varenicline and NRT, respectively, were eligible for analysis. The CAR for the last 4 weeks of treatment was significantly greater for varenicline (55.9%) than NRT (43.2%; OR 1.70, 95% CI 1.26 to 2.28, p<0.001). The week 52 CAR (NRT, weeks 8–52; varenicline, weeks 9–52) was 26.1% for varenicline and 20.3% for NRT (OR 1.40, 95% CI 0.99 to 1.99, p = 0.056). Varenicline significantly reduced craving (p<0.001), withdrawal symptoms (p<0.001) and smoking satisfaction (p<0.001) compared with NRT. The most frequent adverse event was nausea (varenicline, 37.2%; NRT, 9.7%).

Conclusions:

The outcomes of this trial established that abstinence from smoking was greater and craving, withdrawal symptoms and smoking satisfaction were less at the end of treatment with varenicline than with transdermal NRT.

Trial registration number:

NCT00143325.

Rationale, pharmacology and clinical efficacy of partial agonists of alpha4beta2 nACh receptors for smoking cessation

Most smokers repeatedly fail in their attempts to stop smoking because of the addictive nature of the nicotine in tobacco products. Nicotine dependence is probably mediated through the activation of multiple subtypes of neuronal nicotinic acetylcholine receptor (nAChR), among which the mesolimbic alpha(4)beta(2) subtype has a pivotal role. Here, we discuss the rationale for and the design of alpha(4)beta(2) nAChR partial agonists as novel treatments for tobacco addiction. Such agents are expected to exhibit a dual action by sufficiently stimulating alpha(4)beta(2)-nAChR-mediated dopamine release to reduce craving when quitting and by inhibiting nicotine reinforcement when smoking. Potent and selective alpha(4)beta(2) nAChR partial agonists that exhibit dual agonist and antagonist activity in preclinical models can be identified. The validity of this approach is demonstrated by the clinical efficacy of the alpha(4)beta(2) nAChR partial agonist varenicline, which has significantly better quit rates than do other treatments and offers a new option for smoking cessation pharmacotherapy.

A randomized, placebo-controlled trial of varenicline, a selective α4β2 nicotinic acetylcholine receptor partial agonist, as a new therapy for smoking cessation in Asian smokers

BACKGROUND

Rates of smoking in East Asian men range from >35% to >60%, and are increasing in women and the young.

OBJECTIVE

This study evaluated the efficacy and tolerability of 1 mg BID varenicline, a novel alpha4beta2 nicotinic acetylcholine receptor partial agonist, for smoking cessation in smokers in Taiwan and Korea.

METHODS

A randomized, double-blind, placebo-controlled, 12-week treatment, 12-week follow-up trial was conducted at 5 sites each in Korea and Taiwan. Eligible subjects, smoking >or=10 cigarettes/d, received brief smoking-cessation counseling and were randomly assigned in a 1:1 ratio to varenicline 1 mg BID (titrated during the first week) or placebo. Smoking status was established by self-report and confirmed at clinic visits by end-expiratory carbon monoxide <or=10 ppm. The primary end point was continuous abstinence rate (CAR) during the last 4 weeks of treatment. Secondary end points included CAR from weeks 9 to 24 and 7-day point prevalence (PP) of abstinence at weeks 12 and 24. Craving, withdrawal, and smoking satisfaction were determined by the Minnesota Nicotine Withdrawal Scale, the Brief Questionnaire of Smoking Urges, and the modified Cigarette Evaluation Questionnaire. Observed or volunteered adverse-event data were recorded at clinic visits.

RESULTS

Overall, 126 subjects (84.9% male) received varenicline, and 124 (92.7% male) received placebo, Subjects were aged 21 to 73 years (mean age, 39.7 and 40.9 years for varenicline and placebo groups, respectively), and the mean (range) body weights were 69.0 (44.8-110.0) kg and 71.4 (45.5-102.0) kg, respectively. Subjects had smoked for 3 to 52 years (mean, 20.2 and 22.1 years in the varenicline and placebo groups, respectively). Subjects had smoked a mean of 23 cigarettes/d over the past month, with 51.6% (varenicline) and 46.0% (placebo) having made 1 or more prior serious quit attempts. Smoking-cessation rates at the end of treatment were 59.5% with varenicline versus 32.3% with placebo (P < 0.001). CARs through 12 weeks post-treatment (weeks 9-24) were 46.8% with varenicline and 21.8% with placebo (P < 0.001). The 7-day PP was 67.5% with varenicline versus 36.3% with placebo at week 12, and 57.1% versus 29.0% with placebo at week 24 (both, P < 0.001). Treatment-emergent, all-causality adverse events with an incidence >or= 5% for varenicline were nausea (43.7% for varenicline vs 11.3% placebo), insomnia (15.1% vs 13.7%), increased appetite (7.9% vs 6.5%), constipation (7.1% vs 2.4%), anxiety (5.6% vs 2.4%), and abnormal dreams (5.6% vs 0.8%). Adverse events resulted in <10% treatment discontinuations overall.

CONCLUSION

Varenicline was an efficacious and well-tolerated pharmacotherapy for smoking cessation in this group of Asian smokers over a 12-week treatment period, and its effects persisted for a further 12-week follow-up period.

A double-blind study evaluating the long-term safety of varenicline for smoking cessation

OBJECTIVE

We assessed the safety of long-term varenicline administration for smoking cessation.

METHODS

In this randomized, double-blind, multicenter trial, eligible adult smokers (18-75 years) who smoked an average of > or =10 cigarettes/day were randomized to either varenicline 1 mg twice daily (BID) or placebo for 52 weeks. Subjects made weekly clinic visits until week 8, and then every 4 weeks until week 52, with a follow-up visit at week 53. The target quit date was the morning of the week 1 clinic visit. Brief counseling was provided at each visit, and vital signs, adverse events (AEs), and smoking status were documented. Other laboratory measures were collected at specified visits.

RESULTS

A total of 251 subjects were randomized to varenicline and 126 to placebo. Approximately half of the subjects in each arm completed the study (53.8% varenicline; 46.8% placebo). Treatment-emergent AEs were observed in 96.4% of varenicline- and 82.5% of placebo-treated subjects during the study. Common varenicline-associated AEs were nausea (40.2%), abnormal dreams (22.7%), and insomnia (19.1%). Most AEs were considered mild or moderate in intensity. AEs leading to discontinuation of varenicline treatment included nausea (7.6%), insomnia (3.2%), and abnormal dreams (2.4%). A single varenicline-related serious AE, bilateral subcapsular cataracts, was observed. At week 52, 7-day point prevalence abstinence rates were 36.7% (varenicline) and 7.9% (placebo).

CONCLUSIONS

Varenicline 1 mg BID can be safely administered for up to 1 year. Varenicline was also a more effective smoking cessation aid than placebo throughout the study, supporting both its short- (12-week) and long-term (52-week) efficacy.

Pharmacological profile of the alpha4beta2 nicotinic acetylcholine receptor partial agonist varenicline, an effective smoking cessation aid

The preclinical pharmacology of the alpha4beta2 nicotinic acetylcholine receptor (nAChR) partial agonist varenicline, a novel smoking cessation agent is described. Varenicline binds with subnanomolar affinity only to alpha4beta2 nAChRs and in vitro functional patch clamp studies in HEK cells expressing nAChRs show that varenicline is a partial agonist with 45% of nicotine's maximal efficacy at alpha4beta2 nAChRs. In neurochemical models varenicline has significantly lower (40-60%) efficacy than nicotine in stimulating [(3)H]-dopamine release from rat brain slices in vitro and in increasing dopamine release from rat nucleus accumbens in vivo, while it is more potent than nicotine. In addition, when combined with nicotine, varenicline effectively attenuates the nicotine-induced dopamine release to the level of the effect of varenicline alone, consistent with partial agonism. Finally, varenicline reduces nicotine self-administration in rats and supports lower self-administration break points than nicotine. These data suggest that varenicline can reproduce to some extent the subjective effects of smoking by partially activating alpha4beta2 nAChRs, while preventing full activation of these receptors by nicotine. Based on these findings, varenicline was advanced into clinical development and recently shown to be an effective and safe aid for smoking cessation treatment.

Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial

CONTEXT

Varenicline, a partial agonist at the alpha4beta2 nicotinic acetylcholine receptor, has the potential to aid smoking cessation by relieving nicotine withdrawal symptoms and reducing the rewarding properties of nicotine.

OBJECTIVE

To determine the efficacy and safety of varenicline for smoking cessation compared with placebo or sustained-release bupropion (bupropion SR).

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, placebo-controlled trial conducted between June 2003 and March 2005 at 14 research centers with a 12-week treatment period and follow-up of smoking status to week 52. Of 1413 adult smokers who volunteered for the study, 1027 were enrolled; 65% of randomized participants completed the study.

INTERVENTION

Varenicline titrated to 1 mg twice daily (n = 344) or bupropion SR titrated to 150 mg twice daily (n = 342) or placebo (n = 341) for 12 weeks, plus weekly brief smoking cessation counseling.

MAIN OUTCOME MEASURES

Continuous abstinence from smoking during the last 4 weeks of treatment (weeks 9-12; primary end point) and through the follow-up period (weeks 9-24 and 9-52).

RESULTS

During the last 4 weeks of treatment (weeks 9-12), 43.9% of participants in the varenicline group were continuously abstinent from smoking compared with 17.6% in the placebo group (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.69-5.50; P<.001) and 29.8% in the bupropion SR group (OR, 1.90; 95% CI, 1.38-2.62; P<.001). For weeks 9 through 24, 29.7% of participants in the varenicline group were continuously abstinent compared with 13.2% in the placebo group (OR, 2.83; 95% CI, 1.91-4.19; P<.001) and 20.2% in the bupropion group (OR, 1.69; 95% CI, 1.19-2.42; P = .003). For weeks 9 through 52, 23% of participants in the varenicline group were continuously abstinent compared with 10.3% in the placebo group (OR, 2.66; 95% CI, 1.72-4.11; P<.001) and 14.6% in the bupropion SR group (OR, 1.77; 95% CI, 1.19-2.63; P = .004). Treatment was discontinued due to adverse events by 10.5% of participants in the varenicline group, 12.6% in the bupropion SR group, and 7.3% in the placebo group. The most common adverse event with varenicline was nausea, which occurred in 101 participants (29.4%).

CONCLUSIONS

Varenicline is an efficacious, safe, and well-tolerated smoking cessation pharmacotherapy. Varenicline's short-term and long-term efficacy exceeded that of both placebo and bupropion SR.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00143364.

Effect of maintenance therapy with varenicline on smoking cessation: a randomized controlled trial

CONTEXT

The majority of cigarette smokers who achieve abstinence relapse within the first year and require many attempts before achieving permanent abstinence. Evidence to support pharmacological treatment for relapse prevention is insufficient.

OBJECTIVE

To determine whether smokers who quit after 12 weeks of treatment with varenicline, a selective alpha4beta2 nicotinic acetylcholine receptor partial agonist, maintain greater continuous abstinence rates (defined as not a single "puff" of a cigarette) than placebo controls during an additional 12 weeks of treatment and until 52 weeks after treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted at multiple medical clinics in 7 countries with follow-up to 52 weeks after study baseline. Of 1927 cigarette smokers recruited between April 2003 and February 2004 and treated for 12 weeks with open-label varenicline titrated to 1 mg twice per day, 1236 (64.1%) did not smoke, use tobacco, or use nicotine replacement therapy during the last week of treatment and 62.8% (n = 1210) were randomized to additional treatment or placebo.

INTERVENTION

Participants were randomly assigned to receive either double-blind varenicline, 1 mg twice per day (n = 603), or placebo (n = 607) for an additional 12 weeks.

MAIN OUTCOME MEASURES

Carbon monoxide-confirmed continued abstinence during weeks 13 to 24 and weeks 13 to 52 of the study.

RESULTS

The carbon monoxide-confirmed continuous abstinence rate was significantly higher for the varenicline group than for the placebo group for weeks 13 to 24 (70.5% vs 49.6%; odds ratio [OR], 2.48; 95% confidence interval [CI], 1.95-3.16; P<.001) as well as for weeks 13 to 52 (43.6% vs 36.9%; OR, 1.34; 95% CI, 1.06-1.69; P = .02). Adverse events reported in the open-label period were mostly mild; no difference in adverse events between varenicline and placebo was observed during the double-blind period.

CONCLUSIONS

Smokers who achieved abstinence for at least 7 days at the end of 12 weeks of open-label varenicline treatment and were randomized to receive an additional 12 weeks of varenicline treatment showed significantly greater continuous abstinence in weeks 13 to 24 compared with placebo. This advantage was maintained through the nontreatment follow-up to week 52. Varenicline may be an efficacious, safe, and well-tolerated agent for maintaining abstinence from smoking.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00143286.

Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial

CONTEXT

The alpha4beta2 nicotinic acetylcholine receptors (nAChRs) are linked to the reinforcing effects of nicotine and maintaining smoking behavior. Varenicline, a novel alpha4beta2 nAChR partial agonist, may be beneficial for smoking cessation.

OBJECTIVE

To assess efficacy and safety of varenicline for smoking cessation compared with sustained-release bupropion (bupropion SR) and placebo.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, parallel-group, placebo- and active-treatment-controlled, phase 3 clinical trial conducted at 19 US centers from June 19, 2003, to April 22, 2005. Participants were 1025 generally healthy smokers (> or =10 cigarettes/d) with fewer than 3 months of smoking abstinence in the past year, 18 to 75 years old, recruited via advertising.

INTERVENTION

Participants were randomly assigned in a 1:1:1 ratio to receive brief counseling and varenicline titrated to 1 mg twice per day (n = 352), bupropion SR titrated to 150 mg twice per day (n = 329), or placebo (n = 344) orally for 12 weeks, with 40 weeks of nondrug follow-up.

MAIN OUTCOME MEASURES

Primary outcome was the exhaled carbon monoxide-confirmed 4-week rate of continuous abstinence from smoking for weeks 9 through 12. A secondary outcome was the continuous abstinence rate for weeks 9 through 24 and weeks 9 through 52.

RESULTS

For weeks 9 through 12, the 4-week continuous abstinence rates were 44.0% for varenicline vs 17.7% for placebo (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.70-5.50; P<.001) and vs 29.5% for bupropion SR (OR, 1.93; 95% CI, 1.40-2.68; P<.001). Bupropion SR was also significantly more efficacious than placebo (OR, 2.00; 95% CI, 1.38-2.89; P<.001). For weeks 9 through 52, the continuous abstinence rates were 21.9% for varenicline vs 8.4% for placebo (OR, 3.09; 95% CI, 1.95-4.91; P<.001) and vs 16.1% for bupropion SR (OR, 1.46; 95% CI, 0.99-2.17; P = .057). Varenicline reduced craving and withdrawal and, for those who smoked while receiving study drug, smoking satisfaction. No sex differences in efficacy for varenicline were observed. Varenicline was safe and generally well tolerated, with study drug discontinuation rates similar to those for placebo. The most common adverse events for participants receiving active-drug treatment were nausea (98 participants receiving varenicline [28.1%]) and insomnia (72 receiving bupropion SR [21.9%]).

CONCLUSION

Varenicline was significantly more efficacious than placebo for smoking cessation at all time points and significantly more efficacious than bupropion SR at the end of 12 weeks of drug treatment and at 24 weeks.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00141206.

Multiple vaccine and pyridostigmine interactions: Effects on EEG and sleep in the common marmoset

Following active service during the 1990/1991 Gulf conflict, a number of UK and US veterans presented with a diverse range of symptoms, collectively known as Gulf Veterans' Illnesses (GVI). The administration of vaccines and/or the pretreatment against possible nerve agent poisoning, pyridostigmine bromide (PB), given to Armed Forces personnel during the Gulf conflict has been implicated as a possible factor in the aetiology of these illnesses. The possibility that long-term health effects may result from the administration of these vaccines (anthrax, pertussis, plague, yellow fever, polio, typhoid, tetanus, hepatitis B, meningococcal meningitis and cholera) and/or PB, have been investigated using a non-human primate model, the common marmoset. This paper reports the results from two aspects of the study, brain electrical activity (EEG, collected during performance of a touchscreen mediated discrimination task) and sleep. There were no marked long-term changes in EEG or sleep patterns that could be attributed to vaccines and/or PB administration. The changes that were detected were predominantly time related and independent of treatment. Where statistical differences were detected between treatments, the magnitudes of the difference were relatively minor and therefore not regarded as having long term biological significance.

A novel method for activity monitoring in small non-human primates

Patterns of spontaneous activity are valuable reflections of well-being in animals and humans and, because of this, investigations have frequently incorporated some form of activity monitoring into their studies. It is widely believed that activity monitoring, alongside assessments of general behaviour, should be included in initial CNS safety pharmacology screening. As the number of marmoset studies having actimetry as their focus, or as an adjunct, is increasing, we wished to evaluate an alternative approach to those commonly used. The method is based on miniaturized accelerometer technologies, currently used for human activity monitoring.Actiwatch-Minis were used to monitor the activity of two groups of differently housed marmosets for 14 consecutive days. Group A consisted of four mixed-sex pairs of animals and group B comprised eight group-housed males. Activity profiles were generated for weekday and weekend periods. The devices captured quantifiable data which showed differences in total activity between the two differently housed groups and revealed intragroup variations in the temporal spread of activity between weekdays and weekends. The Actiwatch-Mini has been shown to generate retrospective, data-logged activity counts recorded from multiple animals in a single arena by means of non-invasive monitoring.

Attention deficit hyperactivity disorder in children and adolescents following traumatic brain injury

To better characterize pediatric psychopathology after neurological insult, secondary attention deficit hyperactivity disorder (SADHD)-or ADHD that develops after traumatic brain injury (TBI)-and its clinical and neuroimaging correlates were investigated. Outcome data were available for 118 children, ages 5 through 14 at the time of hospitalization following TBI (severe TBI n = 37; mild-moderate TBI n = 57) and orthopedic injury (n = 24). Standardized psychiatric, adaptive functioning, cognitive functioning, family functioning, and family psychiatric history assessments were conducted on all participants. Severity of injury and neuroimaging lesion assessments were conducted on TBI participants only. The diagnosis of SADHD was mutually exclusive with preinjury ADHD, which occurred in 13 of 94 TBI participants and 4 of 24 orthopedic injury participants. SADHD occurred in 13 of 34 eligible participants with severe TBI but resolved in 4 of 13 of these participants. SADHD also occurred in 1 of 8 eligible moderate TBI participants, only in the presence of preinjury ADHD traits and 3 of 39 of eligible mild TBI cases. SADHD occurred in 1 of 20 of eligible participants with orthopedic injury without any brain injury. SADHD was significantly associated with TBI severity recorded by categorical and dimensional measures, intellectual and adaptive functioning deficits, and personality change due to TBI, but not with lesion area or location. These results suggest that SADHD is a clinically important syndrome after severe TBI in children and adolescents.

Specificity and functional impact of post-exercise depression of cortically evoked motor potentials in man

Magnetic stimulation of the motor cortex with electromyographic recordings from exercising muscles has shown corticospinal excitability to be depressed following exercise. We now investigate whether this depression spreads to non-exercising muscles and its influence on performance. Healthy volunteers made unilateral biceps curls to exhaustion and, in another later session, for 25% of the time to exhaustion. Bilateral motor-evoked potentials (MEPs) in biceps brachii and first dorsal interosseus muscles were measured at 2-min intervals before and after exercise. In another experiment, subjects performed exhaustive curls and, in addition to MEP areas, force production in biceps, hand-grip force, simple reaction times and movement times were measured bilaterally. MEPs were depressed after exhaustive exercise in the exercising biceps for over 60 min; depression was also observed 10-15 min after exercise in the non-exercising biceps but not in the first dorsal interosseus of either hand. The shorter exercise period produced depression of MEPs only in the exercising muscle. After exhaustive exercise maximum voluntary contraction fell in the exercising biceps and this correlated with MEP areas. No reduction in force was seen in the non-exercising biceps but hand-grip force fell slightly in both arms. There was no change in reaction times or movement times. Depression of MEPs can occur in non-exercising homonymous muscles but not in heteronymous muscles and only when exercise levels are high. There was no measurable functional deficit in the non-exercising limb, so we conclude that the reduced corticospinal excitability observed in this limb has little or no consequence on the performance parameters measured.

Multimodality therapy for patients with clinical Stage I and II malignant mixed Müllerian tumors of the uterus

BACKGROUND

The role of adjuvant therapy in the management of patients with malignant mixed Müllerian tumors (MMMT) of the uterus has not been defined. The outcome of planned multimodality therapy for patients with apparent early stage disease was assessed.

METHODS

A pilot study was performed on 38 patients with clinical Stage I or II MMMTs of the uterus who were offered treatment according to a standard protocol. The protocol consisted of removal of the uterus, fallopian tubes, and ovaries and surgical staging followed by tailored radiation therapy and chemotherapy, consisting of cisplatin and epirubicin.

RESULTS

The overall survival was 74% (28 of 38 patients), with a mean duration of follow-up for survivors of 55 months (range, 17-121 months). The mean time to death from disease was 26 months (range, 7-87 months). The survival rate for those patients who completed treatment according to the multimodality protocol was 95% (20 of 21 patients), with a disease free survival rate of 90% (19 of 21 patients). The overall survival of patients who did not receive the recommended treatment protocol for various reasons was 47% (8 of 17 patients). An analysis of survival curves demonstrated that there was a significant survival advantage for those patients who completed the treatment according to the multimodality protocol (P = 0.01).

CONCLUSIONS

In this pilot study, patients with clinical Stage I or II MMMTs who underwent surgical staging and aggressive adjuvant radiation and chemotherapy had an excellent survival rate. The results justify a randomized prospective study of this approach.

Activation of the Saccharomyces cerevisiae filamentation/invasion pathway by osmotic stress in high-osmolarity glycogen pathway mutants

Mitogen-activated protein kinase (MAPK) cascades are frequently used signal transduction mechanisms in eukaryotes. Of the five MAPK cascades in Saccharomyces cerevisiae, the high-osmolarity glycerol response (HOG) pathway functions to sense and respond to hypertonic stress. We utilized a partial loss-of-function mutant in the HOG pathway, pbs2-3, in a high-copy suppressor screen to identify proteins that modulate growth on high-osmolarity media. Three high-copy suppressors of pbs2-3 osmosensitivity were identified: MSG5, CAK1, and TRX1. Msg5p is a dual-specificity phosphatase that was previously demonstrated to dephosphorylate MAPKs in yeast. Deletions of the putative MAPK targets of Msg5p revealed that kss1delta could suppress the osmosensitivity of pbs2-3. Kss1p is phosphorylated in response to hyperosmotic shock in a pbs2-3 strain, but not in a wild-type strain nor in a pbs2-3 strain overexpressing MSG5. Both TEC1 and FRE::lacZ expressions are activated in strains lacking a functional HOG pathway during osmotic stress in a filamentation/invasion-pathway-dependent manner. Additionally, the cellular projections formed by a pbs2-3 mutant on high osmolarity are absent in strains lacking KSS1 or STE7. These data suggest that the loss of filamentation/invasion pathway repression contributes to the HOG mutant phenotype.

Orally administered dextran sulfate is absorbed in HIV-positive individuals

Preliminary in vivo studies suggested that oral dextran sulfate was poorly absorbed, but investigations were limited by inadequate methods for measuring the drug in the body. To determine absorption in HIV-positive subjects, hydrogenated dextran sulfate, average molecular weight 8000 (Usherdex 8), was orally administered in a short-term (single dose, 4 g/day for 5 days, 7 subjects) and in a long-term study (1 g, 4 times per day for 29 to 335 days, 8 subjects), which was a continuation of the short-term study with the inclusion of an additional subject. When an agarose gel electrophoresis technique with toluidine blue staining was used, the drug was recovered from plasma (67%, peak 2.2 microg/mL) and circulating peripheral blood lymphocyte (PBL) samples (50%, peak 333 microg/L blood) obtained at 5 and 15 minutes and 1, 3, 6, and 24 hours after the first day's dose and from plasma (56%) and PBL samples (38%) obtained 5 minutes after administration on 4 subsequent days in the short-term study. In the long-term study, the drug was found in plasma (67%, peak 2.4 microg/mL) and PBL samples (25%, peak 126 microg/L blood) obtained at monthly visits within 4 hours of the last dose. The drug was found in all urine samples from all subjects in both studies (short-term study, 24-hour samples up to 4 days after the final dose; long-term study, monthly samples within 4 hours of the last dose). In the long-term study, bone marrow preparations from 3 subjects showed metachromatic inclusions present in reticular cells when the cells were stained with toluidine blue, indicating the presence of sulfated polyanions. A significant rise in activated partial thromboplastin time and a drop in platelet count (P < .025) were demonstrated, with thrombocytopenia developing in 3 patients. Mild-to-moderate gastrointestinal disturbances were experienced by 6 subjects in the short-term study and by all subjects in the long-term study. One subject experienced mild central nervous system symptoms in the short-term study. These results indicate that dextran sulfate is absorbed after oral administration; therefore, further studies on its efficacy, particularly in the early stages of the disease, along with additional observations on its toxicity, are warranted.

Influence of postoperative treatment on survival in patients with uterine papillary serous carcinoma

BACKGROUND

Uterine papillary serous carcinoma (UPSC) is an uncommon, aggressive type of endometrial cancer associated with an advanced stage at initial presentation, rapid progression of disease, and poor prognosis.

METHODS

Twenty-three patients with UPSC were included in this study. History, treatment, follow-up, and 5-year overall survival probability (5-yr OS%) were evaluated.

RESULTS

All women underwent total hysterectomy and bilateral salpingo-oophorectomy. Positive lymph nodes were found in 10 of 17 patients who underwent pelvic lymphadenectomy. Eight patients had FIGO Stage I/II, whereas 15 patients showed Stage III or IV tumors. After surgery 5 women underwent radiotherapy, 5 chemotherapy, and 8 both radiotherapy and chemotherapy. Chemotherapy consisted of cisplatin/carboplatin plus cyclophosphamide. Adjuvant irradiation consisted of vault and external beam irradiation. The median duration of follow-up was 39.4 months (25th and 75th percentiles; 26. 1, 68.1). The median overall survival was 43.3 months (12.9, 75th percentile not reached). Three of 10 patients who received only chemotherapy or radiotherapy are alive, whereas 7/8 patients who received a combination of both are alive with no evidence of disease at the time of reporting. The 5-yr OS% was 80% in those who received radio- and chemotherapy and only 30% in those who were treated with radiotherapy alone (log rank = 0.05).

CONCLUSION

These results stress the need to study and evaluate the usefulness of combined chemo- and radiation therapy in patients with uterine serous papillary cancer.

p53 protein overexpression: a strong prognostic factor in uterine papillary serous carcinoma

Uterine papillary serous carcinoma (UPSC) is an uncommon but aggressive type of endometrial cancer associated with rapid progression of disease and poor prognosis. We investigated 23 cases of UPSC. p53 expression was studied in archival paraffin-embedded tissue by immunohistochemistry. Eleven tumors (47.8%) showed p53 overexpression whereas 12 tumors (52.2%) were p53 negative. One of 8 stage I/II (12.5%) and 10/15 stage III/IV (66.6%) tumors revealed p53 staining (P = 0.027). The median overall survival was 43.3 months. Patients with advanced-stage (III, IV) disease had a 5-year overall survival probability (5-year OS%) of 24% compared to 100% in those in stages I and II (log-rank, P = 0.018). Myometrial invasion, lymphatic space invasion, or lymph node involvement did not correlate with the 5-year OS of these patients. Patients whose tumors overexpressed p53 had a significantly shorter survival than those whose tumors did not (P = 0.033). This study confirms the influence of p53 overexpression on survival in UPSC patients.

Behavioral treatment of obsessive-compulsive disorder in African Americans: clinical issues

African Americans with obessive-compulsive disorder are underrepresented in behavioral treatment outcome studies. This paper consists of a clinical discussion of issues arising during the treatment with exposure plus response prevention of two African-American women with obessive-compulsive disorder. Clinical issues, such as excessive shame, insanity fears, and a sense of uniqueness, complicated the treatment process. However, both clients made significant improvement as assessed by behavioral testing, target ratings and the Yale-Brown Obsessive-Compulsive Scale.