Social ecological influences on treatment decision-making in men diagnosed with low risk, localised prostate cancer

OBJECTIVE

Individuals diagnosed with low risk, localised prostate cancer (PCa) face a difficult decision between active surveillance (AS) and definitive treatment. We aimed to explore perceived influences on treatment decision-making from the patient and partner's perspectives.

METHODS

Patients (and partners) who met AS criteria and had chosen their treatment were recruited. Semi-structured individual interviews were conducted via telephone to explore experiences of diagnosis, impact on patient lifestyle, experiences with physicians, treatment preferences/choice, treatment information understanding and needs, and overall decision-making process. Interviews were audio recorded, transcribed verbatim, and analysed using Reflexive Thematic Analysis.

RESULTS

Twenty-four male patients (18 chose AS) and 12 female partners participated. Five themes relating to social-ecological influences on treatment choice were identified: (1) partner support and direct influence on patient treatment choice, (2) patient and partner vicarious experiences may influence treatment decisions, (3) the influence of the patient's life circumstances, (4) disclosing to wider social networks: friends, family, and co-workers, and (5) the importance of a good relationship and experience with physicians. Additionally, two themes were identified relating to information patients and partners received about the treatment options during their decision-making process.

CONCLUSIONS

A range of individual and social influences on treatment decision-making were reported. Physicians providing treatment recommendations should consider and discuss the patient and partner's existing beliefs and treatment preferences and encourage shared decision-making. Further research on treatment decision-making of partnered and non-partnered PCa patients is required. We recommend research considers social ecological factors across the personal, interpersonal, community, and policy levels.

Impact of different unconditional monetary incentives on survey response rates in men with prostate cancer: a 2-arm randomised trial

Background

Men are often viewed as a difficult group to recruit for psychological research, including in psycho-oncology. Whilst research has demonstrated the effectiveness of small monetary incentives for encouraging research participation, little research has examined different large unconditional incentive amounts. Larger unconditional incentives may result in increased participation of men in psychological research. This randomised study within a case–control trial of men diagnosed with early-stage prostate cancer aimed to investigate whether (a) response rates to a 30-min questionnaire completed via mail, online, or phone would vary with different unconditional incentive amounts, and (b) demographics would vary in those who responded within the different incentive groups.

Methods

We conducted this randomised study within a case–control cross-sectional study aiming to identify the social-ecological factors influencing treatment discontinuation in prostate cancer patients. A total of 238 participants from the cross-sectional study were randomised to receive one of two unconditional incentives (n = 121 received AUD$10, n = 117 received AUD$20) with the study materials (consent form and survey).

Results

Overall, 113 (47%) responded; n = 61/121 (50.4%) in the AUD$10 group, and n = 52/117 (44.4%) in the AUD$20 group. No evidence of a difference was found in response rates by incentive group (odds ratio 1.27, 95% CI = 0.76–2.12, p = 0.36). Additionally, there were no evident differences in the demographics of the responders vs. non-responders within each incentive group (all p > 0.05).

Conclusions

Unlike previous research, we were unable to show that higher monetary incentives were more effective for increasing response rates. An AUD$20 unconditional incentive may be no more effective than a lesser amount for encouraging prostate cancer survivors to participate in research involving long questionnaires. Future research should consider the cost-benefits of providing large unconditional incentives, as non-responses will result in lost resources perhaps better utilised in other engagement strategies.

Why do men with prostate cancer discontinue active surveillance for definitive treatment? A mixed methods investigation

Objectives

To explore the personal and/or medical reasons patients on active surveillance (AS) have, or consider having, further definitive treatment for their prostate cancer. Research suggests up to 50% of patients on AS will discontinue within 5 years, though reasons for discontinuation from the patient's perspective is under‐explored.

Methods

Prostate cancer patients who were or had been on AS for at least 6 months were recruited. A questionnaire assessed reasons for receiving/considering definitive treatment and the extent to which reasons were personal or medical. Clinical information was extracted from a state‐level population registry. A subset of participants were interviewed to further explore questionnaire responses.

Results

One‐hundred and‐three individuals completed the survey; 33 were also interviewed. Fifty‐four survey participants (52%) had discontinued AS for definitive treatment. Common reasons for discontinuation were evidence of disease progression, doctor recommendation, desire to act, and fear of progression. Many participants who considered or had treatment reported weighing medical and personal factors equally in their decision. Interview participants described strongly considering any amount of disease progression and personal factors such as fear of progression, family concerns, and adverse vicarious experiences when deciding whether to pursue treatment.

Conclusion

Both medical and personal factors are considered when deciding whether to discontinue AS. Identifying predictors of discontinuation is essential for informing supportive care services to improve AS management.

Experiences and needs of people with haematological cancers during the COVID-19 pandemic: A qualitative study

Objective

Haematological cancer patients are particularly vulnerable to the effects of COVID‐19. In addition to being immunocompromised, pandemic‐related travel restrictions have impacted access to treatments and overseas stem cell donations for patients requiring transplantation. Given this vulnerability, people with haematological cancers are at risk of experiencing heightened distress during the pandemic. This study aimed to explore haematological cancer patients' experiences and needs.

Methods

Twenty‐four Australian haematological cancer patients completed semi‐structured interviews exploring their concerns and worries during the pandemic, impact of pandemic on management of disease, access to information and support, lifestyle changes, and attitudes towards emerging models of healthcare during the pandemic. Interview transcripts were thematically analysed.

Results

Four themes reflecting the experiences of haematological cancer patients during the pandemic were identified: ‘Fears about contracting COVID‐19' (behaviour changes to protect health, impact on daily routine and habits, annoyance at dismissive attitude of others toward COVID‐19); ‘Reduced sense of connection and support’ (reduced social support and access to external support services); ‘New challenges’ (increased financial hardship, worsened health), and; ‘Underlying system and communication issues' (access to trusted information, satisfaction/dissatisfaction with care, navigating telehealth). Participants expressed a need for improved access to support services and trusted information.

Conclusions

The findings emphasise the additional challenges experienced by haematological cancer patients during the COVID‐19 pandemic and their impact on daily life. Results point to the importance of validation of increased distress during periods of uncertainty; reinforcing recommendations about high‐quality sources of information; and facilitating access to support services when face‐to‐face care is limited.

Evaluating the clinical dyad leadership model: a narrative review

PURPOSE

Dyadic leadership models, in which two professionals jointly lead and share unit responsibilities, exemplifies a recent trend in health care. Nonetheless, much remains unknown about their benefits and drawbacks. In order to understand their potential impact, we conducted a review of literature evaluating dyad leadership models in health systems.

DESIGN/METHODOLOGY/APPROACH

Our narrative review began with a search of PubMed, CINAHL, Web of Science and Scopus using key terms related to dyads and leadership. The search yielded 307 articles. We screened titles/abstracts according to these criteria: (1) focus on dyadic leadership model, i.e. physician-nurse or clinician-administrator, (2) set in health care environment and (3) peer-reviewed with an evaluative component of dyadic model. This yielded 22 articles for full evaluation, of which six were relevant for this review.

FINDINGS

These six articles contribute an assessment of (1) teamwork and communication perceptions and their changes through dyad implementation, (2) dyad model functionality within the health system, (3) lessons learned from dyad model implementation and (4) dyad model adoption and model fidelity.

RESEARCH LIMITATIONS/IMPLICATIONS

Research in this area remains nascent, and most articles focused on implementation over evaluation. It is possible that some articles were excluded due to our methodology, which excluded nonEnglish articles.

PRACTICAL IMPLICATIONS

Findings provide guidance for health care organizations seeking to implement dyadic leadership models. Rigorous studies are needed to establish the impact of dyadic leadership models on quality and patient outcomes.

ORIGINALITY/VALUE

This review consolidates evidence surrounding the implementation and evaluation of a leadership model gaining prominence in health care.

Development and psychometric properties of surveys to assess patient and family caregiver experience with care transitions

BACKGROUND

The purpose of this study was to develop and administer surveys that assess patient and family caregiver experiences with care transitions and examine the psychometric properties of the surveys. The surveys were designed to ask about 1) the transitional care services that matter most to patients and their caregivers and 2) care outcomes, including the overall quality of transitional care they received, patient self-reported health, and caregiver effort/stress.

METHODS

Survey items were developed based on a review of the literature, existing surveys, focus groups, site visits, stakeholder and expert input, and patient and caregiver cognitive interviews. We administered mail surveys with telephone follow up to patients recently discharged from 43 U.S. hospitals. Patients identified the caregivers who helped them during their hospital stay (Time 1 caregiver) and when they were home (Time 2 caregiver). Time 1 and Time 2 caregivers were surveyed by telephone only. The psychometric properties of the survey items and outcome composite measures were examined for each of the three surveys. Items that performed poorly across multiple analyses, including those with low variability and/or a high missing data, were dropped except when they were conceptually important.

RESULTS

The analysis datasets included responses from 9282 patients, 1245 Time 1 caregivers and 1749 Time 2 caregivers. The construct validity of the three proposed outcome composite measures-Overall Quality of Transitional Care (patient and caregiver surveys), Patient Overall Health (patient survey) and Caregiver Effort/Stress (caregiver surveys) -was supported by acceptable exploratory factor analysis results and acceptable internal consistency reliability. Site-level reliability was acceptable for the two patient outcome composite measures, but was low for Caregiver Effort/Stress (< 0.70). In all surveys, the Overall Quality of Transitional Care outcome composite measure was significantly correlated with other outcome composite measures and most of the single-item measures.

CONCLUSIONS

Overall, the final patient and caregiver surveys are psychometrically sound and can be used by health systems, hospitals, and researchers to assess the quality of care transitions and related outcomes. Results from these surveys can be used to improve care transitions, focusing on what matters most to patients and their family caregivers.

Validation of a commercially available indirect assay for SARS-CoV-2 neutralising antibodies using a pseudotyped virus assay

OBJECTIVES

To assess whether a commercially available CE-IVD, ELISA-based surrogate neutralisation assay (cPass, Genscript) provides a genuine measure of SARS-CoV-2 neutralisation by human sera, and further to establish whether measuring responses against the RBD of S was a diagnostically useful proxy for responses against the whole S protein.

METHODS

Serum samples from 30 patients were assayed for anti-NP responses, for 'neutralisation' by the surrogate neutralisation assay and for neutralisation by SARS-CoV-2 S pseudotyped virus assays utilising two target cell lines. Correlation between assays was measured using linear regression.

RESULTS

The responses observed within the surrogate neutralisation assay demonstrated an extremely strong, highly significant positive correlation with those observed in both pseudotyped virus assays.

CONCLUSIONS

The tested ELISA-based surrogate assay provides an immunologically useful measure of functional immune responses in a much quicker and highly automatable fashion. It also reinforces that detection of anti-RBD neutralising antibodies alone is a powerful measure of the capacity to neutralise viral infection.

Assessing Anti-HCMV Cell Mediated Immune Responses in Transplant Recipients and Healthy Controls Using a Novel Functional Assay

HCMV infection, reinfection or reactivation occurs in 60% of untreated solid organ transplant (SOT) recipients. Current clinical approaches to HCMV management include pre-emptive and prophylactic antiviral treatment strategies. The introduction of immune monitoring to better stratify patients at risk of viraemia and HCMV mediated disease could improve clinical management. Current approaches quantify T cell IFNγ responses specific for predominantly IE and pp65 proteins ex vivo, as a proxy for functional control of HCMV in vivo. However, these approaches have only a limited predictive ability. We measured the IFNγ T cell responses to an expanded panel of overlapping peptide pools specific for immunodominant HCMV proteins IE1/2, pp65, pp71, gB, UL144, and US3 in a cohort of D+R- kidney transplant recipients in a longitudinal analysis. Even with this increased antigen diversity, the results show that while all patients had detectable T cell responses, this did not correlate with control of HCMV replication in some. We wished to develop an assay that could directly measure anti-HCMV cell-mediated immunity. We evaluated three approaches, stimulation of PBMC with (i) whole HCMV lysate or (ii) a defined panel of immunodominant HCMV peptides, or (iii) fully autologous infected cells co-cultured with PBMC or isolated CD8+ T cells or NK cells. Stimulation with HCMV lysate often generated non-specific antiviral responses while stimulation with immunodominant HCMV peptide pools produced responses which were not necessarily antiviral despite strong IFNγ production. We demonstrated that IFNγ was only a minor component of secreted antiviral activity. Finally, we used an antiviral assay system to measure the effect of whole PBMC, and isolated CD8+ T cells and NK cells to control HCMV in infected autologous dermal fibroblasts. The results show that both PBMC and especially CD8+ T cells from HCMV seropositive donors have highly specific antiviral activity against HCMV. In addition, we were able to show that NK cells were also antiviral, but the level of this control was highly variable between donors and not dependant on HCMV seropositivity. Using this approach, we show that non-viraemic D+R+ SOT recipients had significant and specific antiviral activity against HCMV.

A systematic review of the unmet supportive care needs of men on active surveillance for prostate cancer

OBJECTIVE

Understanding the unmet supportive care needs of men on active surveillance for prostate cancer may enable researchers and health professionals to better support men and prevent discontinuation when there is no evidence of disease progression. This review aimed to identify the specific unmet supportive care needs of men on active surveillance.

METHODS

A systematic review following PRISMA guidelines was conducted. Databases (Pubmed, Embase, PsycINFO, and CINAHL) were searched to identify qualitative and/or quantitative studies that reported unmet needs specific to men on active surveillance. Quality appraisals were conducted before results were narratively synthesised.

RESULTS

Of the 3613 unique records identified, only eight articles were eligible (five qualitative and three cross-sectional studies). Unmet Informational, Emotional/Psychological, Social, and "Other" needs were identified. Only three studies had a primary aim of investigating unmet supportive care needs. Small active surveillance samples, use of nonvalidated measures, and minimal reporting of author reflexivity in qualitative studies were the main quality issues identified.

CONCLUSIONS

The unmet needs of men on active surveillance is an underresearched area. Preliminary evidence suggests the information available and provided to men during active surveillance is perceived as inadequate and inconsistent. Men may also be experiencing unmet psychological/emotional, social, and other needs; however, further representative, high-quality research is required to understand the magnitude of this issue. Reporting results specific to treatment type and utilising relevant theories/models (such as the social ecological model [SEM]) is recommended to ensure factors that may facilitate unmet needs are appropriately considered and reported.

Src family kinase activity drives cytomegalovirus reactivation by recruiting MOZ histone acetyltransferase activity to the viral promoter

Human cytomegalovirus (HCMV) latency and reactivation rely on a complex interplay between cellular differentiation, cell signaling pathways, and viral gene functions. HCMV reactivation in dendritic cells (DCs) is triggered by IL-6 and extracellular signal-regulated kinase (ERK)-mitogen-activated protein kinase signaling. However, activation of the same pathway fails to reactivate HCMV in other myeloid cell types, despite this signaling axis being active in those cells. We hypothesized that IL-6-induced ERK activation initiates the changes in chromatin structure required for viral reactivation but that a concomitant signal is necessary to complete the changes in chromatin structure required for gene expression to occur. Using a differential phosphoproteomics approach in cells that do or do not support IL-6-induced viral reactivation, we identified the concomitant activation of an Src family kinase (SFK), hematopoietic cell kinase (HCK), specifically in DCs in response to IL-6. Pharmacological and genetic inhibition of HCK activity indicated that HCK is required for HCMV reactivation. Furthermore, the HCK/SFK activity was linked to recruitment of the monocytic leukemia zinc finger protein (MOZ) histone acetyltransferase to the viral promoter, which promoted histone acetylation after ERK-mediated histone phosphorylation. Importantly, pharmacological and genetic inhibition of MOZ activity prevented reactivation. These results provide an explanation for the selective activation of viral gene expression in DCs by IL-6, dependent on concomitant SFK and ERK signaling. They also reveal a previously unreported role for SFK activity in the regulation of chromatin structure at promoters in eukaryotic cells via MOZ histone acetyltransferase activity.

A systematic review of the feasibility, acceptability, and efficacy of online supportive care interventions targeting men with a history of prostate cancer

PURPOSE

To examine the feasibility, acceptability, and efficacy of online supportive care interventions targeting prostate cancer survivors (PCS).

METHODS

Studies were identified through structured searches of PubMed, Embase and PsycINFO databases, and bibliographic review. Inclusion criteria were (1) examined feasibility, acceptability, or efficacy of an online intervention designed to improve supportive care outcomes for PCS; (2) presented outcome data collected from PCS separately (if mixed cancer); and (3) evaluated efficacy outcomes using randomized controlled trial (RCT) design.

RESULTS

Sixteen studies met inclusion criteria; ten were classified as RCTs. Overall, 2446 men (average age 64 years) were included. Studies reported on the following outcomes: feasibility and acceptability of an online intervention (e.g., patient support, online medical record/follow-ups, or decision aids); reducing decisional conflict/distress; improving cancer-related distress and health-related quality of life; and satisfaction with cancer care.

CONCLUSION

We found good preliminary evidence for online supportive care among PCS, but little high level evidence. Generally, the samples were small and unrepresentative. Further, inadequate acceptability measures made it difficult to determine actual PCS acceptability and satisfaction, and lack of control groups precluded strong conclusions regarding efficacy. Translation also appears minimal; few interventions are still publicly available. Larger trials with appropriate control groups and greater emphasis on translation of effective interventions is recommended.

IMPLICATIONS FOR CANCER SURVIVORS

Prostate cancer survivors have a variety of unmet supportive care needs. Using online delivery to improve the reach of high-quality supportive care programs could have a positive impact on health-related quality of life among PCS.

Human cytomegalovirus and transplantation: drug development and regulatory issues

Cytomegalovirus (CMV) infection is highly prevalent worldwide and can cause serious disease among immunocompromised individuals, including persons with HIV and transplant recipients on immunosuppressive therapies. It can also result in congenital cytomegalovirus when women are infected during pregnancy. Treatment and prevention of CMV in solid organ and haematopoietic stem cell transplant recipients is accomplished in one of three ways: (1) prophylactic therapy to prevent CMV viraemia; (2) pre-emptive therapy for those with low levels of replicating virus; and (3) treatment for established disease. Despite the high prevalence of CMV, there are few available approved drug therapies, and those that are available are hampered by toxicity and less-than-optimal efficacy. New therapies are being developed and tested; however, inconsistency in standardisation of virus levels and questions about potential endpoints in clinical trials present regulatory hurdles that must be addressed. This review covers the current state of CMV therapy, drugs currently under investigation, and clinical trial issues and questions that are in need of resolution.

A novel rare sugar inhibitor of murine herpes simplex keratitis

Purpose

To determine the therapeutic efficacy of a novel rare sugar, L-psicose, for the treatment of HSV-1 induced herpetic stromal keratitis (HSK) in a mouse eye model.

Methods

One rare sugar L-psicose was assayed for HSV-1 inhibition of in vitro virus adsorption. The IC₅₀ and IC₉₀ values of L-psicose were determined using plaque reduction assay (PRA) in CV-1 cell. Female Balb/c mice were corneally infected with HSV-1, strain KOS-GFP; A topical eye drop treatment of L-psicose was started 24 h after infection and continued four times daily for ten consecutive days. The severity of HSK was monitored by slit lamp examination in a masked fashion and Infectious HSV-1 shedding was determined by PRA.

Results

L-psicose was found to have anti-viral activity in vitro at an IC₅₀ dose of 99.5 mM and an IC₉₀ dose of 160 mM. Topical eye drop treatment with 200 mM L-psicose in PBS solution significantly reduced the severity of HSK compared to the mock treatment group. The in vivo mouse ocular model results of L-psicose therapy correlated with accelerated clearance of virus from eye swabs.

Conclusion

The results suggest that topical treatment with rare sugar L-psicose has efficacy against HSK through inhibition of HSV-1.

Hearing outcome of early postnatal exposure to hypoxia in Sprague-Dawley rats

Objective: To determine the effect of experimentally induced hypoxia, in the first 10 days of life, on physiological hearing in a Sprague-Dawley rat model. Methods: A prospective, controlled animal study was carried out using 22 male rat pups. The rats in the hypoxic group (n = 12) were reared in hypoxia for the first 10 days of life, and subsequently reared in normoxia, while those in the control group (n = 10) were reared in normoxia for the duration of the experiment. Hearing was assessed using auditory brainstem response testing at approximately 72 days of age. Results: The hypoxia group had higher auditory brainstem response thresholds for all frequencies tested (more pronounced at 16 kHz), compared with controls. Wave I-V inter-peak latencies were more prolonged in the hypoxic rats, while both groups had similar wave I latencies. Conclusion: Chronic postnatal hypoxia induced permanent hearing loss in this Sprague-Dawley rat model. Prolonged wave I-V inter-peak latencies suggested functional abnormality in the central auditory pathway.

Virus and Antibody Diagnostics for Swine Samples of the Dominican Republic Collected in Regions Near the Border to Haiti

The Dominican Republic (DR) and Haiti share the island of Hispaniola, and reportable transboundary animal diseases have been introduced between the two countries historically. Outbreaks of severe teschovirus encephalomyelitis in pigs began occurring in Haiti in February 2009, and a field and laboratort study in April 2010 indicated that the teschovirus disease is prevalent in many regions in Haiti including areas near the border with DR and that other viral disease agents, including CSF virus (CSFV), porcine circovirus type 2 (PCV-2), porcine reproductive and respiratory syndrome virus (PRRSV), and swine influenza virus (SIV), are present in the swine population in these regions. The purpose of this study was to evaluate the introduction of teschovirus encephalomyelitis from Haiti to DR and to identify the other viral disease agents present in the swine population in regions of DR near the border with Haiti. Six of 7 brains and 6 of 7 spinal cords collected from pigs with central nervous system (CNS) signs were positive in reverse transcription-polymerase chain reaction for PTV. Genome sequencing on the Dominican PTV and phylogenetic analysis on the polyprotein of PTV strains indicate that the sequence of the Dominican PTV is 99.1% identical to the Haitian isolate and closely related to other PTV-1 strains in the world. Among 109 serum samples tested, 65 (59.6%) were positive for antibodies to PCV-2, and 51 (46.8%) were positive for antibodies to CSFV. Fifty-four of the 109 serum samples were tested for antibodies to other agents. Among the 54 samples, 20 (37.0%) were seropositive to PTV-1, 17 (31.5%) tested seropositive to SIV H3N2, 12 (22.2%) were seropositive to SIV H1N1, and 1 (1.9%) was seropositive to PRRSV.

Ongoing in vivo studies with cytoskeletal drugs in tau transgenic mice

Most drug discovery efforts for Alzheimer's disease (AD) have focused on prevention or clearance of beta-amyloid (Abeta) fibrils or oligomers, with far less attention to prevention of tau abnormalities that lead to neurofibrillary tangles (NFTs). Much evidence now indicates that Abeta multimers can trigger neurodegenerative changes that involve formation of dystrophic neurites and cytoskeletal collapse, possibly due loss of microtubule (MT) stabilization by the tau protein. We have found that several MT-stabilizing agents such as Taxol significantly enhanced neuronal survival in the presence of Abeta and identified agents that enter the brain, a necessity for in vivo testing in animal models of tau pathology. Studies were designed to test two agents in the tau mutant (JNPL3) mouse that develops severe motor deficits at about seven months of age, accompanied by neuropathological markers of tau pathology. In addition to using motor performance tests through the planned period of drug administration, we designed a simple appetitive memory test that required a reduction in ad lib food intake. Although the neurochemical data are still being analyzed, we were surprised to find that all of the JNPL3 mice, whether receiving the drug or not, developed no signs of motor impairment up to 10 months of age. This is considerably beyond the age at which free-fed mice survived and suggests that the food restriction alone may have delayed the pathological process. A study is ongoing with free-fed mice to determine if the drug interventions do have any beneficial effects in these mutant mice.

Curdlan and other bacterial (1→3)-β-d-glucans

Three structural classes of (1-->3)-beta-D-glucans are encountered in some important soil-dwelling, plant-associated or human pathogenic bacteria. Linear (1-->3)-beta-glucans and side-chain-branched (1-->3,1-->2)-beta-glucans are major constituents of capsular materials, with roles in bacterial aggregation, virulence and carbohydrate storage. Cyclic (1-->3,1-->6)-beta-glucans are predominantly periplasmic, serving in osmotic adaptation. Curdlan, the linear (1-->3)-beta-glucan from Agrobacterium, has unique rheological and thermal gelling properties, with applications in the food industry and other sectors. This review includes information on the structure, properties and molecular genetics of the bacterial (1-->3)-beta-glucans, together with an overview of the physiology and biotechnology of curdlan production and applications of this biopolymer and its derivatives.

Worry about ovarian cancer risk and use of ovarian cancer screening by women at risk for ovarian cancer

OBJECTIVE

This study examined reports of perceived risk of ovarian cancer, worry, and screening use in a large sample of women. While screening for asymptomatic women is not generally recommended, in 1994 a consensus conference concluded that women with multiple affected relatives are at high risk for ovarian cancer and should be encouraged to participate in screening. The consensus report also suggested that women with a single affected first-degree relative are at elevated risk and while these women were not encouraged to get screening it was suggested that they may choose to pursue screening outside of a randomized trial [NIH Consensus Conference. JAMA 1995;273(6) 491-7].

METHODS

A total of 3257 women participated in this research by completing a mailed survey on ovarian cancer risk, worry, and use of screening. One hundred forty-two of these women were at high risk for this disease due to a strong family history. An additional 144 women were at elevated risk due to a single first-degree affected relative with ovarian cancer.

RESULTS

Family history did predict perceived risk, difficulties due to worry, and use of ovarian cancer screening. However, the group of women most likely to report high levels of perceived risk and to have received screening for ovarian cancer were women with a single affected relative rather than those at high risk, for whom screening is recommended.

CONCLUSIONS

These results suggest that many women need additional education about ovarian cancer risk. Most women overestimated their risk for this disease. Some average-risk women get screening although it is not recommended outside of randomized trials, and a significant percentage of women at high risk fail to get recommended screening.

Trans-10, cis-12 conjugated linoleic acid increases fatty acid oxidation in 3T3-L1 preadipocytes

The purpose of this study was to examine the effect of 0-50 micromol/L trans-10, cis-12 conjugated linoleic acid (CLA) and cis-9, trans-11 CLA isomers on lipid and glucose metabolism in cultures of differentiating 3T3-L1 preadipocytes. Specifically, we investigated the effects of 6 d of CLA treatment on the following: 1) (14)C-glucose and (14)C-oleic acid incorporation and esterification into lipid; 2) (14)C-glucose and (14)C-fatty acid oxidation; and 3) basal and isoproterenol-stimulated lipolysis. Trans-10, cis-12 CLA supplementation (25 and 50 micromol/L) increased both (14)C-glucose and (14)C-oleic acid incorporation into the cellular lipid fraction, which was primarily triglyceride (TG), compared with bovine serum albumin (BSA) controls. Although glucose oxidation ((14)C-glucose to (14)C-CO(2)) was unaffected by CLA supplementation, oleic acid oxidation ((14)C-oleic acid to (14)C-CO(2)) was increased by approximately 55% in the presence of 50 micromol/L trans-10, cis-12 CLA compared with BSA controls. In contrast, 50 micromol/L linoleic acid (LA) and cis-9, trans-11 CLA-treated cultures had approximately 50% lower CO(2) production from (14)C-oleic acid compared with control cultures after 6 d of fatty acid exposure. Finally, 50 micromol/L trans-10, cis-12 CLA modestly increased basal, but not isoproterenol-stimulated lipolysis compared with control cultures. Thus, the TG-lowering actions of trans-10, cis-12 CLA in cultures of 3T3-L1 preadipocytes may be via increased fatty acid oxidation, which exceeded its stimulatory effects on glucose and oleic acid incorporation into lipid.

Trans-10,cis-12 conjugated linoleic acid reduces triglyceride content while differentially affecting peroxisome proliferator activated receptor gamma2 and aP2 expression in 3T3-L1 preadipocytes

A series of experiments was conducted using 3T3-L1 preadipocytes as the cell model to determine: (i) whether the triglyceride (TG)-lowering effects of a crude mixture of conjugated linoleic acid (CLA) isomers were due to a specific isomer of CLA and the timing of treatment, (ii) if CLA reduced TG content by inhibiting a key regulator of adipogenesis, (iii) if CLA incorporated into either neutral lipid or phospholipid cell fractions, and (iv) whether the effects of CLA treatment were reversible. Trans-10,cis-12 CLA reduced TG content, whereas the cis-9,trans-11 isomer increased TG content compared to vehicle [bovine serum albumin (BSA)] controls. Treatment with 50 microM trans-10,cis-12 CLA during the entire 6 d of differentiation reduced TG content to a greater extent than treatment during either the first 3 d or last 3 d of differentiation. Trans-10,cis-12 CLA treatment of preadipocyte cultures for 48 h increased peroxisome proliferator activated receptor gamma2 (PPARgamma2) protein expression compared to cultures treated with linoleic acid (LA) or the BSA controls. CLA had no effect on adipose P2 (aP2), a fatty acid-binding protein regulated by PPARgamma2. Both the cis-9,trans-11 and the trans-10,cis-12 isomers of CLA were incorporated into neutral lipids and phospholipids. However, cis-9,trans-11 CLA levels were one- to twofold higher than trans-10,cis-12 CLA levels. Moreover, trans-10,cis-12 CLA treatment reduced cis-11 18:1 concentrations in both neutral lipids and phospholipids while increasing cis-9 18:1 and 18:2 concentrations. Palmitoleic acid (16:1) levels were also lower in the neutral lipid fraction of cultures treated with trans-10,cis-12 CLA. Supplementing trans-10,cis-12 CLA-treated cultures (50 microM) with increasing levels of LA resulted in a dose-dependent increase in TG content compared to cultures treated with 50 microM CLA alone. LA supplementation also prevented some of the morphological changes associated with trans-10,cis-12 CLA treatment as seen with scanning electron microscopy. Treatment with 50 microM trans-10,cis-12 CLA for 6 d decreased PPARgamma2 levels, and supplementation of CLA-treated cultures with LA increased PPARgamma2 levels compared with cultures treated with CLA alone. Taken together, these data indicate that in cultures of 3T3-L1 preadipocytes: (i) trans-10,cis-12 CLA is the TG-lowering isomer of CLA, and its effects are dependent on dose, duration of treatment, and the amount of LA in the cultures; (ii) trans-10,cis-12 CLA treatment alters the monounsaturated fatty acid profile of neutral- and phospholipids of the cultures; and (iii) although acute (2-d) trans-10,cis-12 CLA treatment increased PPARgamma2 protein levels, chronic (6-d) treatment decreased PPARgamma2 levels.

Handling missing data in nursing research with multiple imputation

BACKGROUND

In the data analysis phase of research, missing values present a challenge to nurse investigators. Common approaches for addressing missing data generally include complete-case analysis, available-case analysis, and single-value imputation methods. These methods have been the subject of increasing criticism with respect to their tendency to underestimate standard errors, overstate statistical significance, and introduce bias.

OBJECTIVES

This article reviews the limitations of standard approaches for handling missing data, and suggests multiple imputation is a useful method for nursing research.

METHOD

Secondary analysis was conducted to examine the effect of a public policy on the health of women using a data set that had a large degree and complex patterns of missing data.

DISCUSSION

In the example, accommodation of the incomplete data was critical to making valid inferences; however, complete-case, available-case, or single imputation could not be defended as an adequate method for dealing with the missing data patterns. Alternative methods for dealing with incomplete data were sought, and a multiple imputation approach was selected given the missing data pattern. Nurse researchers confronting similar complex patterns of missing data may find multiple imputation a useful procedure for conducting data analysis and avoiding the bias associated with other methods of handling missing data.

Trans-10, cis-12, but not cis-9, trans-11, conjugated linoleic acid attenuates lipogenesis in primary cultures of stromal vascular cells from human adipose tissue

We have previously shown that both a commercially available mixture of conjugated linoleic acid (CLA) isomers and the trans-10, cis-12 isomer of CLA reduced the triglyceride (TG) content and induced apoptosis in differentiating cultures of murine 3T3-L1 preadipocytes. However, the influence of CLA isomers on differentiating human (pre)adipocytes is unknown. Therefore, we conducted a series of studies using primary cultures of stromal vascular cells isolated from human adipose tissue to determine: 1) the influence of seeding density and thiazolidinedione (TZD) concentration on TG content; 2) the chronic dose response of cis-9, trans-11 CLA vs. trans-10, cis-12 CLA on TG content; 3) whether chronic linoleic acid supplementation could rescue the TG content of CLA-treated cultures; and 4) whether trans-10, cis-12-mediated reduction in cellular TG was due to decreased lipogenesis and/or increased lipolysis. In expt. 1, the TG content [micromol/(L x 10(6) cells)] increased as both seeding density and TZD concentration increased. For example, cultures seeded at 4 x 10(4) cells/cm(2) and supplemented with 10 micromol/L BRL 49653 had 10-fold more TG than similarly seeded cultures without BRL 49653. In expt. 2, TG content decreased as the level of trans-10, cis-12 CLA increased from 1 to 10 micromol/L, whereas the TG content increased with increasing concentrations of either linoleic acid or cis-9, trans-11 CLA. In expt. 3, linoleic acid supplementation restored the TG content of cultures treated with trans-10, cis-12 CLA compared with cultures treated with CLA alone, suggesting that attenuation of TG content by CLA is reversible. In expt. 4, glucose incorporation into total lipid decreased with increasing levels of trans-10, cis-12 CLA, whereas neither CLA isomer acutely affected lipolysis. These data suggest that the reported antiobesity actions of a supplement containing a crude mixture of CLA isomers given to humans may be due to inhibition of lipogenesis by the trans-10, cis-12 isomer.

Design issues for conducting cost-effectiveness analyses alongside clinical trials

In response to rising demands for timely economic data on new medical technologies, cost-effectiveness studies are increasingly being conducted alongside clinical trials. Because of the historical differences in perspective and methods between cost-effectiveness studies and clinical trials, the design phase of these hybrid trials requires special consideration. Cost-effectiveness studies require more comprehensive evaluations of outcomes than the endpoints typically measured in clinical trials. Often, these comprehensive outcome measures (such as quality of life) prove useful for interpreting the other endpoints measured in the trial, as well as for estimating the cost-effectiveness of the intervention. In this manuscript, we discuss several aspects related to the design of joint clinical/economic trials, including study perspective, hypothesis testing, sample size estimation, and methods for collecting cost and outcome data. We also discuss issues that may limit the external validity of the cost-effectiveness results of these trials. Many potential threats to external validity can be successfully addressed if they are identified and accounted for in the design phase of the study.

Linoleic acid partially restores the triglyceride content of conjugated linoleic acid-treated cultures of 3T3-L1 preadipocytes

We have previously demonstrated that a crude mixture of commercially available conjugated linoleic acid (CLA) isomers suppressed triglyceride (TG) content and induced apoptosis in post-confluent cultures of murine 3T3-L1 preadipocytes. Furthermore, we found that 100 &mgr;M of trans-10, cis-12 isomer of CLA had a greater TG-lowering and apoptotic effect than the crude mixture of CLA isomers. Therefore, the purpose of this study was to: 1) compare the potencies of the two main isomers found in the crude mixture of CLA isomers, e.g. cis-9, trans-11 (41%) and trans-10, cis-12 (44%); and 2) determine if the TG-reducing actions of CLA could be attenuated by the addition of increasing levels of linoleic acid to the cultures. Preadipocyte differentiation was assessed on day 7 of the differentiation protocol by measuring TG content (per 10(6) cells), cell size, and lipid staining. In experiment 1, post-confluent cultures of 3T3-L1 preadipocytes treated for the first 6 d of differentiation with 100 &mgr;M of a crude mixture of CLA isomers or 44 &mgr;M of trans-10, cis-12 CLA had less TG content than all other cultures. In contrast, cultures supplemented with 41 &mgr;M of the cis-9, trans-11 CLA isomer had the same amount of TG as the BSA controls. In experiment 2, post-confluent cultures of 3T3-L1 preadipocytes treated for the first 6 d of differentiation with 50 &mgr;M trans-10, cis-12 CLA had less TG content and a greater number of smaller cells (10-12.5 microns) compared to all other treatments. CLA-treated cultures supplemented with increasing levels of linoleic acid (50-200 &mgr;M) had greater TG contents and greater numbers of larger cells (15-20 microns) than cultures treated with 50 &mgr;M of the trans-10, cis-12 CLA isomer alone. These data demonstrate that: 1) the TG-lowering effects of the crude mixture of CLA isomers is due almost exclusively to the trans-10, cis-12 isomer; and 2) linoleic acid partially reverses CLA's attenuation of TG content, suggesting that these unsaturated fatty acids may compete for incorporation into TG or phospholipid-derived eicosanoids that regulate preadipocyte differentiation.

Relationship between underlying renal disease and renal transplantation outcome

The purpose of this study is to better characterize graft and patient survival posttransplantation by examining survival according to underlying renal disease for all first-time renal allograft recipients in the United Network for Organ Sharing (UNOS) registry. From 1987 through 1996, the UNOS registry collected data on 23,838 living and 67,183 cadaveric renal transplantations. This investigation included all patients undergoing their first renal transplantation for whom the underlying cause of renal failure could be identified and categorized. Gross 1- and 3-year patient and graft survival according to underlying renal disease are included. In addition, a Cox proportional hazards model was created to analyze the effect of underlying disease on graft and patient survival after adjusting for comorbid conditions, demographics, and type of renal transplant (living versus cadaveric). The association between underlying disease and graft and patient survival is shown. Amyloidosis, sickle cell anemia, scleroderma, and radiation nephritis are associated with poor graft and patient survival. The risk ratio for patient mortality was more than twice that for immunoglobulin A nephropathy for a number of conditions, including analgesic nephropathy, amyloidosis, and both forms of diabetes mellitus.

Factors influencing serum CA125II levels in healthy postmenopausal women

Our objective was to identify factors that correlate with CA125 concentrations in healthy postmenopausal women and to introduce recommendations for reporting and interpreting individual CA125 assay results. We analyzed repeated serum CA125 levels, as measured by the CA125II assay, in 18,748 postmenopausal women who participated in the ST: Bartholomew's/Royal London Hospital Ovarian Cancer screening trial from 1986 to 1994 and were not diagnosed with ovarian cancer during the 12-year follow-up period. We found that race is a substantial predictor of normal levels of CA125, with average CA125II concentration from African (median, 9.0; 95% range, 4.0-26.0 units/ml) and Asian women (median, 13.0; range, 5.9-33.3 units/ml) lower than that in Caucasian women (median, 14.2; range, 6.0-41.0 units/ml; P < 0.001). Women with a hysterectomy have lower CA125II values (median, 13.6; range 5.5-39.0 units/ml; P < 0.001), and women with a prior cancer diagnosis other than ovarian cancer have higher levels of CA125 II (median, 16.0; range, 6.0-49.0 units/ml; P < 0.003). Regular smoking and caffeine consumption decrease CA125 levels (P < 0.001). A woman's age, age at menarche, age at menopause, and history of a previous ovarian cyst (P < 0.05) are also predictive of baseline CA125 levels. Parity, history of hormone replacement therapy or unilateral oopherectomy, and previous use of oral contraceptives or talcum powder are not significant predictors of CA125 concentrations (P > 0.05). We concluded that clinically significant differences in individual patient characteristics need to be reflected in the screening algorithms that use CA125II so that designed performance characteristics (sensitivity and specificity) are maintained in practice.

Race, ethnicity, and the health care system: public perceptions and experiences

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

A diet containing food rich in soluble and insoluble fiber improves glycemic control and reduces hyperlipidemia among patients with type 2 diabetes mellitus

The clinical significance of fiber on metabolic control among people with type 2 diabetes is debatable. Patients with type 2 diabetes who consumed a diet containing food naturally rich in fiber (e.g., 50 g fiber/day, 50% soluble) for 6 weeks had significant improvements in glycemic control and lipid panels when compared with patients who consumed a diet with moderate amounts of fiber (e.g., 25 g fiber/day, 50% soluble). Whether this high intake of fiber-rich food, especially fruits, can be maintained, tolerated without side effects or micronutrient deficiencies, and affordable for longer than 6 weeks in people with type 2 diabetes remains to be determined.

Parameter solicitation for planning cost effectiveness studies with dichotomous outcomes

When economic endpoints are included alongside clinical effectiveness measures in randomized clinical trials (RCT), they are summarized together by the incremental cost effectiveness ratio (ICER). Adding economic endpoints to an RCT complicates the planning of experiments because investigators must now solicit their beliefs about costs, but even more challenging, they must also specify their association with effectiveness. Solicitation of correlations between costs and effects can be unintuitive, and so potentially highly inaccurate. This is unfortunate because power is highly sensitive to the association between costs and effects. Mis-specification in this association may lead to substantially underpowered or overpowered studies. We show that when clinical effectiveness measures are dichotomous, specification of the correlation between costs and effects can be avoided by instead describing their association with a mixture model. This representation leads to simple and highly intuitive parameter specifications. It may also be used to generate realistic raw data that can be used to evaluate experiment power with simulation. We give particular attention to evaluating and interpreting power when Fieller's theorem method (FTM) is used to calculate confidence for, and test hypotheses about, the ICER. Data from a previously published clinical trial are used to demonstrate the use of this new method to calculate sample size for a cost effectiveness study.

Conjugated linoleic acid suppresses triglyceride accumulation and induces apoptosis in 3T3-L1 preadipocytes

Four sets of experiments were conducted to examine the influence of conjugated linoleic acid (CLA) isomers during proliferation and differentiation of cultures of 3T3-L1 preadipocytes using physiological culturing conditions. Cultures treated with either albumin [bovine serum albumin (BSA) vehicle] or linoleic acid (LA) served as controls. For the proliferation study (Expt.1), cells were cultured in media containing a crude mixture of CLA isomers or pure LA at 0, 10, 50, or 200 microM for 4 d. Preadipocyte proliferation (cell number, 3H-thymidine incorporation into DNA) decreased as the level of CLA increased in the cultures. In contrast, LA had no impact on DNA synthesis. In Experiment 2a, postconfluent cultures were grown in media containing a crude mixture of CLA isomers or LA at 0, 10, 50, or 200 microM for the next 6 d. Postconfluent cultures supplemented with 50-200 microM CLA had less triglyceride (TG) and were smaller in size than cultures supplemented with similar amounts of LA. In Experiment 2b, postconfluent cultures supplemented with 200 microM of a crude mixture of CLA isomers or LA were harvested on days 1, 3, 6, or 9. Differences in TG content of cultures supplemented with 200 microM CLA compared to control and LA-supplemented cultures became apparent after 3 d of culture. Experiments 3a and 3b examined whether the fatty acid vehicle (BSA vs. ethanol) or the vitamin E status (+/-0.2 mM alpha-tocopherol) of the cultures altered CLA's impact on preadipocyte TG content. In Experiment 3a, ethanol-treated cultures had more TG than non-ethanol-treated cultures regardless of the fatty acid treatment. In Experiment 3b, cultures treated with 100 microM of either a crude mixture of CLA or the trans-10,cis-12 CLA isomer without supplemental vitamin E for 6 d had less TG than CLA-treated cultures containing vitamin E. In Experiment 4, postconfluent cultures were grown in media containing 100 microM LA or either a crude mixture of CLA isomers or the trans-10,cis-12 CLA isomer for 24-96 h to assess CLA's influence on the cell cycle and indices of apoptosis. Cultures treated with 100 microM CLA for 24-96 h had more apoptotic cells than BSA- or LA-treated cultures. Furthermore, cultures treated for 48 h with CLA had fewer cells in the S-phase than control cultures. The effects of the trans-10,cis-12 CLA isomer were more pronounced than those of the crude mixture of CLA isomers. These data suggest that CLA may exert its antiobesity effects by inhibiting proliferation, attenuating TG content, and/or inducing apoptosis in (pre)adipocytes.

Simulation modeling of outcomes and cost effectiveness

Modeling will continue to be used to address important issues in clinical practice and health policy issues that have not been adequately studied with high-quality clinical trials. The apparent ad hoc nature of models belies the methodologic rigor that is applied to create the best models in cancer prevention and care. Models have progressed from simple decision trees to extremely complex microsimulation analyses, yet all are built using a logical process based on objective evaluation of the path between intervention and outcome. The best modelers take great care to justify both the structure and content of the model and then test their assumptions using a comprehensive process of sensitivity analysis and model validation. Like clinical trials, models sometimes produce results that are later found to be invalid as other data become available. When weighing the value of models in health care decision making, it is reasonable to consider the alternatives. In the absence of data, clinical policy decisions are often based on the recommendations of expert opinion panels or on poorly defined notions of the standard of care or medical necessity. Because such decision making rarely entails the rigorous process of data collection, synthesis, and testing that is the core of well-conducted modeling, it is usually not possible for external audiences to examine the assumptions and data that were used to derive the decisions. One of the modeler's most challenging tasks is to make the structure and content of the model transparent to the intended audience. The purpose of this article is to clarify the process of modeling, so that readers of models are more knowledgeable about their uses, strengths, and limitations.

beta3 subunit is present in different nicotinic receptor subtypes in chick retina

Although the neuronal nicotinic beta3 subunit was cloned several years ago, it has only recently been shown to form heteromeric channels when associated with other nicotinic subunits, and very little information is available concerning its assembly in the native nicotinic receptors of the nervous system. Using subunit-specific antibodies and immunoprecipitation experiments, we have identified the retina as being the chick central nervous system (CNS) area that expresses the highest level of the beta3 subunit. Sequential immunopurification experiments showed that there are at least two populations of beta3-containing receptors in chick retina: in one, the beta3 subunit is associated with the alpha6 and beta4 subunits; in the other more heterogeneous population, the beta3 subunit is associated with the alpha2, alpha3, alpha4, beta2 and beta4 subunits. Both of these receptor populations bind [3H]epibatidine and a number of nicotinic receptor agonists with high affinity (nM) and nicotinic receptor antagonists with a lower affinity (microM). The greatest pharmacological difference between the two populations is the affinity for the alpha-conotoxin MII, which inhibits binding to alpha6-containing receptors and not that to beta3-containing receptors. We also searched for the presence of the beta3 subunit associated with the alpha-bungarotoxin binding subunits alpha7 and/or alpha8 in retina and chick brain. Immunoprecipitation studies using anti-beta3 antibodies did not detect any specific alpha-bungarotoxin labeled receptors, thus, indicating that the beta3 subunit is not present in the alpha-bungarotoxin receptors of these areas.