Promoting informed prostate cancer screening decision-making for African American men in a community-based setting

PURPOSE

Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes.

METHODS

To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest.

RESULTS

Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them.

CONCLUSION

Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Central nervous system relapse in high-risk stage 4 neuroblastoma: The HR-NBL1/SIOPEN trial experience

BACKGROUND

There is rising concern on the impact of new strategies, such as high-dose chemotherapy (HDC) and immunotherapy, on the pattern of relapse in high-risk neuroblastoma (HR-NBL). Our aim is to evaluate the incidence and identify risk factors for first recurrence in the central nervous system (CNS) in HR-NBL.

PATIENTS AND METHODS

Data from patients with stage 4V HR-NBL included from February 2002 to June 2015 in the prospective HR-NBL trial of the European International Society of Pediatric Oncology Neuroblastoma Group were analysed. Characteristics at diagnosis, treatment and the pattern of first relapse were studied. CNS imaging at relapse was centrally reviewed.

RESULTS

The 1977 included patients had a median age of 3 years (1 day-20 years); 1163 were boys. Among the 1161 first relapses, 53 were in the CNS, with an overall incidence of 2.7%, representing 6.2% of all metastatic relapses. One- and three-year post-relapse overall survival was 25 ± 6% and 8 ± 4%, respectively. Higher risk of CNS recurrence was associated with female sex (hazard ratio [HR] = 2.0 [95% confidence interval {CI}: 1.1-3.5]; P = 0.016), MYCN-amplification (HR = 2.4 [95% CI: 1.2-4.4]; P = 0.008), liver (HR = 2.5 [95% CI: 1.2-5.1]; P = 0.01) or >1 metastatic compartment involvement (HR = 7.1 [95% CI: 1.0-48.4]; P = 0.047) at diagnosis. Neither HDC nor immunotherapy was associated with higher risk of CNS recurrence. Stable incidence of CNS relapse was reported over time.

CONCLUSIONS

The risk of CNS recurrence is linked to both patient and disease characteristics, with neither impact of HDC nor immunotherapy. These findings support the current treatment strategy and do not justify a CNS prophylactic treatment.

Circulating TFH cells, serological memory, and tissue compartmentalization shape human influenza-specific B cell immunity

Immunization with the inactivated influenza vaccine (IIV) remains the most effective strategy to combat seasonal influenza infections. IIV activates B cells and T follicular helper (T_FH) cells and thus engenders antibody-secreting cells and serum antibody titers. However, the cellular events preceding generation of protective immunity in humans are inadequately understood. We undertook an in-depth analysis of B cell and T cell immune responses to IIV in 35 healthy adults. Using recombinant hemagglutinin (rHA) probes to dissect the quantity, phenotype, and isotype of influenza-specific B cells against A/California09-H1N1, A/Switzerland-H3N2, and B/Phuket, we showed that vaccination induced a three-pronged B cell response comprising a transient CXCR5^-CXCR3⁺ antibody-secreting B cell population, CD21^hiCD27⁺ memory B cells, and CD21^loCD27⁺ B cells. Activation of circulating T_FH cells correlated with the development of both CD21^lo and CD21^hi memory B cells. However, preexisting antibodies could limit increases in serum antibody titers. IIV had no marked effect on CD8⁺, mucosal-associated invariant T, γδ T, and natural killer cell activation. In addition, vaccine-induced B cells were not maintained in peripheral blood at 1 year after vaccination. We provide a dissection of rHA-specific B cells across seven human tissue compartments, showing that influenza-specific memory (CD21^hiCD27⁺) B cells primarily reside within secondary lymphoid tissues and the lungs. Our study suggests that a rational design of universal vaccines needs to consider circulating T_FH cells, preexisting serological memory, and tissue compartmentalization for effective B cell immunity, as well as to improve targeting cellular T cell immunity.

P77 Type II PEG fractures: collar or no collar

Objectives

Type 2 peg fractures are known to have low fusion rates but most are elderly with comorbidities and not fit for surgery. Increasingly, clinicians want to stop using hard collars due to its complications, but with little supporting evidence. We aim to provide data to add to this debate.

Design

Single centre cohort study.

Subjects

145 consecutive patients referred to a Major Trauma Centre as type 2 peg fracture.

Methods

All patients referred with a suspected peg fracture between March 2015 and December 2017 were included. All imaging were assessed and case notes reviewed for patient demographics, fracture management, complications and outcomes.

Results

102 cases were peg fractures (mean age=80 years). 92 (90.2%) were managed conservatively with a hard collar (mean of 87 days). 37% developed symptoms from the collar, namely pain, stiffness and non-tolerance. Bony union was achieved in only 39.1% of patients with increasing age being an independent risk factor (p<0.001). Of the 56 patients who did not have bony union, there were no reported symptoms and 90% were discharged without a collar. 2 patients were offered but declined fixation and neither reported any on-going symptoms.

Conclusions

This study adds to the body of evidence that fusion rates are low, and collar complications are not insignificant when type 2 peg fractures are treated in a hard collar. However, outcomes are good regardless of union, potentially rendering the collar unnecessary. We aim to conduct a randomised prospective study to further investigate.

Amelioration of mechanism-based inactivation of CYP3A4 by a H-PGDS inhibitor

This work describes the rational amelioration of mechanism-based inactivation (MBI) of Cytochrome P450 (CYP) 3A4 in a human hematopoietic prostaglandin D synthase (hH-PGDS) inhibitor (cpd 1). We utilized metabolism reports in order to check if patterns in the metabolism of 1 and similar compounds by CYP3A4 could be deciphered. Then we used structure based design, first modifying the CYP3A4 crystal structure (pdb code: 4NY4) by adding an oxyferryl moiety to the heme, followed by validating the modified structure to obtain the 1' and 4 position oxidation products of midazolam and then recapitulating the metabolism patterns deciphered previously for 1 and analogs. We checked if the pattern deciphered could lead to a putative reactive moiety. Finally we used the docking pose of 1 into this model of the modified CYP3A4 crystal structure to guide transformation of 1 into MBI-free H-PGDS inhibitors.

Happiness among South African private sector physiotherapists

BACKGROUND

Happiness of people can affect their daily functioning and work performance. There is limited research assessing the happiness levels of various disciplines within the health care industry. This article is the first attempt to evaluate the happiness levels of private sector physiotherapists in South Africa.

OBJECTIVES

Research in happiness and physiotherapy studies are two research areas that are not associated with one another in a global perspective. The objective of this study was to assess the happiness levels of private sector physiotherapists in South Africa.

METHODS

A hypothesised model was statistically tested using a quantitative questionnaire, which was completed online. The target population of this study were all private sector physiotherapists who are members of the South African Society of Physiotherapy. A total of 395 respondents participated in the study.

RESULTS

This study confirmed that factors such as influence, social relations, life balance, optimism, work and leisure are all positively associated with the happiness levels of private sector physiotherapists in South Africa. These variables are recommended as key focus areas for physiotherapy practice owners to address, in order to positively affect the happiness levels of all people in their workplace.

CONCLUSION

The study concludes the following: if happiness becomes a priority, then owners of physiotherapy practices need to generate a workforce who are more productive, demonstrate greater collaboration with colleagues and patients, are more positively energised, are less absent and are more loyal to the practice.

CLINICAL IMPLICATIONS

The contribution of this study is that it highlights the importance of managing staff in private physiotherapy practices in a holistic manner.

Resuspension of house dust and allergens during walking and vacuum cleaning

Conventional wisdom has been that hard, resilient surfaces resuspend fewer particles than carpeted surfaces, however, exceptions to this have been demonstrated and uncertainty remains about the factors that lead to this resuspension, notably, the effect of vacuum cleaning on either increasing or reducing resuspension from flooring. The purpose of this study was to determine how resuspension of house dust by aerodynamic size or particle type, including cat allergen and bacterial endotoxin, is affected by flooring, dust loading, embedding dust, and walking/cleaning activities. House dust was blown in and allowed to settle in a walk-in chamber after overnight deposition followed by walking or a vacuum cleaning procedure. Using an aerosol particle sizer and large-volume air samplers at different heights in the chamber, concentrations of airborne particles, resuspension rates, and fractions were computed for four types of flooring conditions during six walking activities. Carpeting resulted in significantly more airborne cat allergen and airborne endotoxin than a laminate floor. Height does have an effect on measured allergen over carpet and this is apparent with concentrations at the infant and adult air samplers. Walking on laminate flooring resuspends less house dust than walking on an equally dusty carpeted floor, where dust is entirely on the surface of the carpet. However, vacuum cleaning a laminate floor resuspended more dust than vacuum cleaning carpets, at large particle sizes of 5 µm and 10 µm. Activities following a deep cleaning of hard resilient or a carpeted surface is likely to leave no differences in resuspended particles between them.

The Integrin LFA-1 Controls T Follicular Helper Cell Generation and Maintenance

T follicular helper (Tfh) cells are a CD4⁺ T cell subset critical for long-lived humoral immunity. We hypothesized that integrins play a decisive role in Tfh cell biology. Here we show that Tfh cells expressed a highly active form of leukocyte function-associated antigen-1 (LFA-1) that was required for their survival within the germinal center niche. In addition, LFA-1 promoted expression of Bcl-6, a transcriptional repressor critical for Tfh cell differentiation, and inhibition of LFA-1 abolished Tfh cell generation and prevented protective humoral immunity to intestinal helminth infection. Furthermore, we demonstrated that expression of Talin-1, an adaptor protein that regulates LFA-1 affinity, dictated Tfh versus Th2 effector cell differentiation. Collectively, our results define unique functions for LFA-1 in the Tfh cell effector program and suggest that integrin activity is important in lineage decision-making events in the adaptive immune system.

Compartmentalization of Total and Virus-Specific Tissue-Resident Memory CD8+ T Cells in Human Lymphoid Organs

Disruption of T cell memory during severe immune suppression results in reactivation of chronic viral infections, such as Epstein Barr virus (EBV) and Cytomegalovirus (CMV). How different subsets of memory T cells contribute to the protective immunity against these viruses remains poorly defined. In this study we examined the compartmentalization of virus-specific, tissue resident memory CD8+ T cells in human lymphoid organs. This revealed two distinct populations of memory CD8+ T cells, that were CD69+CD103+ and CD69+CD103-, and were retained within the spleen and tonsils in the absence of recent T cell stimulation. These two types of memory cells were distinct not only in their phenotype and transcriptional profile, but also in their anatomical localization within tonsils and spleen. The EBV-specific, but not CMV-specific, CD8+ memory T cells preferentially accumulated in the tonsils and acquired a phenotype that ensured their retention at the epithelial sites where EBV replicates. In vitro studies revealed that the cytokine IL-15 can potentiate the retention of circulating effector memory CD8+ T cells by down-regulating the expression of sphingosine-1-phosphate receptor, required for T cell exit from tissues, and its transcriptional activator, Kruppel-like factor 2 (KLF2). Within the tonsils the expression of IL-15 was detected in regions where CD8+ T cells localized, further supporting a role for this cytokine in T cell retention. Together this study provides evidence for the compartmentalization of distinct types of resident memory T cells that could contribute to the long-term protection against persisting viral infections.

Head and neck multidisciplinary team meetings: Effect on patient management

BACKGROUND

The purpose of this study was for us to present our findings on the prospectively audited impact of head and neck multidisciplinary team meetings on patient management.

METHODS

We collected clinical data, the pre-multidisciplinary team meeting treatment plan, the post-multidisciplinary team meeting treatment plans, and follow-up data from all patients discussed at a weekly multidisciplinary team meeting and we recorded the changes in management.

RESULTS

One hundred seventy-two patients were discussed in 39 meetings. In 52 patients (30%), changes in management were documented of which 20 (67%) were major. Changes were statistically more likely when the referring physician was a medical or radiation oncologist, when the initial treatment plan did not include surgery, and when the histology was neither mucosal squamous cell cancer nor a skin malignancy. Compliance to the multidisciplinary team meeting treatment recommendation was 84% for all patients and 70% for patients with changes in their treatment recommendation.

CONCLUSION

Head and neck multidisciplinary team meetings changed management in almost a third of the cases.

Evolution in health and medicine Sackler colloquium: Comparative genomics of autism and schizophrenia

We used data from studies of copy-number variants (CNVs), single-gene associations, growth-signaling pathways, and intermediate phenotypes associated with brain growth to evaluate four alternative hypotheses for the genomic and developmental relationships between autism and schizophrenia: (i) autism subsumed in schizophrenia, (ii) independence, (iii) diametric, and (iv) partial overlap. Data from CNVs provides statistical support for the hypothesis that autism and schizophrenia are associated with reciprocal variants, such that at four loci, deletions predispose to one disorder, whereas duplications predispose to the other. Data from single-gene studies are inconsistent with a hypothesis based on independence, in that autism and schizophrenia share associated genes more often than expected by chance. However, differentiation between the partial overlap and diametric hypotheses using these data is precluded by limited overlap in the specific genetic markers analyzed in both autism and schizophrenia. Evidence from the effects of risk variants on growth-signaling pathways shows that autism-spectrum conditions tend to be associated with up-regulation of pathways due to loss of function mutations in negative regulators, whereas schizophrenia is associated with reduced pathway activation. Finally, data from studies of head and brain size phenotypes indicate that autism is commonly associated with developmentally-enhanced brain growth, whereas schizophrenia is characterized, on average, by reduced brain growth. These convergent lines of evidence appear most compatible with the hypothesis that autism and schizophrenia represent diametric conditions with regard to their genomic underpinnings, neurodevelopmental bases, and phenotypic manifestations as reflecting under-development versus dysregulated over-development of the human social brain.

Statistical disclosure control architectures for patient records in biomedical information systems

Patient record data are potentially highly sensitive and their secondary use raises both ethical and data protection issues. Disclosure of patient data could cause serious difficulties for the medical profession and be potentially damaging for individual patients and clinicians. Yet at the same time patient records are a hugely valuable resource in terms of clinical research and patient treatment. A secure, remote access system for such data would therefore provide numerous benefits. In this paper we outline the statistical disclosure risks posed by patient record data in the context of establishing a grid based medical data repository. We review good practice in existing patient databases, outline a scenario model for assessing risk and suggest a new model for statistical disclosure control of patient data. The architecture and the research method we have described have general relevance for any remote data access system where maximizing both data utility and security is a priority, and has specific relevance to medical data and bioinformatics. It can straightforwardly be integrated into data access and analysis tools.

Multicenter experience of ABO-incompatible pediatric cardiac transplantation

Although ABO blood group incompatible cardiac transplantation in neonates and infants reduces waiting list mortality without compromising outcome, the technique has not been adopted by all centers, and to date Toronto remains the only center to have published results from a large case series. We present a review of ABO-incompatible heart transplantation in the United Kingdom (UK) where current recipient selection criteria differ somewhat from those used in the United States (US) and Canada. Between February 2000 and November 2006, 21 ABO-incompatible cardiac transplants were performed in children aged 2-40 months (median 10.0). Immunosuppression followed standard regimens. Pretransplant donor-specific isohemagglutinins of >1:4, (the UNOS cutoff), were present in five patients and reduced by plasma exchange. After transplantation, 19/21 recipients demonstrated persisting deficiency of donor-specific isohemagglutinins. Significant donor-specific isohemagglutinins levels were detected repeatedly in 2/21 recipients who have shown no clinical or biopsy evidence of rejection. All recipients survive without retransplantation and there have been no episodes of humoral rejection. We conclude it is possible for other centers to replicate the excellent results achieved in Toronto and that ABO-incompatible transplantation may be performed successfully in some patients beyond infancy with established isohemagglutinin production providing preoperative antibody removing strategies are used.

AUTOMATED SCREENING WITH CONFIRMATION OF MECHANISM-BASED INACTIVATION OF CYP3A4, CYP2C9, CYP2C19, CYP2D6, AND CYP1A2 IN POOLED HUMAN LIVER MICROSOMES

A strategy is proposed to profile compounds for mechanism-based inactivation of CYP3A4, CYP2C19, CYP2C9, CYP2D6, and CYP1A2 based on an apparent partition ratio screen. Potent positives from the screen are confirmed by time- and concentration-dependent inactivation assays. Quasi-irreversible inhibitions are then differentiated from irreversible inactivations by oxidation with potassium ferricyanide and/or dialysis. The three-step screening procedure has been validated with acceptable accuracy and precision for detection and confirmation of mechanism-based inactivators in drug discovery. We report here the apparent partition ratios for 19 mechanism-based inactivators and four quasi-irreversible inhibitors obtained under the same experimental conditions. The apparent partition ratio screen was automated to provide throughput for determining structure-mechanism-based inactivation relationships. Information about reversibility can be used to assess potential toxicity mediated by covalent adducts, as well as the potential for pharmacokinetic drug-drug interactions. Direct comparison of known mechanism-based inactivators and quasi-irreversible inhibitors, based on our screening of apparent partition ratios, has identified ritonavir, mibefradil, and azamulin as highly effective mechanism-based inactivators; e.g., 1 mol of CYP3A4 was inactivated on turnover of about 2 mol of compound. Other mechanism-based inactivators we identified include bergamottin (CYP1A2 besides previously reported CYP3A4), troglitazone (CYP3A4), rosiglitazone (CYP3A4), and pioglitazone (CYP3A4). Comparison of the apparent partition ratios and inactivation clearance data for the three glitazones suggests that the chromane moiety on troglitazone contributes to its greater potency for mechanism-based inactivation.

Design of bivalent ligands using hydrogen bond linkers: synthesis and evaluation of inhibitors for human β-tryptase

We exploit the concept of using hydrogen bonds to link multiple ligands for maintaining simultaneous interactions with polyvalent binding sites. This approach is demonstrated by the syntheses and evaluation of pseudo-bivalent ligands as potent inhibitors of human beta-tryptase.

Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD

From the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder--a randomized clinical trial of 579 children ages 7-9 years receiving 14 months of medication management, behavioral treatment, combination, or community care--the authors matched each African American and Latino participant with randomly selected Caucasian participants of same sex, treatment group, and site. Although Caucasian children were significantly less symptomatic than African American and Latino children on some ratings, response to treatment did not differ significantly by ethnicity after controlling for public assistance. Ethnic minority families cooperated with and benefited significantly from combination (multimodal) treatment (d = 0.36, compared with medication). This incremental gain withstood statistical control for mother's education, single-parent status, and public assistance. Treatment for lower socioeconomic status minority children, especially if comorbid, should combine medication and behavioral treatment.

A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage

OBJECTIVE

To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration.

STUDY DESIGN

Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder.

RESULTS

A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23).

CONCLUSIONS

The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.

Sexual dysfunction following vulvectomy

OBJECTIVE

This is a pilot study to evaluate sexual dysfunction in women after vulvectomy.

METHODS

An 88-question survey was used to assess body image and the DSM IV criteria for sexual dysfunction on women who had undergone vulvectomy.

RESULTS

Forty-seven women agreed to participate in the study and 41 women (87%) returned the survey. There was a significant alteration of body image in these women after vulvectomy (P = 0.004). Sexual frequency significantly decreased after surgery (P = 0.001) and there was significant sexual dysfunction in the categories of sexual aversion disorder (P = 0.01), arousal disorder (P = 0.02), and hypoactive sexual disorder (P = 0. 001). The extent of surgery did not correlate with degree of sexual dysfunction in any category. Women who were depressed at the time of survey (as determined by the PRIME-MD scale) were more likely to suffer sexual aversion disorder (P = 0.05) and tended to have more body image disturbance (P = 0.1) and global sexual dysfunction (P = 0.06).

CONCLUSIONS

Women experience significant sexual dysfunction after vulvectomy and the extent of surgery or type of vulvectomy did not correlate with degree of sexual dysfunction. There is a significant need to address sexual problems with all women after any vulvectomy. Age, depression, worsening GOG performance status, and preoperative hypoactive sexual dysfunction were risk factors for sexual dysfunction after vulvar surgery. Appropriate counseling and treatment of depression may be of benefit to this patient population.

Increased urinary nitric oxide metabolites in patients with multiple sclerosis correlates with early and relapsing disease

Nitric oxide (NO) has been implicated in the immunopathogenesis of MS as a potential mediator of neuronal loss. To investigate the role of.NO in the development of progressive disease we measured the NO metabolites (nitrate and nitrite) and neopterin, in the urine of 129 patients with demyelinating disease (DD): 23 with clinically isolated syndromes compatible with demyelination and in 46 relapsing remitting (RR) and 60 patients with progressive MS. Eighty-nine of these 129 patients underwent Gd-enhanced MRI. In addition 58 normal control subjects (NC), 19 AIDS and 35 rheumatoid arthritis (RA) patients were studied. Patients with DD, AIDS and RA had significantly elevated urinary nitrate plus nitrite (nit : creat. urine) and neopterin (neopt : creat.urine) to creatinine ratios compared to NC subjects. (Median[25th - 75th%] nit : creat.urine: NC=1183[962 - 1365] vs DD=1245[875 - 2403], AIDS=1686[1231 - 2531], and RA=1950[1214 - 2726] mumol/mol, P<0.001 and median[25th - 75th%] neopt : creat.urine: NC=99[76 - 151] vs DD=163[119 - 266], AIDS=972[653 - 1456], and RA=389[257 - 623] mu mol/mol, P<0.001). Patients with early DD and RR MS had significantly elevated nit : creat.urine compared to patients with progressive MS (nit : creat. urine: 1612[1020 - 2733] vs 1159[790 - 1641] mu mol/mol, P=0.006). The nit : creat.urine and neopt : creat.urine did not correlate with clinical relapse or MRI activity. Excretion of.NO metabolites is increased in patients with early or relapsing-remitting disease.NO appears to be a double-edged sword, mediating tissue damage and modulating complex immunological functions which may be protective in MS.

Cervical wet mount as a negative predictor for gonococci- and Chlamydia trachomatis-induced cervicitis in a gravid population

OBJECTIVE

The purpose of this study was to determine whether a wet mount preparation of endocervical secretions from obstetric patients can accurately rule out the presence of gonococci and Chlamydia trachomatis.

STUDY DESIGN

Gravid patients were screened for gonococci and C trachomatis with a deoxyribonucleic acid probe and a wet mount preparation of endocervical secretions. The number of polymorphonuclear lymphocytes was counted and averaged per x400 high-power field. A count of <10 polymorphonuclear lymphocytes per high-power field was defined as predicting the absence of gonococci- and C trachomatis -induced cervicitis. A chi(2) analysis was used to compare the wet mount results to the deoxyribonucleic acid probe.

RESULTS

Between January and March 1998, 341 patients were enrolled in the study. Wet mount results showed 32% (108/341) of patients had <10 polymorphonuclear lymphocytes per high-power field. The incidence of infection with gonococci and C trachomatis in this population, as determined by deoxyribonucleic acid probe, was 10 of 341 (2.9%) and 30 of 340 (8.8%), respectively. The sensitivity values for gonococci and C trachomatis were 90% and 87%, respectively. The negative predictive value of the wet mount for gonococci-induced cervicitis was 99%, and that for C trachomatis -induced cervicitis was 96%.

CONCLUSION

In this population the wet mount accurately predicted the absence of gonococci- and C trachomatis -induced cervicitis. Use of this screening protocol in gravid patients has the potential to reduce the cost of screening for these 2 diseases.

Changes in serum hepatitis C virus RNA in interferon nonresponders retreated with interferon plus ribavirin: a preliminary report

Ribavirin, a nucleoside analogue, inhibits replication of RNA and DNA viruses and may control hepatitis C virus (HCV) infection through modulation of anti-inflammatory and antiviral actions. Ribavirin monotherapy has no effect on serum HCV RNA levels. In combination with interferon, this agent appears to enhance the efficacy of interferon. The aim of this study was to monitor serum HCV RNA levels early during therapy with interferon and ribavirin compared with that previously seen in the same patients during interferon monotherapy. Five patients who previously showed no response to therapy with interferon alfa 3 MU three times weekly for 6 months were retreated with the identical dose of interferon alfa 2b in combination with oral ribavirin 1,000 mg/day. Serum HCV RNA levels were monitored at baseline, week 4, week 8, and week 12 of therapy by a quantitative multicycle polymerase chain reaction assay. In the first 8 to 12 weeks, serum HCV RNA levels showed a greater decrease in all patients when retreated with combination therapy compared with interferon alone. Mean (+/- SEM) serum HCV RNA levels for interferon therapy alone were 3.3 +/- 0.95, 1.2 +/- 0.95, 1.6 +/- 1.2, and 2.3 +/- 1.2 x 10(6) copies/ml at week 0, 4, 8, and 12, respectively. This was compared with 3.3 +/- 0.83, 0.3 +/- 0.2, 0.03 +/- 0.02, and 0.15 +/- 0.14 x 10(6), respectively, for the interferon and ribavirin group (p < 0.07 at week 8). Two of five patients had undetectable serum HCV RNA during combination therapy. Combination therapy with interferon and ribavirin in prior interferon nonresponders reduces serum HCV RNA levels compared with interferon alone. This may suggest some additional antiviral effect of ribavirin when given with interferon.

Tissue distribution and metabolism of gamma-linolenoyl-3-eicosapentaenoyl propane diol enterally or intravenously administered to mice bearing human pancreatic carcinomas

Synthetic propane diol lipids have been proposed as novel compounds to deliver cytocidal polyunsaturated fatty acids (PUFA) such as gamma-linolenic (GLA) and eicosapentaenoic (EPA) acids. To assess the biodistribution and metabolism of these PUFA in immunodeficient mice bearing human pancreatic carcinomas (AsPC-1), gamma-linolenoyl-3-eicosapentaenoyl propane diol (GE diol) was provided in a fat-free diet (5% w:w) for 6 weeks or parentally administered as 14C-GE diol (1 or 3 consecutive doses of 1.66 g/kg/day) in an innovative non-ionic-digalactosyldiacylglycerol emulsion. In tumor, liver, brain, kidney, plasma and fat tissue of mice fed GE diol, PUFA were increased over 25-fold, except for arachidonic acid (AA) levels, which were reduced or remained constant when compared to mice fed control corn oil diet. GLA and EPA were mainly stored in fat tissue. The recovery of radioactivity from the i.v. infected 14C-GE diol was dose and time dependent. Ten days after the i.v. infusion, GLA was only detected in substantial concentrations in tumor and in fat tissue (21 and 202 micrograms/g, respectively). Overall, these studies showed that: GE diol emulsions provide 640-fold higher doses of both GLA and EPA without causing hemolysis or adverse effects in the host mouse when compared to free PUFA infusions; GE diol is metabolized after oral or i.v. administration; tumor concentrations of GLA and EPA from the enterally administered diol were 4 to 13-fold higher than the in vitro cytotoxic levels; EPA, competes with AA and probably inhibits the activity of delta 5 desaturase without affecting the elongation of GLA in the host and tumor tissue; the change in PUFA profile modifies the substrates for eicosanoid synthesis. In short, a potentially desirable cytotoxic PUFA pattern can be achieved in host tissues and, in particular, in a human pancreatic tumor by providing GLA and EPA in the form GE-diol. These findings guarantee further investigations in oncology with this neutral diol lipid.

When mom's sick: changes in a mother's role and in the family after her diagnosis of cancer

As social entities, individuals enact roles and carry out responsibilities. Roles are learned and influenced by many social forces. They give meaning and value to life and foster a sense of belonging and contribution. Roles can undergo profound transformation during and after a diagnosis of cancer. In most family situations, the role of mother is a significant caretaking role. However, little research has focused on understanding the alterations that can occur in the mother's role when a woman faces cancer. The purpose of this study was to explore, from a woman's perspective, the experience of being a mother living with life-threatening illness. In-depth interviews were held with 47 mothers diagnosed as having cancer. Their children ranged in age from 1 to 18 years. Content and theme analyses were performed on the transcribed texts. The findings describe the impact of the cancer on the women and their families and how they felt about any changes in their roles as mothers.

The bldD gene of Streptomyces coelicolor A3(2): a regulatory gene involved in morphogenesis and antibiotic production

The bld mutants of Streptomyces coelicolor A3(2) are blocked at the earliest stage of sporulation, the formation of aerial hyphae, and are pleiotropically defective in antibiotic production. Using a phage library of wild-type S. coelicolor DNA, we isolated a recombinant phage which restored both sporulation and antibiotic production to strains carrying the single known bldD mutation. Nucleotide sequence analysis of a 1.3-kb complementing subclone identified an open reading frame, designated bldD, encoding a translation product of 167 amino acid residues. Nucleotide sequence analysis of the bldD-containing fragment amplified from the chromosome of a bldD mutant strain revealed a point mutation changing a tyrosine residue at amino acid position 62 to a cysteine. Although a comparison of the BldD sequence to known proteins in the databases failed to show any strong similarities, analysis of the BldD sequence for secondary structural elements did reveal a putative helix-turn-helix, DNA recognition element near the C terminus of the protein. A comparison of bldD transcript levels in the bldD+ and bldD mutant strains using both Northern blot analysis and S1 nuclease protection studies showed vast overexpression of bldD transcripts in the mutant, suggesting that BldD negatively regulates its own synthesis. High-resolution S1 nuclease mapping identified the transcription start point as a G residue 63 nucleotides upstream from the bldD start codon and 7 nucleotides downstream from -10 and -35 sequences resembling E. coli-like streptomycete promoters.

Severity adjustment for length of stay: is it always necessary?

OBJECTIVE

Severity adjustment is an oft-cited requirement when comparing physicians or medical delivery systems. Each application of severity adjustment, however, has to be tested to validate the need, the method, and its value. We examined the value of severity adjustment for identifying physician outliers when studying length of stay in the hospital.

DESIGN

We compared the placement of physicians in an outlier category using a severity-adjusted average length of stay (SLOS) index with their placement using the unadjusted average length of stay (ALOS). Changes in placement of the list were validated by the utilization review coordinators.

SETTING

A 614-bed tertiary-care university teaching hospital.

SUBJECTS

We analyzed 11,146 discharges from 138 physicians in 1992.

RESULTS

The mean ALOS +/- standard deviation was 9.05 + 4.50 days, and the SLOS Index was 7.56 +/- 3.06. There were 120 inliers, 6 high outliers, and 12 low outliers by the ALOS method. Using the SLOS index, 27 of 138 physicians had their categories changed from inlier to outlier or from outlier to inlier. The difference in group changes was more significant for those going from outlier to inlier status (8/120 vs 6/18; P < .001). The patients of the six physicians whose status changed from outlier to inlier status were sicker, as indicated by the comorbidity, complications, and manifestations of disease processes score. The utilization reviewers validated the status changes in 8 of 14 instances.

CONCLUSIONS

Severity-adjusted length of stay by the SLOS index appears to provide a more accurate measure than the unadjusted ALOS. The changes, however, were small. It is not clear that the added effort is worthwhile.

In vivo and in vitro biotransformation of the lithium salt of gamma-linolenic acid by three human carcinomas

Lipid metabolism has been considered recently as a novel target for cancer therapy. In this field, lithium gamma-linolenate (LiGLA) is a promising experimental compound for use in the treatment of human tumours. In vivo and in vitro studies allowed us to assess the metabolism of radiolabelled LiGLA by tumour tissue and different organs of the host. In vitro studies demonstrated that human pancreatic (AsPC-1), prostatic (PC-3) and mammary carcinoma (ZR-75-1) cells were capable of elongating GLA from LiGLA to dihomo-gamma-linolenic acid (DGLA) and further desaturating it to arachidonic acid (AA). AsPC-1 cells showed the lowest delta5-desaturase activity on DGLA. In the in vivo studies, nude mice bearing the human carcinomas were given Li[1-(14)C]GLA (2.5 mg kg(-1)) by intravenous injection for 30 min. Mice were either sacrificed after infusion or left for up to 96 h recovery before sacrifice. In general, the organs showed a maximum uptake of radioactivity 30 min after the infusion started (t = 0). Thereafter, in major organs the percentage of injected radioactivity per g of tissue declined below 1% 96 h after infusion. In kidney, brain, testes/ovaries and all three tumour tissues, labelling remained constant throughout the experiment. The ratio of radioactivity in liver to tumour tissues ranged between 16- and 24-fold at t = 0 and between 3.1- and 3.7-fold at 96 h. All tissues showed a progressive increase in the proportion of radioactivity associated with AA with a concomitant decrease in radiolabelled GLA as the time after infusion increased. DGLA declined rapidly in liver and plasma, but at a much slower rate in brain and malignant tissue. Seventy-two hours after the infusion, GLA was only detected in plasma and tumour tissue. The sum of GLA + DGLA varied among tumour tissues, but it remained 2-4 times higher than in liver and plasma. In brain, DGLA is the major contributor to the sum of these fatty acids. Data showed that cytotoxic GLA and DGLA, the latter provided either by the host or by endogenous synthesis, remained in human tumours for at least 4 days.

Filtration of fentanyl is not the cause of the elevation of arterial blood pressure associated with post-bypass ultrafiltration in children

Modified ultrafiltration after cardiopulmonary bypass in children has been shown to be associated with an increase in arterial blood pressure. As part of a series of studies to investigate the possible causes of this blood pressure elevation, the hypothesis that if filtration was removing a significant amount of fentanyl, then the increase in blood pressure might be due to pain was proposed. Ten children, aged between 0.5 and 9.3 years (median 3.8 years), weighing 5.9 to 25.5 kg (median 15.7 kg), underwent corrective cardiac surgery (incorporating modified ultrafiltration). A standard anesthetic protocol was followed, with up to 78 micrograms/kg of fentanyl given prebypass for analgesia. After completion of cardiopulmonary bypass, modified ultrafiltration was commenced at 100 mL/min until a hematocrit of 35% was reached. Samples were taken of arterial blood (prefiltration, 3, 10, and 20 minutes postfiltration), the venous reservoir blood (prefiltration) and the filtrate (5 and 10 minutes into filtration). Hemodynamic data were recorded both prefiltration and postfiltration. The hemodynamic data showed the expected rise in both systemic arterial pressure and cardiac index after ultrafiltration. The plasma fentanyl concentrations did not significantly change after ultrafiltration: 1.59 to 12.39 ng/mL (median 6.27 ng/mL) prefiltration and 2.05 to 15.59 ng/mL (6.29 ng/mL) at 3 minutes, 2.22 to 12.64 ng/mL (6.87 ng/mL) at 10 minutes, and 1.83 to 11.52 ng/mL (5.85 ng/mL) at 20 minutes postfiltration.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethanol-responsive genes in neural cells include the 78-kilodalton glucose-regulated protein (GRP78) and 94-kilodalton glucose-regulated protein (GRP94) molecular chaperones

Previously we found that ethanol increases expression of the constitutive 70-kDa heat shock protein (Hsc70) in NG108-15 neuroblastoma x glioma cells. We suggested that known ethanol actions on cellular protein trafficking may relate to Hsc70 induction because Hsc70 functions as a molecular chaperone. Here we use a subtractive hybridization protocol to isolate ethanol-responsive genes (EtRGs). Northern blot hybridization verified ethanol-induced increases in mRNA abundance for five cDNA clones isolated from ethanol-treated NG108-15 neuroblastoma x glioma cells. DNA sequence analysis identified one EtRG as 94-kDa glucose-regulated protein (GRP94), a member of the "glucose-responsive" subgroup of stress proteins. Other identified EtRGs included an insulin-induced growth-response protein gene and an intracisternal A-type particle gene. Sequence analysis of the remaining two EtRGs showed no homology in DNA sequence databases. All EtRGs showed wide tissue expression, except SL64, which was not detected in Northern blot analyses of adult mouse or rat tissues. Ethanol also increased mRNA abundance for 78-kDa glucose-regulated protein (GRP78), a molecular chaperone known to function in glycoprotein trafficking and usually coordinately regulated with GRP94. However, ethanol induced GRP94 more than GRP78, a pattern distinct from those of other inducers of these genes. All EtRGs, including GRP94 and GRP78, showed similar ethanol concentration-dependent increases in mRNA abundance. In contrast, thapsigargin and other inducers of glucose-responsive proteins increased GRP94 and GRP78 mRNA levels without altering expression of other EtRGs. Our studies demonstrate that several molecular chaperones constitute a subset of EtRGs. Ethanol appears to regulate these EtRGs by a unique mechanism, rather than one shared by classical inducers of stress proteins.

Metabolism of n-6 fatty acids by NIH-3T3 cells transfected with the ras oncogene

N-6 fatty acid metabolism was compared in NIH-3T3 cells and DT cells, which differ only in the presence of the v-Ki-ras oncogene. Non-dividing cells were incubated with [1-14C]-labelled fatty acids (18:2n-6, 18:3n-6, 20:3n-6 and 20:4n-6) at different time intervals (2-24 h) and concentration (0-120 microM). In both cells lines, the uptake of different fatty acids from the medium was similar and reached a maximum at 6-8 h. All fatty acids reached the same maximum level in DT cells, whereas, the relative uptake of added fatty acids by NIH-3T3 cells was different: 20:4n-6 > 20:3n-6 > 18:2n-6 = 18:3n-6. Throughout the incubation (2-24 h), desaturation and elongation of n-6 fatty acids was more active in DT cells than in NIH-3T3 cells. However, in both cell lines, incubated with different n-6 fatty acid precursors, the levels of radiolabelled 20:4n-6 were relatively constant. In DT cells, phosphatidylcholine was found to be the major fraction labelled with n-6 fatty acids precursors and those of endogenous synthesis, whereas, in NIH-3T3 cells the neutral lipid fraction, particularly triglycerides, was also strongly labelled. In concentration dependent studies, phospholipid labelling by fatty acids was saturable. At lower concentrations, especially in DT cells, phospholipids were labelled predominantly. As the concentration increased there was an overflow into the triglyceride fraction. Since the differences in fatty acid metabolism between the two cell lines cannot be related to the growth rate, it is suggested that they were a consequence of the expression of the v-Ki-ras oncogene.

Liver delta 5 and delta 6 desaturase activity differs among laboratory rat strains

This study was designed to examine the variations among rat strains in hepatic fatty acid desaturase activities and to determine the correlations between the activities of these enzymes and the levels of each microsomal fatty acid. Wistar rats from two different sources as well as Long-Evans and Sprague-Dawley rats were selected to assess, under standard and identical experimental conditions, the liver delta 5 and delta 6 desaturase activities. Both desaturase activities were significantly reduced by 56% in Sprague-Dawley rats when compared to BB-Wistar control rats, whereas intermediate reduced values were detected in Wistar (CR) and Long-Evans strains. The activities of delta 5 and delta 6 desaturases were significantly and positively correlated with each other. However, no significant correlations were detected between either delta 5 or delta 6 desaturase activities and levels of any of their fatty acid substrates or any other of the major microsomal fatty acids. Fatty acid composition of microsomal total lipids showed strain dependency. A positive correlation was detected between the microsomal levels of the two major final products of both desaturases, namely 20:4n-6 and 22:6n-3. In general, the sum of n-3 or n-6 fatty acids but not the ratio of one to the other, varied among rat strains. The study demonstrated that delta 6 and delta 5 desaturase activities are strain-related. The data also suggested that (i) the desaturation activity should be measured and not predicted from the fatty acid composition and (ii) different rat strains should be used for lipid metabolic studies before conclusions are drawn for rats in general.

Plain chest radiographic changes of the absent pulmonary valve syndrome

The plain chest radiographs of 40 patients with the absent pulmonary valve syndrome in association with tetralogy of Fallot have been reviewed. The conventional frontal projection showed characteristic changes of massively dilated central pulmonary arteries with normal peripheral markings in all patients (100%). Lobar hyperinflation was present in a significant proportion of the infant group (38%) which in a smaller group can be a complication requiring surgery in addition to that for the cardiac malformation.

Metabolism of radiolabelled 18:2n-6 and 18:3n-6 by NIH-3T3 cells and the DT subclone

The incorporation and metabolism of delta-6-desaturase substrate and product, [1-14C]-linoleic (18:2n-6) and [1-14C]-gamma-linolenic acid (18:3n-6), was examined in NIH-3T3 cells and the DT subclone which differs only in the presence of the v-Ki-ras oncogene. Similar amounts of post delta-6 and delta-5 desaturase metabolites were found in both cell lines indicating that the activity of these important enzymes of fatty acid metabolism was not affected by the expression of the oncogene. However, measurable quantities of the direct elongation product of 18:2n-6, 20:2n-6, were only found in DT cells. Radiolabel was recovered predominantly from the phospholipid fraction at low fatty acid concentrations, whereas neutral lipid labelling occurred when higher concentrations of exogenous fatty acid were present. This effect was most pronounced in DT cells and may result from the presence of the activated ras oncogene.

Relationship between mouse liver delta 9 desaturase activity and plasma lipids

This study was undertaken to investigate the total plasma fatty acid composition and the relationship between plasma triacylglycerol (TG) levels and liver delta 9 desaturase activity in mice fed n-3 and/or n-6 fatty acid or hydrogenated coconut oil (HCO) (maximum 25 mg/g) supplemented diets. Generally, plasma TG levels and delta 9 desaturase activity were inversely correlated with the ratio of the sum of long chain n-6 fatty acids to 18:2n-6 and to the ratio of the sum of long chain n-3 fatty acids to 18:n-3, but they were positively correlated with the ratio of products and substrates (18:1/18:0) of the enzyme in plasma total lipids. The n-3 fatty acid (mainly 20:5n-3) enriched diet, when compared to the HCO diet at 21 d, caused a significant reduction in plasma TG levels but not in delta 9 desaturase activity. However, a marked reduction in plasma TG content (50-60%) and delta 9 desaturase activity (55-70%) was observed when both 20:5n-3 and 18:3n-6 were supplemented in the diet. The plasma TG levels and delta 9 desaturase activity rose again when the animals were fed the HCO diet or chow. The results suggest that low dose supplementation of a mixture of n-3 (mainly 20:5n-3) and n-6 (18:3n-6) fatty acids modified both plasma TG content and liver delta 9 desaturase activity, in parallel.

Effect of n-3 and n-6 fatty acids on hepatic microsomal lipid metabolism: a time course study

The present study examines the time dependent effects of n-6 and n-3 polyunsaturated fatty acids on liver microsomal lipid metabolism in FVB mice fed a diet supplemented with a mixture of free fatty acids (mainly 18:3n-6 and 20:5n-3) at 25 mg/g diet. Significant changes in the fatty acid composition of total liver and microsomal lipids were observed after 7 days on the diets. Thereafter, some animals remained on the same diet while others were fed a diet supplemented with hydrogenated coconut oil (HCO). With the exception of 20:5n-3 which showed a slower recovery, establishment of the HCO pattern was rapid indicating that the diet-induced changes could be easily reversed. The unsaturation index, the cholesterol/phospholipid ratio and the microviscosity of the microsomal membranes were not affected by these dietary manipulations. Unsaturated fatty acid supplementation reduced the activity of delta 9 desaturase by 50%. Feeding the HCO diet to mice previously fed the EPA/GLA diet led to a progressive increase in delta 9 desaturase activity, reaching 80% of the day zero values after 14 days. The monoene content of hepatic total lipids reflected, in most cases, the changes in enzyme activity. This study shows that a low dose of a n-3 and n-6 free fatty acid mixture increases the quantities of members of the n-3 family, without loss of n-6 fatty acids in microsomal membranes and modifies the activity of delta 9 desaturase without altering the microsome physicochemical parameters.

The effect of n-6 fatty acids on normal and v-Ki ras transformed NIH-3T3 cells

The effect of exogenous gamma-linolenic acid (18:3n-6) was examined on NIH-3T3 and a subclone expressing the v-Ki-ras oncogene (DT). 18:3n-6 inhibited DT cell growth more readily than NIH-3T3 cell growth. In comparison, linoleic acid (18:2n-6) had no effect on the growth of either cell line. DT cells elongated and desaturated both 18:2n-6 and 18:3n-6 to dihomo-gamma-linolenic acid (20:3n-6) and arachidonic acid (20:4n-6) to a much greater extent than NIH-3T3 cells and had a much higher membrane fluidity. The presence of the ras gene or its product appears to increase the metabolism of polyunsaturated fatty acids and potentiate the cytostatic actions of 18:3n-6.

sigma receptors in rat brain and testes show similar reductions in response to chronic haloperidol

The effect of haloperidol upon [3H]1,3-di-o-tolylguanidine ([3H]DTG) binding sites was assessed in rat brain and testes. An acute injection (10 mg/kg), in rats culled 2 h later, changed Kd values from 18 +/- 2 to 108 +/- 26 nM (brain) and 14 +/- 1 to 116 +/- 35 nM (testes), with unchanged Bmax values. Rats were injected with 4 mg/kg per day for 7, 14 and 21 days and culled 4 days after the last injection. By day 21, there was an average fall in Bmax for brain of 30% and for testes of 38%. Kd values remained unchanged. Thus peripheral and central [3H]DTG binding sites were reduced by chronic haloperidol in a similar way.