Global rural health disparities in Alzheimer's disease and related dementias: State of the science

INTRODUCTION

Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators.

METHODS

An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings.

RESULTS

A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions.

DISCUSSION

A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities.

HIGHLIGHTS

Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

A POLICY ANALYSIS OF ELDER ABUSE PREVENTION LEGISLATION: TRANSLATION OF NATIONAL INITIATIVES TO THE STATE LEVEL

Elder abuse (EA) is an under-recognized global public health threat in need of enhanced research and policy attention, with 1 in 6 older adults experiencing at least one form of abuse/neglect. Public policy changes, such as the federal 2017 Elder Abuse Prevention and Prosecution Act (EAPPA), aim to address EA, but little is known regarding translation and implementation of the initiatives to state-levels. Applying a thematic analytic approach, we identified four major themes from the EAPPA: criminal investigation support; abuse reporting; financial exploitation; and training/technical assistance. Then, we conducted a comparative policy analysis to evaluate each state’s EA statutes enacted since 2017 to determine whether statutes were updated to reflect the EAPPA’s goals. Preliminary findings from 10 states (i.e., states with the greatest proportion of older adults in each Health & Human Services region) showed that eight states had updated statutes relevant to an identified theme(s). Eight states updated statutes related to financial exploitation, highlighting the growing concern over this specific type of abuse. Four states updated statutes related to reporting, reflecting problems with identifying and detecting elder abuse. Two states updated statutes regarding investigation, demonstrating minimal emphasis on elder abuse investigation. No states updated statutes relevant to training/technical assistance. These findings indicate significant state-level variability in translation and implementation of recent legislation. More recognition, research, and policy attention to EA, in the U.S. and globally, is needed. We conclude with recommendations for innovation and prevention policy efforts coupled with multidisciplinary collaborations to strengthen implementation against EA at the state-level.

A CLINICAL-COMMUNITY PARTNERSHIP TO ADDRESS OLDER ADULTS’ SOCIAL DETERMINANTS OF HEALTH NEEDS

Social determinants of health (SDH) are non-medical social needs key to reducing health disparities and improving health outcomes. Adequately identifying patients’ unmet SDH needs in primary care (PC) is a critical first step in addressing them, yet many questions remain regarding feasibility and implementation of screenings and how to effectively meet patients’ needs and improve their outcomes. With formative and process evaluation analyses, we report on the development and implementation of a community-based pilot study to proactively target high-risk, low-income, older patients with SDH needs. Over a six-month planning period, leadership from a PC clinic and a community based aging services organization (CBO) collaboratively created a shared infrastructure for in-office SDH screening by clinicians with direct referral to CBO for SDH support. The research team addressed challenges of workflow and barriers to sharing/accessing electronic health records. The pilot program will cover a 2-year period (12-month enrollment; 12-month follow-up) in which patients are screened at annual visits and followed-up in the community. In the first 6 months, 286 patients were screened, from which 34 (12%) CBO referrals were made, and nine patients were receptive to receiving more information, suggesting a need to explore patient barriers and receptiveness to services/supports. We report on lessons learned, adaptations to the pilot, efforts to increase identification of eligible patients, and strategies to enhance uptake of services beyond the traditional health care setting. Investment in health and aging services partnerships is a viable pathway to reducing health care use and spending, especially for older adult populations

High death anxiety and ambiguous loss: Lessons learned from teaching through the COVID-19 pandemic

For gerontological educators, topics such as mortality, loss, and end-of-life issues often emerge or are central in their courses. However, teaching in the era, and aftermath, of the COVID-19 pandemic has heightened the salience of death and loss, raising questions about best practices and teaching pedagogies to support student learning amidst a global crisis. This qualitative study utilized written narratives collected during the pandemic from students enrolled in an undergraduate thanatology course. Content analysis of written narratives (n = 44) revealed three themes that can help inform strategies to best support student learning during challenging times. Participants desired more flexibility; compassion and understanding; and more targeted resources and socioemotional support. Results have immediate implications for educators teaching during the pandemic and for years to come. We provide recommendations for teaching and learning support, as well as advocate for more university and community-based thanatology and gerontology education offerings.

Experiences With Physical Distancing: Coping Strategies and Positive Experiences

A representative U.S. sample of adults completed an online survey (N=360) about perceived changes in social health and wellbeing since the implementation of physical distancing restrictions in April. Analyses are conducted on a subsample of adults aged 60+ (n=93; m=65.7 years; SD=4.7). Baseline bivariate descriptive analyses showed no geographic-based differences in self-rated health, resilience, perceived financial wellbeing, or family/friend support measures. Content analysis of rural residents’ (n=20) responses about coping strategies and positive experiences across three time points (April/July/November) revealed aspects of resilience. Individuals coped via acceptance and planning; engaging in activities; and keeping with routines. Positive experiences were relatively stable over time, with individuals describing improved health habits and enhanced social connectedness with family/neighbors. Individuals identified societal betterment and saving money as unintended benefits of the efforts to mitigate the spread of COVID-19. When faced with adversity, identifying positive experiences may help individuals cope with challenges in the long-term

Program Practices Predict Intergenerational Interaction among Youth and Older Adults

Non-familial intergenerational programs engage younger and older people in shared programming for mutual benefit, frequently involving senior centers or adult day programs and preschools. With growing interest in the potential benefits of intergenerational strategies, it is imperative to know their effects on participant interaction during intergenerational programming. To address this knowledge gap, activity leaders at five sites serving older adults and/or preschoolers received training to implement 14 evidence-based practices during intergenerational activities involving 109 older adult and 105 preschool participants over four years. We utilized multi-level modeling to test whether variations in implementation of practices were associated with variations in participants’ responses to programming on a session-by-session basis. For both preschool and older adult participants, analyses revealed that the implementation of certain practices was associated with significantly more intergenerational interaction. Specifically, when person-centered best practices (e.g., leading activities that are age- and role-appropriate for older adults) were implemented, preschoolers (estimate=5.83, SD=2.11, p=0.01 and older adults (estimate=5.11, SD=.10, p=0.02) had more intergenerational interaction. Likewise, when environmental-centered best practices were implemented, such as pairing materials between intergenerational partners, preschoolers (estimate=6.05, SD=1.57, p=0.002) and older adults (estimate=6.50, SD=1.85, p=0.001) had more intergenerational interaction. Our findings reveal session-by-session variation in intergenerational interaction that can be impacted by implementation practices, which highlights the importance of training activity leaders to implement evidence-based practices. Researchers and practitioners should consider how session-by-session variation in program implementation affects participant response.

Health and Social Determinants Associated With Delay of Health Care Among Rural Older Adults

Delaying healthcare has the capacity to increase morbidity and mortality, especially among individuals with chronic and acute health conditions. Older adults in rural areas are more likely to have chronic health conditions and are more likely to delay care due to financial barriers than their urban counterparts. To further investigate these associations, we conducted descriptive, bivariate, and regression analyses using data from a needs assessment designed to identify health needs and service delivery gaps among an economically diverse eight-county region. A random sample of adults responded to the survey, with 1,226 respondents aged 60+ (mean age = 71). The majority of respondents were White, female, and had insurance coverage. Overall, 35% of respondents experienced a delay in healthcare. We used logistic regression to determine the associations of age, gender, number of health conditions, household income, distance from medical facility, and perceived quality of neighborhood with delay of healthcare. Individuals with younger age (p = .017), more chronic conditions (p < .001), lower income (p < .001), and lower perceived quality of neighborhood (p = .008) were more likely to experience a delay in healthcare. These findings highlight risk factors that were salient prior to the onset of the COVID-19 pandemic. However, the pandemic has contributed to an increasing trend of delaying healthcare and may have amplified existing challenges. Findings may inform efforts led by healthcare providers and policy makers to facilitate timely and preventive healthcare use. Future research is needed to investigate the compounding long-term health implications of delaying healthcare.

High Death Anxiety and Ambiguous Loss: Lessons Learned From Teaching Through the COVID-19 Pandemic

For gerontological educators, topics such as mortality, loss, and end-of-life issues often emerge or are central in their courses. However, the COVID-19 pandemic has raised our awareness of loss and death on a global scale and teaching during the pandemic has raised questions about how educators, communities, or systems of higher education can support students’ learning while simultaneously experiencing losses during intense times of uncertainty. In this mixed-method study of 246 students enrolled in undergraduate thanatology courses, we explored their levels of death anxiety and their experiences with pandemic-related losses. We found that students’ death anxiety increased significantly during the pandemic, in comparison to the years prior (p < .001). We also conducted a content analysis in a subset of students’ written narratives (n = 44) regarding their pandemic experiences. We identified three themes. Participants desired: (a) more flexibility from instructors, no questions asked; (b) more compassion and understanding; and (c) specific, targeted support resources. The voices of students were filtered through the authors’ interpretation as educators to provide several teaching recommendations that support student learning during challenging times. The recommendations align with a trauma-informed approach, given the high rates of death anxiety and ambiguous loss among students, and have immediate implications for educators teaching during the pandemic, and for years to come. Finally, we also advocate for more university and community-based thanatology, and gerontology education offerings in general, to help normalize conversations about death, loss, and bereavement.

Risk Profiles of Older Rural Residents With Functional, Nutritional, and Social Needs

Community-based service organizations are well positioned to address social determinants of health by offering a range of services/supports to community residents. To identify health needs and service delivery gaps among a geographically and economically diverse eight-county region, a needs assessment was conducted to support community-based agencies efforts to better support aging residents. A random sample of adults responded to the survey, with 1,280 respondents aged 60+ (mean age=71); the majority of participants were White, female, retired, reported at least some college education, and lived with at least one person. Cluster analysis distinguished three groups of residents, informed by typical enrollment-type data and a social engagement index. A series of one-way ANCOVA and chi-square analyses were conducted to examine how low-, moderate-, and high-risk groups differed on social, nutritional, and functional health needs. High-risk respondents were significantly more likely to report needing social, nutritional, and functional health services, compared to moderate- and low-risk respondents. High-risk respondents were more likely to experience barriers to seeing a physician (X2=34.054, p<.001), a non-emergency ED visit (X2=22.799, p<.001), and an unplanned hospital visit (X2=14.484, p=.001) compared to members of either low- or moderate-risk groups. Ongoing efforts to identify high-risk residents and proactively target moderate-risk residents support low-cost community interventions (i.e., assessing residents for services in locations regularly attended, such as senior meal centers), rather than high-cost interventions (e.g., emergency care, hospitalizations) are essential. Findings inform community-based outreach approaches that target social, economic, and environmental factors essential in improving health and achieving health equity.

Memories of a Grandparent’s Death: Preparation for Future Losses

Experiences of death in early life may result in identity-defining memories that last a lifetime. Autobiographical memories serve psychosocial functions, acting as guides for future behavior. Understanding early death experiences may thus inform lifelong personal views about death, dying, and bereavement. We queried 50 adults (ages 19 – 67 years) using a structured set of questions to recall and write about their earliest and most significant losses. The narratives were qualitatively analyzed using the constant comparative method associated with grounded theory. Results indicated a grandparent’s death was the most frequently reported significant loss, reflecting the value of intergenerational relationships and the long-lasting impact of grandparent death. Themes also emerged concerning participants’ reports of the benefits of actively remembering and reflecting on loss, as well as learning from others’ losses, which further deepened their views of death. These findings highlight how early memories of death, including one's grandparents, can have lifelong impact.

Sex in Late Life: Assessing Adults’ Expectations and the Role of Healthcare Professionals

Sexual activity contributes to quality of life throughout the lifespan. However, stigma about sex in late life influences older adults’ perceptions and healthcare professionals’ perceptions of older adults’ sexual health/behaviors. Using a multi-methods approach, we examined attitudes and knowledge about sexual health/behaviors in late life. Using longitudinal data from the Midlife in the US Study (Wave 1-3; N=7049), we ran age-based growth curve models to analyze changes in levels of optimism about sex in their future. We also piloted a survey with healthcare professionals assessing attitudes, knowledge, and awareness of policy about sexual health/behaviors among older adults. Adults’ expectations became less optimistic with increased age (β = -0.1, SE = 0.003, p < .0001). Men were more optimistic than women at age 20 (p = 0.016), but men’s optimism decreased over the life course at a faster rate than did women’s (p < .0001), so that from ages 40-93, men were less optimistic than women. Among healthcare professionals (N=21), the majority indicated never or rarely asking their clients about sexual history or health/behaviors; however, they indicated some knowledge about issues relevant to older adults (e.g., safe-sex practices, sexual dysfunction). Few indicated awareness about policies related to sexual behavior among residents (i.e., issues of consent, STIs). Among adults, there is a need to address declining optimism for expectations about sex in late life. Health professionals are well-situated to raise awareness and normalize discussions about sexual health, thus countering negative stigma and contributing to increasing optimism for expectations to remain sexually active.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study

AIMS

People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population.

METHODS

We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA_1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA_1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control.

RESULTS

In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control.

CONCLUSIONS

Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Abstract P1-12-04: A phase 2 study of eribulin in breast cancer not achieving a pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC)

Background: Residual breast cancer after NAC is associated with a high risk of recurrence. Little evidence supports the use of further chemotherapy in this setting. Eribulin, an inhibitor of microtubule dynamics, demonstrated a survival advantage in patients with metastatic breast cancer who had progressed after previous anthracycline and taxane therapy. This phase 2 trial assessed the efficacy of eribulin (2-yr disease-free survival) administered postoperatively to breast cancer pts not achieving a pCR following standard NAC.

Methods: Women with invasive breast cancer (stage T1-4b, N0-2, M0 at diagnosis) and evidence of residual cancer (&gt;5 mm) in the breast or axillary lymph nodes (LN) following ≥4 cycles of standard anthracycline and/or taxane-containing NAC were eligible. Additional eligibility criteria: age ≥18 yrs, peripheral neuropathy &lt; 1, adequate hematologic, hepatic, and renal function. 3 groups were studied: Cohort A-triple negative (TN), Cohort B-HR+/HER2-, Cohort C-HER2+. After recovery from definitive surgery, all pts received eribulin mesylate 1.4mg/m2 IV on days 1 and 8 every 21 days for 6 cycles. Cohort C pts also received trastuzumab 6mg/kg IV day 1 every 21 days for a total of 1 yr from start of NAC. Adjuvant hormonal therapy and loco-regional radiotherapy were administered per institutional guidelines. We hypothesized post-operative eribulin would result in a 40% increase over the reported 40% 2 yr DFS for TN, and a 15% increase over the reported 80% 2 yr DFS for HR+/HER2- pts who did not achieve pCR following standard NAC.

Results: 127 pts were enrolled (54, Cohort A; 42, Cohort B; 31, Cohort C). Pts on Cohort C continue with study treatment. Here, we present the results of 95 pts treated on Cohorts A and B. Median age-52 yrs (range, 27-74). 87 pts (92%) had invasive ductal adenocarcinoma, 6 (6%) invasive lobular, 1 (1%) mucinous, and 1 (1 %) unknown; 34 pts (36%) had T3 or T4 tumors and 65 (68%) had N1-2 disease at diagnosis. NAC with anthracyclines was administered to 74 pts (78%), taxanes to 88 (93%), and 72 (76%) received both. 71 pts (75%) had mastectomies, 24 (25%) had breast conserving surgery. Median residual tumor was 17.5 mm (range 0.1 to 80); 60 pts (63%) were LN+. 78 pts (81%) completed the planned 6 cycles of eribulin. Adjuvant radiation was administered in 28 pts (30%). 3 pts discontinued treatment due to toxicity (1 each with G3 neutropenia, G3 nausea, and unknown grade neuropathy). The most common treatment-related G3/4 adverse events were neutropenia [29 pts (31%)] and leukopenia [10 pts (11%)]. 3 pts (3%) had G3/4 febrile neutropenia and 2 pts (2%) had G3/4 neuropathy. Growth factors were administered to 22 pts (24%). There were no treatment-related deaths. With a median follow up of 19.2 and 14.9 months for Cohorts A and B respectively, the 2 yr DFS probabilities calculated from date of surgery were 61.1 % (95% CI-41.2-76.0) for Cohort A; 82.2% (95% CI-60.2-92.7) for Cohort B.

Conclusions: The addition of eribulin is safe and feasible in pts who do not achieve pCR following anthracycline and/or taxane based NAC. At a median follow up of 19.2 months, a statistically significant improvement in the estimated 2 yr DFS was evident in the TN (Cohort A) pts.

Citation Format: Yardley DA, Peacock N, Shroff S, Molthrop, Jr DC, Anz B, Daniel BR, Young RR, Weaver R, Harwin W, Webb CD, Ward P, Shastry M, DeBusk LM, Midha R, Hainsworth JD, Burris III HA. A phase 2 study of eribulin in breast cancer not achieving a pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-12-04.

How can we improve our understanding of cardiovascular safety liabilities to develop safer medicines?

Given that cardiovascular safety liabilities remain a major cause of drug attrition during preclinical and clinical development, adverse drug reactions, and post-approval withdrawal of medicines, the Medical Research Council Centre for Drug Safety Science hosted a workshop to discuss current challenges in determining, understanding and addressing 'Cardiovascular Toxicity of Medicines'. This article summarizes the key discussions from the workshop that aimed to address three major questions: (i) what are the key cardiovascular safety liabilities in drug discovery, drug development and clinical practice? (ii) how good are preclinical and clinical strategies for detecting cardiovascular liabilities? and (iii) do we have a mechanistic understanding of these liabilities? It was concluded that in order to understand, address and ultimately reduce cardiovascular safety liabilities of new therapeutic agents there is an urgent need to: • Fully characterize the incidence, prevalence and impact of drug-induced cardiovascular issues at all stages of the drug development process. • Ascertain the predictive value of existing non-clinical models and assays towards the clinical outcome. • Understand the mechanistic basis of cardiovascular liabilities; by addressing areas where it is currently not possible to predict clinical outcome based on preclinical safety data. • Provide scientists in all disciplines with additional skills to enable them to better integrate preclinical and clinical data and to better understand the biological and clinical significance of observed changes. • Develop more appropriate, highly relevant and predictive tools and assays to identify and wherever feasible to eliminate cardiovascular safety liabilities from molecules and wherever appropriate to develop clinically relevant and reliable safety biomarkers.

Prognostic factors for non-Hodgkin's lymphoma patients treated with chemotherapy may not predict outcome in patients treated with rituximab

Several factors predict outcome for patients with non-Hodgkin's lymphoma (NHL) after chemotherapy. However, predictors of response to rituximab have not been identified. Baseline characteristics for 166 NHL patients (130 follicular) in a phase III trial of rituximab were analysed by univariate and multivariate methods to determine whether any of 27 factors predict response and/or response duration. In a univariate analysis, response to rituximab was associated with follicular histology, no prior fludarabine therapy, prior autologous bone marrow transplantation (ABMT), lack of bone marrow involvement or extranodal disease, positive bcl-2 in blood, and fewer relapses. By univariate analysis, longer median time to progression (TTP) and/or duration of response (DR) after rituximab therapy was associated with International Prognostic Index lower-risk group, multiagent chemotherapy, and low/normal serum lactate dehydrogenase (LDH) or beta2 microglobulin. In the multivariate analysis, response to rituximab correlated with follicular histology, prior ABMT, multiagent chemotherapy, and no bone marrow involvement; longer TTP and/or DR correlated with low/normal serum LDH or beta2 microglobulin, high CD3+ cells, and response to last chemotherapy. The follicular lymphoma international prognostic index (FLIPI) did not correlate consistently with response to rituximab or response duration. Several factors associated with prognosis following chemotherapy did not correlate with response to rituximab or response duration. NHL patients can respond to rituximab despite having factors associated with a poor outcome to chemotherapy.

A venom metalloproteinase from the parasitic wasp Eulophus pennicornis is toxic towards its host, tomato moth (Lacanobia oleracae)

Three genes encoding clan MB metalloproteinases (EpMP1-3) were identified from venom glands of the ectoparasitic wasp Eulophus pennicornis. The derived amino acid sequences predict mature proteins of approximately 46 kDa, with a novel two-domain structure comprising a C-terminal reprolysin domain, and an N-terminal domain of unknown function. EpMP3 expressed as a recombinant protein in Pichia pastoris had gelatinase activity, which was inhibited by EDTA. Injection of recombinant EpMP3 into fifth instar Lacanobia oleracea (host) larvae resulted in partial insect mortality associated with the moult to sixth instar, with surviving insects showing retarded development and growth. EpMP3 is expressed specifically in venom glands. These results suggest that EpMP3 is a functional component of Eulophus venom, which is able to manipulate host development.

Evaluation of bladder dose in intensity-modulated radiation therapy of the prostate

Day-to-day variation in bladder and rectal filling affects prostate location and positioning accuracy. Systems using ultrasonic localization or gold seed placement are most often used to help correct for these changes. At some institutions, patients are instructed to empty their rectum and fill their bladders prior to treatment in an attempt to standardize the prostate location, displace small bowel out of the radiation field, and move some of the bladder wall away from the high-dose area. Although instructed to come to treatment with a full bladder, it is presumed that there is variability in bladder filling each day of treatment, depending on the amount of fluids consumed and time to treatment. We have reviewed daily bladder volumes on a subset of 5 prostate patients, all of them prescribed to receive 7560 cGy in 42 fractions, and have evaluated the dosimetric consequences of bladder volume changes from full to two-third or one-third filling. All of these patients' positions were verified daily with ultrasonic localization. Those measurements have been used to help analyze the actual treated bladder volumes for comparison with the treatment plan. We find that, in general, maximum filling only occurred on the initial simulation/image acquisition day and was typically smaller on all the following treatment days. Based on our dose-volume model, we estimate that average bladder daily doses were 8-50% higher than predicted by the initial intensity-modulation radiation therapy (IMRT) plan.

Monoclonal antibodies: a new era in the treatment of non-Hodgkin's lymphoma

Monoclonal antibodies (MAbs) have been used as therapeutic agents for many years. In 1997, Rituxan (IDEC-C2B8, rituximab, MabThera) became the first MAb to be approved by the FDA for a cancer indication. Rituxan served to heighten interest in the therapeutic applications of MAbs. Herceptin (for patients with breast cancer) and Mylotarg (for patients with acute myeloid leukemia) were approved shortly thereafter. Literally dozens of antibodies are currently under investigation for a variety of malignant and non-neoplastic indications. Rituxan is effective in patients with low-grade or follicular, relapsed or refractory non-Hodgkin's lymphoma (NHL). The response rate and time to progression (responders) are in the 50% and 13 months range, respectively. It is also active in intermediate-grade NHL where a large randomized study, in combination with CHOP chemotherapy, has shown a statistically significant increase in complete response (CR) rate (75% vs. 60%), prolongation of 1 year event-free survival (69% vs. 49%) and of overall survival (83% vs. 68%) as compared to CHOP alone. This marks the first time that any agent has shown results superior to CHOP, the curative gold standard for this type of NHL. Other promising antibodies under clinical investigation include: Hu1D10; Anti CD19, 22, 52, and anti-Id antibodies. The safety profile, clinical activity, and mechanism of action of these MAbs make them ideal candidates for combination with chemotherapy or biologicals. Over the next few years, we will see very significant therapeutic advances emerge as this important research yields additional clinical results.

Infected branchial cleft cyst due to Bordetella bronchiseptica in an immunocompetent patient

A healthy 23-year-old man with fever and a tender mass in his right anterior neck was found to have a branchial cleft cyst infected with Bordetella bronchiseptica. Initial testing suggested a Brucella species, but further laboratory testing identified the organism definitively. B. bronchiseptica infection in healthy adults is an unusual event.

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

A new form of arthropod phenoloxidase is abundant in venom of the parasitoid wasp Pimpla hypochondriaca

We have recently identified phenoloxidase (PO) activity among several biologically active factors in venom from the parasitoid wasp Pimpla hypochondriaca. We have now isolated three genes, designated POI, POII and POIII, from a cDNA library made from venom-producing glands and found that their products are related to pro-phenoloxidases (PPOs), which are expressed as proenzymes in haemocytes and which mediate immune processes in arthropods. This is the first report of PO as a venom constituent. Amino acid sequence comparisons between the three Pimpla POs and PPOs revealed several notable differences, including the absence of sequences which specify the site of proteolytic activation in insect PPOs and the unprecedented occurrence of signal peptide sequences. NH(2)-terminal amino acid analysis of PO purified from venom yielded a peptide sequence matching the predicted mature NH(2) termini of POI and POII, confirming the authenticity of the signal peptide and indicating that proteolytic processing, other than to remove the signal peptide, does not occur in the wasp. Expression of POI, analysed by Northern hybridization, was approximately uniform from the time of adult emergence to day 6 post-emergence, after which it declined. A novel means of host immune suppression, mediated by the unregulated activity of venom PO in the haemocoel, is proposed.

Prediction of interindividual variation in drug plasma levels in vivo from individual enzyme kinetic data and physiologically based pharmacokinetic modeling

A strategy is presented to predict interindividual variation in drug plasma levels in vivo by the use of physiologically based pharmacokinetic modeling and human in vitro metabolic parameters, obtained through the combined use of microsomes containing single cytochrome P450 enzymes and a human liver microsome bank. The strategy, applied to the pharmaceutical compound (N-[2-(7-methoxy-1-naphtyl)-ethyl]acetamide), consists of the following steps: (1) estimation of enzyme kinetic parameters K(m) and V(max) for the key cytochrome P450 enzymes using microsomes containing individual P450 enzymes; (2) scaling-up of the V(max) values for each individual cytochrome P450 involved using the ratio between marker substrate activities obtained from the same microsomes containing single P450 enzymes and a human liver microsome bank; (3) incorporation into a physiologically based pharmacokinetic model. For validation, predicted blood plasma levels and pharmacokinetic parameters were compared to those found in human volunteers: both the absolute plasma levels as well as the range in plasma levels were well predicted. Therefore, the presented strategy appears to be promising with respect to the integration of interindividual differences in metabolism and prediction of the possible impact on plasma and tissue concentrations of drugs in humans.

Rituximab: the first monoclonal antibody approved for the treatment of lymphoma

Rituximab, a genetically engineered monoclonal chimeric antibody, targets the CD20 antigen expressed on B cells. It was approved by the US Food and Drug Administration on November 26, 1997, for the indication of relapsed or refractory, CD20-positive, B-cell, low-grade or follicular non-Hodgkin's lymphoma (LG/F NHL), and by the European Agency for the Evaluation of Medicinal Products on June 2, 1998, for therapy of patients with Stage III/IV, follicular, chemoresistant or relapsed NHL. Eight Phase II or II clinical trials in LG/F NHL patients have been completed: five single-agent studies and three combination studies. Rituximab has a favorable safety profile: most adverse events (AEs) are Grade 1 or 2, and the frequency of AEs decrease with subsequent infusions. AEs in the combination studies are consistent with those seen with individual agents. For evaluable patients in the single-agent studies, overall response rates (ORR) ranged from 40% to 60%, median duration of response (DR) ranged from 5.9 to 15.0+ months, and median time to progression (TTP) ranged from 8.1 to 19.4+ months. For evaluable patients in the combination studies, the ORR ranged from 45% to 100%, median DR ranged from 11.7+ to 39.1+ months, and median TTP ranged from 12.9+ to 40.5+ months. Studies in intermediate- and high-grade NHL are ongoing. Long-term development plans include evaluating the safety and efficacy of rituximab in various types of lymphoma and in combination with other lymphoma regimens. Future studies may explore ways to increase rituximab efficacy by upregulating CD20 or increasing effector function with different cytokines.

Determination of plate source, detector separation from one signal

We address the problem of locating a transient source, such as an acoustic emission source, in a plate. We apply time-frequency analysis to the signals detected at a receiver. These highly dispersive and complex waveforms are measured for source-receiver separations ranging from 40 to 180 plate thicknesses and at frequencies such that 10 to 20 Rayleigh-Lamb branches are included. Reassigned, smoothed, pseudo-Wigner-Ville distributions are generated that exhibit the expected sharp ridges in the time-frequency plane, lying along the predicted frequency-time-of-arrival relations. The source-receiver separation can be determined from such plots.

Single-agent monoclonal antibody efficacy in bulky non-Hodgkin's lymphoma: results of a phase II trial of rituximab

PURPOSE

A phase II trial was performed to evaluate the safety and efficacy of rituximab, a chimeric anti-CD20 monoclonal antibody, in patients with bulky (> 10-cm lesion) relapsed or refractory low-grade or follicular non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Thirty-one patients received intravenous infusions of rituximab 375 mg/m(2) weekly for four doses. All patients had at least one prior therapy (median, three; range, one to 13) and had progressive disease at study entry. Patients were a median of 4 years from diagnosis.

RESULTS

No patient had treatment discontinued because of an adverse event. No patient developed human antichimeric antibody. The overall response rate in 28 assessable patients was 43% with a median time to progression of 8.1 months (range, 4.5 to 18.6+ months) and median duration of response of 5.9 months (range, 2.8 to 12.1+ months). The average decrease in lesion size in patients who achieved a partial response was 76%, and patients with stable disease had a decrease in average lesion size of 26%. Median serum antibody concentration was higher in responders compared with nonresponders, and a negative correlation was shown between antibody concentration and tumor bulk at baseline.

CONCLUSION

Rituximab single-agent outpatient therapy is safe and shows significant clinical activity in patients with bulky relapsed or refractory low-grade or follicular B-cell NHL.

Human mitogen-activated protein kinase kinase kinase mediates the stress-induced activation of mitogen-activated protein kinase cascades

The mitogen-activated protein kinase (MAPK) cascades represent one of the important signalling mechanisms in response to environmental stimuli. We report the identification of a human MAPK kinase kinase, MAPKKK4, via sequence similarity with other MAPKKKs. When truncated MAPKKK4 (DeltaMAPKKK4) was overexpressed in HEK293 cells, it was constitutively active and induced the activation of endogenous p38alpha, c-Jun N-terminal kinase (JNK)1/2 and extracellular signal-regulated kinase (ERK)2 in vivo. Kinase-inactive DeltaMAPKKK4 partly inhibited the activation of p38alpha, JNK1/2 and ERK2 induced by stress, tumour necrosis factor alpha or epidermal growth factor, suggesting that MAPKKK4 might be physiologically involved in all three MAPK cascades. Co-expressed MAP kinase kinase (MKK)-1, MKK-4, MKK-3 and MKK-6 were activated in vivo by DeltaMAPKKK4. All of the above MKKs purified from Escherichia coli were phosphorylated and activated by DeltaMAPKKK4 immunoprecipitates in vitro. When expressed by lower plasmid doses, DeltaMAPKKK4 preferentially activated MKK-3 and p38alpha in vivo. Overexpression of DeltaMAPKKK4 did not activate the NF-kappaB pathway. Immunoprecipitation of endogenous MAPKKK4 by specific antibodies showed that MAPKKK4 was activated after the treatment of K562 cells with various stress conditions. As a broadly distributed kinase, MAPKKK4 might serve as a stress responder. MAPKKK4 is 91% identical with the recently described murine MEKK-4beta and might be its human homologue. It is also identical with the recently cloned human MAP three kinase 1 except for the lack of an internal sequence homologous to the murine MEKK-4alpha isoform. Differences in the reported functional activities of the three kinases are discussed.

An approach to use an unusual adenosine transporter to selectively deliver polyamine analogues to trypanosomes

In this paper we describe an approach to selectively deliver compounds to trypanosomes using an adenosine transporter which is unique to the trypanosome. Various polyamine analogues have been attached to known substrates of this adenosine transporter. The compounds prepared interact specifically with the adenosine transporter, some with a similar efficiency to berenil, a known substrate.

Active transport of nitrofurantoin across the mammary epithelium in vivo

Nitrofurantoin is a commonly used urinary tract antibiotic that has been found at high concentrations in human milk. In vivo studies in rats were carried out to determine the mechanism by which this drug crosses the mammary epithelium. Lactating rats were gavage-fed with nitrofurantoin, and their milk and plasma levels of the antibiotic were measured at intervals up to 8 hr. The average milk-to-plasma (M/P) ratio, calculated from the areas under the milk and plasma curves, respectively, was 23 compared with a ratio predicted to be about 0.3 on the basis of lipid partitioning and protein binding determinations. M/P ratios for two nitrofurantoin congeners were also calculated. The neutral compound furazolidone had a M/P ratio of about 1, as predicted, whereas the basic compound furaltadone had a M/P ratio of 3.49 compared with a predicted ratio of 1.4. These data suggest that nitrofurantoin and, to a lesser extent, furaltadone are actively transported across the mammary epithelium into milk.

Evaluation of renal masses detected by excretory urography: cost-effectiveness of sonography versus CT

OBJECTIVE

The purpose of this study was to compare the cost-effectiveness of sonography and CT for the evaluation of renal masses discovered at excretory urography.

MATERIALS AND METHODS

The records of 225 patients with a renal mass shown by urography who then had either sonography or CT within 3 months were reviewed retrospectively. The number, location, and size of lesions; initial and subsequent imaging tests; and final diagnoses were determined. Using the current Medicare reimbursements for sonography and CT, we calculated the economic implications of using sonography or CT as the initial examination. Any effect of the location or size of the lesion on the most cost-effective examination was also determined.

RESULTS

Twenty-one percent of patients had both initial sonography and follow-up CT because of indeterminate findings or detection of a solid mass that required further staging. When CT was done first, CT findings were equivocal in 12%, necessitating follow-up sonography. At the prevailing charges, CT would have to be needed in 70% of patients initially imaged with sonography to justify the use of CT as the initial examination. The location and size of the lesion did not affect the need for CT at a rate (greater than 70%) that would economically justify use of CT as the first imaging test. Eighty-six percent of patients with a mass detected by urography had either a simple cyst or no evidence of a mass on sonography or CT.

CONCLUSION

Sonography is the most cost-effective imaging method for the workup of a renal mass detected at urography. The number of sonographic examinations in which findings are indeterminate or positive (for a solid mass) is not sufficiently high to warrant replacement of sonography by CT, regardless of the size and location of the lesion. CT should be reserved for a limited number of specific indications.

The growth of postdoctoral general dentistry programs

From 1972 to 1990, the number of Postdoctoral General Dentistry (PGD) programs increased by 57% and enrollment increased by 57% and enrollment increased by 131% for a total of 118 PGD programs and 1,367 positions. Although there has been some increase in military and Veterans Affairs (VA) programs, the major increase was in civilian programs. From 1972-78, the major impetus for growth was hospital sponsorship of General Practice Residency (GPR) programs. With federal funding of PGD programs, civilian GPR programs continued to be the main source of growth until the accreditation of Advanced Education in General Dentistry (AEGD) programs in 1981. Subsequently, almost all increases were in AEGD programs. Over the 12-year period of federal funding (1978-90), there was an increase of 406 civilian PGD positions to make a total of 925 positions. The increase in enrollment directly attributable to federal funding was 242. The "unmet demand" for PGD programs was estimated to be approximately 300 positions for 1990, from data derived from the Survey of Dental Seniors and the Matching Program. Assuming that the number of PGD positions continues to increase by 35 positions a year, as it has in the past 12 years, the unmet demand would be met in slightly less than 10 years. If, however, a postdoctoral year was mandated for licensure, the increase in the number of positions would be far short of projected need.

Mono-(2-ethylhexyl) phthalate suppresses estradiol production independent of FSH-cAMP stimulation in rat granulosa cells

Di-(2-ethylhexyl) phthalate (DEHP) exposure suppressed preovulatory granulosa cell estradiol production in adult cycling rats. The active metabolite of DEHP, mono-(2-ethylhexyl) phthalate (MEHP), suppressed follicle-stimulating hormone (FSH)-stimulated cAMP and progesterone production in cultured rat granulosa cells. To examine how DEHP altered granulosa cell estradiol production, the effects of MEHP were studied in cultures of rat granulosa cells. Granulosa cells were obtained from DES-implanted 25-day-old female Fisher 344 rats and exposed in culture to various concentrations of MEHP (0 to 400 microM) in DMSO. Granulosa cells were stimulated with FSH, 8-bromo cyclic adenosine monophosphate (8br-cAMP), a stable cAMP analog, and various concentrations of testosterone. Estradiol production was measured by standard radioimmunoassays and normalized to cell protein. MEHP suppressed estradiol in a concentration-dependent manner whether granulosa cells were stimulated by FSH or 8-br cAMP. Therefore, MEHP suppressed estradiol independent of its suppression of the FSH-cAMP pathway and, thus, suppressed aromatase conversion of testosterone to estradiol. MEHP (100 microns) decreased the maximum velocity of aromatase in cells supplied with increasing concentrations of testosterone. However, MEHP did not alter the velocity or affinity of microsomal aromatase isolated from adult virgin Sprague-Dawley rat ovaries. Therefore, MEHP altered the absolute amount or availability of aromatase in granulosa cells. Decreased aromatase in granulosa cells would explain decreased estradiol concentrations from DEHP exposure in vivo.