Providing uninterrupted oral oncolytic therapies during the COVID-19 pandemic

226

Background: Uninterrupted utilization of oral oncolytics is critical to maximizing safety and efficacy of cancer treatment. The COVID-19 pandemic presented numerous challenges to delivering a continuous and safe supply of oral oncolytics to patients with cancer including potential loss of insurance coverage, patient lost income making copays more difficult, remote pharmacy staffing difficulties, and logistical challenges in safely distributing drug to cancer patients. Tennessee Oncology has an in-house Specialty Pharmacy that utilizes home delivery of oral oncolytics while coordinating care with providers during changing patient situations. Methods: We analyzed patients who received an oral oncolytic from our pharmacy in two periods: January-May 2019 and January-May 2020. We compared the aggregate patient copay amounts during these periods, the number of patients who utilized copay assistance or foundational financial support. For insights on continuation we also assessed the medication possession ratios (MPR, the sum of the day’s supply for all fills of a given drug in a particular period divided by the number of days in that period) during these time periods for five of our most commonly dispensed drugs. Results: The aggregate patient copay was similar between the two time periods. A 22% increase in the utilization of copay cards indicated patient’s insurance coverage was sustained. We also observed a 12% increase in the number of patients utilizing foundation support for prescriptions filled. MPRs for five commonly dispensed oral oncolytics were unchanged during COVID-19. Conclusions: Our in-house specialty pharmacy maintained delivery of oral oncolytics during the COVID-19 pandemic. Patient cost share was contained by our pharmacy staff proactively utilizing copay cards for all eligible patients and diligently securing foundational grant support. The pharmacy interventions allowed for affordability, uninterrupted pharmacy operations, and consistent medication supply. This led to continued medication adherence. MPR for the 5 top dispensed medications was consistent in a year-on-year comparison. [Table: see text]

Use of antiemetic prophylaxis and oral breakthrough medication for highly emetogenic chemotherapy (HEC) in a large community oncology network

253

Background: Prophylaxis for highly emetogenic chemotherapy (HEC) is well established in clinical guidelines, but real-world treatment patterns are unclear. Today, consistent use of prophylaxis is more easily accomplished due to the incorporation of ordering premeds into the workflow prior to administration of intravenous chemotherapy. However, prescription of oral agents for treatment of breakthrough chemotherapy induced nausea and vomiting (CINV) is less consistent and standardized and has a scant evidence base. In an effort to standardize utilization, we evaluated the use of prophylaxis and oral breakthrough medications in a large national community oncology network. Methods: Data from electronic medical records at five practices comprising over 100 clinic sites was analyzed to examine the frequency of guideline-recommended triplet 5-HT3 receptor antagonist, NK-1 receptor antagonist, and corticosteroid use for prophylaxis prior to the administration of HEC agents. Oral breakthrough medication use and preference was also analyzed. Data was collected and analyzed at the practice level. Results: We identified 2645 patients that received HEC between 1/1/2019 and 5/8/2020. We found consistently high utilization of guideline-concordant triplet prophylaxis regimens for patients receiving HEC, ranging from 90-100% at each of the five practices. In addition, most patients (mean 83%, range 67% - 94%) received a prescription for at least one oral breakthrough medication, but the agent(s) utilized varied widely across practices (Table). Ondansetron was the most commonly prescribed oral breakthrough medication (mean 68%, range 53% - 88%), while olanzapine use for either prophylaxis or breakthrough CINV across practices ranged from 1% - 4%. Conclusions: In this national community oncology network, standard recommended triplet agent prophylaxis for HEC was delivered successfully. However, opportunity exists to increase appropriate use of olanzapine and reduce variation of oral breakthrough antiemetic medications in order to optimize clinical care. [Table: see text]

Feasibility of and associated cost savings from transitioning to therapeutic biosimilar use in a large community oncology network

9

Background: The use of biosimilar drugs in the treatment of cancer offer an opportunity for oncology providers to decrease total cost of care while preserving quality. However, it remains unclear whether providers and patients may resist biosimilar use due to concerns over safety and efficacy. Our national network of 5 practices with over 100 clinics committed to a conversion to therapeutic biosimilars for trastuzumab and bevacizumab after their introduction in July 2019. Methods: Common steps to foster therapeutic biosimilar conversion included frequent communication from medical directors to providers and staff, incorporation of biosimilars into default treatment regimen orders, providing clinical teams lists identifying candidates for conversion, and tracking reasons why biosimilar switch did not occur. Most practices prioritized converting patients initiating new treatments, then later transitioning patients receiving maintenance therapy. This phased approach was taken to ensure that prior authorization and patient consent could be obtained prior to conversion. Rates of biosimilar use were calculated by comparing the number of administrations for which a biosimilar was given to the total number of administrations for which a biosimilar could have been given. Cost savings were calculated by comparing the difference in Medicare allowed rates for each originator and biosimilar drug pair at the time of administration. Results: Biosimilar use increased over time at all practices, from 0% to an average of 67% for trastuzumab and 78% for bevacizumab. The decrease in cost attributed to the use of biosimilars in the study period totaled over $4.4 million. Challenges to biosimilar use included physician preference for the originator drug, difference in preferred agents across payers, and challenges with biosimilar drug storage. Patients rarely had concerns over efficacy and safety. Conclusions: Therapeutic biosimilar adoption in a large oncology network is feasible and can lead to significant cost savings. [Table: see text]

The effects of COVID-19 on new oral oncolytic treatments

102

Background: Dependable and timely dispensing and delivery of oral oncolytics to patients with a new indication for therapy is a central part of modern cancer care. The COVID-19 pandemic has presented numerous impediments and challenges to patients receiving oral therapy from many specialty pharmacies in a timely due to remote pharmacy staffing and drug shipment. Tennessee Oncology has an integrated URAC and ACHC accredited Specialty Pharmacy to ensure the seamless care for our patients prescribed oral oncolytics. We investigated the effect of COVID-19 on the number of patients initiating care with an oral oncolytic and the time to fill during the pandemic. Methods: We analyzed the number of overall new patients to the practice and new patients receiving oral oncolytics in two year-to-year comparisons: (1) January-March 2019 vs. January-March 2020 and (2) April-May 2019 vs. April-May 2020. We then compared the average pharmacy turnaround time (defined as the time of entry of a regimen in the electronic medical record that contained an oral oncolytic until the time that prescription was ready for shipment) and the average time from regimen entry until the patient received that medication. Prescriptions received and filled on the day of order entry were recorded as a one-day turnaround time. Results: A year to year increase of 7% in practice new-patient volume was associated with a 13% increase in new oral oncolytic patients from January-March 2020. Year to year April and May comparisons, noted a 33% decrease in new-patient volume to our practice with an associated 10% decrease in new oral oncolytic patients. Time to fill remained consistent in March and April 2020 at 1.84 days vs. 1.78 for 2019. The time from regimen entry to patient shipment receipt was also stable year to year (3.10 vs. 3.06 days). Conclusions: Our in-house Specialty Pharmacy was able to continue delivery of new prescriptions for oral oncolytics during the COVID-19 pandemic. There was a fall in the number of new patient dispensing in April-May 2020 that we attribute to a decrease in cancer diagnoses related to COVID-19 as reflected by a fall in total practice new patients. New patient on-boarding activities including prior authorizations, co-pay assistance, patient education were maintained and the measured time to fill from regimen entry to patient receipt were unchanged.

Impact of a built-in electronic medical record prompt on guideline-recommended prophylactic antiviral usage in patients with multiple myeloma receiving proteasome inhibitors

248

Background: Guidelines support the use of prophylactic antivirals to prevent reactivation of herpes varicella in patients with multiple myeloma (MM) on proteasome inhibitors (PI). In our network of five oncology practices spanning over 100 clinic sites, one practice has a built-in prompt for acyclovir use in patients receiving a PI, while the other four practices do not. We used this natural experiment to determine the impact of this prompt on appropriate prophylactic antiviral usage in this patient population. Methods: We retrospectively identified all patients in our network with MM beginning a regimen containing a PI between 1/1/19 and 5/28/20. Of these patients, we identified those with documentation of a prescription for acyclovir or valacyclovir before or within 2 days of the first PI dose. We compared prophylactic usage across five practices. Practice 1 had built a prompt for the prescription of acyclovir in regimens containing bortezomib or carfilzomib within the electronic medical record (EMR) which both reminded physicians and nurses and simplified the prescribing process. No other practices had similar EMR prompts. Results: We identified 583 patients with MM who received a PI during the study period. Wide variation in rates of prophylactic antiviral usage existed across the five practices (range 21%-94%). The highest rate of prophylactic antiviral usage was practice 1 (94%). This was the only practice with a built-in EMR prompt for acyclovir usage in PI regimens. We found no association between use of prophylactic antivirals and individual provider-level volume of patients with MM. Conclusions: Use of prophylactic therapy is heterogeneous across practices. A comprehensive treatment plan containing a prompt in the EMR can markedly increase appropriate utilization. We plan to add an EMR prompt and analytics-driven reminders across our network to improve utilization of all guideline-recommend, orally administered prophylactic medications. [Table: see text]

Care coordination for oral oncolytics through pharmacy integration and cycle 1-day 1 documentation

260

Background: The growing number of oral oncolytic therapies (OOTs) necessitates a standardized EMR workflow that integrates pharmacy activities for dispense and patient management and standardizes cycle-1/day-1 (C1D1) documentation. Our practice’s treatment plans contain appropriately timed OOT follow-up activities including labs, physician follow-up visits, and pharmacy calls for toxicity and adherence checks, however complications in prescription fulfillment such as prior authorization, co-pay assistance, or inability of in-practice pharmacy to dispense limit the predictability of C1D1 dates of OOTs. Methods: An EMR query identified patients at a single clinic location of 5-medical oncologists (MDs) for whom oral oncolytic treatment plans were entered from January 1 to June 30, 2018. C1D1 date entered by the MD in the EMR was compared to the pharmacy processing system dispense date. Ten patients were identified, and 10% (1/10) had an accurate C1D1 documented within the EMR. As part of the ASCO Quality Training Program, to improve the accuracy of C1D1 documentation, a new workflow was implemented whereby: (1) a “hold” activity was added to new EMR treatment plans so that C1D1 remained pending until patients had received medication; (2) clinic checkout staff provided patients with information on the in-practice pharmacy and expectations for next steps; (3) pharmacists utilized existing reporting tools to identify newly entered treatment plans and transcribed orders into e-prescriptions sent to our practice pharmacy; (4) the pharmacy workflow ensued with pharmacy staff leading patient engagement, drug counseling; (5) pharmacists confirm C1D1, document within EMR (6) subsequent treatment plan activities were scheduled. Results: Following education and process changes within the clinic and pharmacy, accurate C1D1 documentation occurred in 90% (9/10) of patients initiating OOTs. Conclusions: Including pharmacy fulfillment time in EMR workflow can improve C1D1 documentation accuracy and associated management of OOTs. Education regarding roles and processes of prescribing MDs, pharmacy staff and clinic staff will be required to scale this process improvement throughout the organization.

Future Burden of Cancer Attributable to Current Modifiable Behaviours: A Pooled Study of Seven Australian Cohorts

Background: The Population Attributable Fraction (PAF) quantifies the fraction of cancer cases attributable to specific exposures. PAF estimates for the future burden of cancer preventable through modifications to current exposure distributions are lacking. Previous PAF studies have also not compared population subgroup differences. Aim: To apply a novel PAF method and i) assess the future burden of cancer in Australia preventable through modifications to current behaviors, and ii) compare the distribution of the preventable cancer burden between population subgroups. Methods: We harmonized and pooled data from seven Australian cohort studies (N=367058) and linked them to national registries to identify cancers and deaths. We estimated the strength of the associations between behaviors and cancer incidence and death using a proportional hazards model, adjusting for age, sex, study and other risk factors. Exposure prevalence was estimated from contemporary national health surveys. We then combined these estimates to calculate PAFs and their 95% confidence intervals for both individual and joint behavior modifications using a novel method accounting for competing risk of death and risk factor interdependence. We also compared PAFs between population subgroups by calculating the 95% confidence interval of the difference in PAF estimates. Results: During the first 10 years of follow-up, there were 22078 deaths and 27483 incident cancers, including 2025 lung, 3471 colorectal, 640 premenopausal and 2632 postmenopausal breast cancers. The leading preventable cause for lung cancer is current smoking (PAF = 53.7%), for colorectal and postmenopausal breast cancer body fatness or BMI ≥ 25 kg/m2 (PAF = 11.1% and 10.9% respectively), and for premenopausal breast cancer regular alcohol intake (PAF = 12.3%). Three in five lung cancers, but only one in five colorectal and breast cancers, are jointly attributable to potentially modifiable exposures, which also included physical inactivity and inadequate fruit intake for lung, excessive alcohol intake and current smoking for colorectal, regular alcohol intake and current menopausal hormone therapy for 1 year or more for postmenopausal breast and current oral contraceptive use for 5 years or more for premenopausal breast cancer. The cancer burden attributable to modifiable factors is markedly higher in certain population subgroups, including men (lung, colorectal), people with risk factor clustering (lung, colorectal, breast), and individuals with low educational attainment (lung, breast). Conclusion: We provided up-to-date estimates of the future Australian cancer burden attributable to modifiable risk factors, and identified population subgroups that experience the highest preventable burden. Application of the novel PAF method can inform timely public health action to improve health and health equity, by identifying those with the most to gain from programs that support behavior change and early detection.

Dual-role FilmArray® diagnostics for high-impact viral diseases

In this study, we explored the potential utility of the human-focused FilmArray® Respiratory Panel for the diagnosis of a broad range of influenza viruses of veterinary concern as compared with the standard portfolio of recommended TaqMan®-based diagnostic tests. In addition, we discuss some potential operational advantages associated with the use of such integrated sample extraction, amplification and analysis devices in the context of a future long-term, dual-role strategy for the detection of emergency diseases of both human and veterinary concern.

Comparing levels of social capital in three northern post-industrial UK cities

OBJECTIVES

A high level of 'excess' mortality (i.e. that seemingly not explained by deprivation) has been shown for Scotland compared to England & Wales and, in particular, for its largest city, Glasgow, compared to the similarly deprived postindustrial English cities of Liverpool and Manchester. The excess has been observed across all social classes, but, for premature mortality, has been shown to be highest in comparison of those of lowest socio-economic status (SES). Many theories have been proposed to explain this phenomenon. One such suggestion relates to potential differences in social capital between the cities, given the previously evidenced links between social capital and mortality. The aim of this study was to ascertain whether any aspects of social capital differed between the cities and whether, therefore, this might be a plausible explanation for some of the excess mortality observed in Glasgow.

STUDY DESIGN

Cross-sectional study.

METHODS

A representative survey of Glasgow, Liverpool and Manchester was undertaken in 2011. Social capital was measured using an expanded version of the Office for National Statistics (ONS) core 'Social Capital Harmonised Question Set'. Differences between the cities in five sets of social capital topics (views about the local area, civic participation, social networks and support, social participation, and reciprocity and trust) were explored by means of a series of multivariate regression models, while controlling for differences in the characteristics (age, gender, SES, ethnicity etc.) of the samples.

RESULTS

Some, but not all, aspects of social capital were lower among the Glasgow sample compared to those in Liverpool and Manchester. A number of these differences were greatest among those of higher, rather than lower, SES. Levels of social participation, trust and (some measures of) reciprocity were lower in Glasgow, particularly in comparison with Liverpool. However, assessment of any potential impact of these differences is limited by the cross-sectional nature of the data.

CONCLUSIONS

The analyses suggest it is at least possible that differences in some aspects of social capital could play some part in explaining Glasgow's excess mortality, especially among particular sections of its population (e.g. those of higher SES). However, in the absence of more detailed longitudinal data, this remains speculative.

7q11.23 Microduplication: a recognizable phenotype

Williams-Beuren syndrome is a well-known microdeletion syndrome with a recognizable clinical phenotype. The subtle phenotype of the reciprocal microduplication of the Williams-Beuren critical region has been described recently. We report seven further patients, and a transmitting parent, with 7q11.23 microduplication. All our patients had speech delay, autistic features and facial dysmorphism consistent with the published literature. We conclude that the presence of specific dysmorphic features, including straight, neat eyebrows, thin lips and a short philtrum, in our patients with speech delay and autistic features provides further evidence that the children with 7q11.23 microduplication have a recognizable phenotype.

Lingual sucrose reduces the pain response to nasogastric tube insertion: a randomised clinical trial

OBJECTIVE

To determine whether lingual sucrose modifies the pain response to nasogastric tube insertion in preterm infants.

DESIGN

Randomised, double-blind, placebo controlled clinical trial.

SETTING

Special care baby unit.

PATIENTS

20 stable preterm infants who required nasogastric tube insertion for feeding, randomised on 51 occasions.

INTERVENTION

Lingual 24% sucrose or water placebo (0.5-2 ml varying with body weight) administered 2 min before nasogastric tube insertion.

OUTCOME MEASURES

Heart rate, oxygen saturation (SaO2), Neonatal Facial Coding Score and presence or absence of cry.

RESULTS

Infants who received sucrose demonstrated a significantly lower Neonatal Facial Coding Score during nasogastric tube passage compared with the placebo group (median 1 (range 0-4) vs 3 (0-4), p = 0.004). There was a trend for sucrose-treated infants to have little change in heart rate during nasogastric tube passage compared with the placebo group (mean (SD) -0.73 (23) vs +11 (17), p = 0.055). Mean SaO2 did not change significantly. Pain response measurements quickly returned to baseline after nasogastric tube insertion. Adverse effects, such as apnoea or oxygen desaturation, were few and occurred equally in each group.

CONCLUSIONS

Nasogastric tube insertion induces a pain response comparable with previously reported responses to heel lance in neonates. Single-dose lingual 24% sucrose is effective in reducing the behavioural and physiological pain response to nasogastric tube insertion in preterm infants and it appears to be safe.

Critical dependence of acetate thermal mattress on gel activation temperature

BACKGROUND

Sodium acetate gel mattresses provide an active method of warming patients through release of latent heat of crystallisation. They can be used as an adjunct to incubator care or as an exclusive heat source.

OBJECTIVE

To determine activation temperatures of the Transwarmer mattress needed to achieve plateau temperatures of 38-42 degrees C.

DESIGN AND SETTING

In vitro testing of mattress temperature.

METHODS AND OUTCOME MEASURES

Transwarmer mattresses were activated at initial temperatures ranging from 5 to 40 degrees C. Mattress temperature was recorded up to 4 h to determine peak and plateau temperatures. Peak and plateau temperatures achieved by the mattress were related to the initial starting temperature.

RESULTS

The starting temperature of the mattress was strongly correlated with peak and plateau temperature (r = 0.99, p<0.001). To achieve the target temperature of 38-42 degrees C, the Transwarmer mattress requires activation between 19.2 degrees C and 28.3 degrees C. A temperature of 37 degrees C could be generated by activation at 17 degrees C.

CONCLUSIONS

Safe use of this device is critically dependent on gel temperature at the point of activation. To ensure warming of a hypothermic neonatal patient without running any risk of burns, the mattress should be activated with a gel temperature between 19 degrees C and 28 degrees C.

Epidemiology of bovine brucellosis in Northern Ireland between 1990 and 2000

Between 1990 and 2000, 317 herds of cattle in Northern Ireland were identified as being seropositive to Brucella abortus, and 68 per cent of them were attributed to transmission from neighbouring herds or to local spread. Of particular significance were three primary outbreaks in 1997, which resulted in significant secondary and tertiary spread. Three spatial clusters were identified, corresponding to two of the primary outbreaks, and the herd density and within-herd spread were highest in the largest cluster. Abortions in an infected herd and the disease-risk status of the disclosure test were positively associated with an increased within-herd prevalence.

Endotracheal tube position in neonates requiring emergency interhospital transfer

A malpositioned endotracheal tube (ETT) is common following initial intubation. This study assessed ETT position in 53 orotracheally intubated neonates referred for interhospital transfer during a 3-month period. Position of the ETT on first chest radiograph (CXR) after intubation was assessed and related to radiographic lung expansion, with documentation that the final ETT length had achieved a satisfactory position. At the time of first CXR, median ETT length at the lips was 7.0 cm (range, 5 to 12 cm) with median tip position at T3.0 (range, C7 to T6). The ETT required repositioning in 58% of patients. Most malpositioned tubes were too low (26 were withdrawn and only four were advanced; p < 0.001), with lung expansion more closely related to vertebral than clavicular position of the ETT. Final ETT length correlated well with corrected gestation ( r = 0.83; p < 0.01) and marginally less well with weight ( r = 0.79; p < 0.01). From the regression analysis, we provide a table of recommended tube lengths by gestation.

Effects of vasectomy on spermatogenesis and fertility outcome after testicular sperm extraction combined with ICSI

BACKGROUND

Each year 40,000 men have a vasectomy in the UK whilst another 2400 request a reversal to begin a second family. Sperm can now be obtained by testicular biopsy and subsequently used in assisted conception with ICSI. The study aims were to compare sperm yields of men post-vasectomy or with obstructive azoospermia (OA) of unknown aetiology with yields of fertile men and to assess any alteration in the clinical pregnancy rates after ICSI.

METHODS

Testicular tissue was obtained by Trucut needle from men who had undergone a vasectomy >5 years previously or had OA from other causes and from fertile men during vasectomy. Seminiferous tubules were milked to measure sperm yields. Numbers of Sertoli cells and spermatids and thickness of the seminiferous tubule walls were assessed using quantitative computerized analysis.

RESULTS AND CONCLUSIONS

Sperm yields/g testis were significantly decreased in men post-vasectomy and in men with OA, relative to fertile men. Significant reductions were also observed in early (40%) and mature (29%) spermatid numbers and an increase of 31% was seen in the seminiferous tubule wall (basal membrane and collagen thickness) of vasectomized men compared with fertile men. Clinical pregnancy rates in couples who had had a vasectomy were also significantly reduced.

MLL amplification in acute leukaemia: a United Kingdom Cancer Cytogenetics Group (UKCCG) study

The MLL gene, located at 11q23, is frequently rearranged in acute leukaemia as either chimaeric fusion genes or partial tandem duplications. We report a series of 12 acute leukaemia cases with apparent amplification of the MLL gene ascertained using fluorescence in situ hybridisation (FISH). Seven cases showed intrachromosomal amplification of MLL, four cases showed extrachromosomal amplification as double minute chromosomes (dmin) and one case had separate subclones with dmin and homogenously staining region (hsr). Southern blot analysis of the MLL gene showed MLL gene rearrangement in three of the 10 successful cases. These cases do not naturally fall into either of the two recognised categories of MLL rearrangement and may represent a third variety of MLL gene abnormalities.

Sensitivity of FISH in detection of MLL translocations

Fluorescence in situ hybridisation (FISH) detection of MLL translocations is now commonplace in cytogenetics laboratories. One of the most widely used probes is the Oncor MLL probe (Oncor, Gaithersburg, MD) that theoretically demonstrates the presence of an MLL rearrangement by a splitting of the FISH signal between the two derivative chromosomes generated by a translocation. Recently, another commercial probe has been made available from Vysis (Vysis, Downers Grove, IL) that uses a dual colour system. We examined material from 29 patients and 4 cell lines, all with recognised MLL translocations by G-banding, that were confirmed using Southern blot analysis of the MLL breakpoint cluster region. Both Oncor and Vysis MLL FISH probes were applied to these cases to compare their performance in detection of the MLL translocations. Thirty of the 33 cases demonstrated a clear splitting of Oncor MLL FISH signal in concordance with the Southern blot analysis and cytogenetics. Three cases failed to demonstrate a split MLL FISH signal. Therefore, we conclude that the Oncor MLL FISH probe has a 9.1% false negative rate, i.e., 90.9% sensitivity in detection of classic MLL translocations. Vysis MLL FISH detected the rearrangement in all 33 cases.

Collection and interpretation of respiratory cytology

Advances in pulmonary cytological sampling have helped establish a more accurate diagnosis and better therapeutic choices for the respiratory patient. Choosing the appropriate test is necessary to maximize the potential diagnostic yield and should be based on the clinical presentation of the patient as well as the minimum database. This article describes several methods of collection of cytological samples for the canine and feline upper and lower respiratory tracts, defines normal respiratory cytology, and discusses normal cytological characterization of various respiratory diseases. Categorization of cytological findings may aid the clinician in narrowing the potential etiologies for the pulmonary disorder. The authors focus on cytological recovery and analysis from transtracheal wash (TTW), bronchial brushing, transthoracic lung aspiration (TTLA), bronchoalveolar lavage (BAL), and open chest biopsy. Indications, complications, and contraindications for each procedure are discussed. Variation in expected findings among BAL, TTW, TTLA, and bronchial brushings are described. Appropriate sampling technique, transport, and processing are also emphasized.

Jumping translocation at 11q23 with MLL gene rearrangement and interstitial telomeric sequences

myeloid leukemia of acute myeloid leukemia (AML) M5a showing a jumping translocation with a breakpoint at 11q23. Fluorescence in situ hybridization (FISH) demonstrated triplication of the MLL gene and the presence of interstitial telomeric sequences, supporting the role of repetitive sequences in the mechanism of jumping translocations. Southern blot analysis of the MLL breakpoint cluster region showed the presence of an MLL gene rearrangement. Jumping translocation with MLL gene rearrangement is a previously unreported phenomenon in leukemia cytogenetics.

Face processing by deaf ASL signers: evidence for expertise in distinguished local features

Several previous studies have shown that ASL signers are 'experts' on at least one test of face processing: the Benton Test of Face Recognition, a discrimination task that requires subjects to select a target face from a set of faces shown in profile and/or in shadow. The experiments reported here were designed to discover why ASL signers have superior skill as measured by this test and to investigate whether enhanced performance extends to other aspects of face processing. Experiment 1 indicated that the enhancement in face-processing skills does not extend to recognition of faces from memory. Experiment 2 revealed that deaf and hearing subjects do not differ in their gestalt face-processing ability; they perform similarly on a closure test of face perception. Finally, experiment 3 suggested that ASL signers do exhibit a superior ability to detect subtle differences in facial features. This superior performance may be linked both to experience discriminating ASL grammatical facial expression and to experience with lipreading. We conclude that only specific aspects of face processing are enhanced in deaf signers: those skills relevant to detecting local feature configurations that must be generalized over individual faces.

Enhanced facial discrimination: effects of experience with American sign language

On-line comprehension of American Sign Language (ASL) requires rapid discrimination of linguistic facial expressions. We hypothesized that ASL signers' experience discriminating linguistic facial expressions might lead to enhanced performance for discriminating among different faces. Five experiments are reported that investigate signers' and non-signers' ability to discriminate human faces photographed under different conditions of orientation and lighting (the Benton Test of Facial Recognition). The results showed that deaf signers performed significantly better than hearing non-signers. Hearing native signers (born to deaf parents) also performed better than hearing nonsigners, suggesting that the enhanced performance of deaf signers is linked to experience with ASL rather than to auditory deprivation. Deaf signers who acquired ASL in early adulthood did not differ from native signers, which suggests that there is no 'critical period' during which signers must be exposed to ASL in order to exhibit enhanced face discrimination abilities. When the faces were inverted, signing and nonsigning groups did not differ in performance. This pattern of results suggests that experience with sign language affects mechanisms specific to face processing and does not produce a general enhancement of visual discrimination. Finally, a similar pattern of results was found with signing and nonsigning children, 6-9 years old. Overall, the results suggest that the brain mechanisms responsible for face processing are somewhat plastic and can be affected by experience. We discuss implications of these results for the relation between language and cognition.

Prevalence of Helicobacter pylori infection in different ethnic groups in New Zealand children and adults

BACKGROUND

Helicobacter pylori infection is a major risk factor for peptic ulcer disease and gastric cancer. A study of patients with dyspepsia attending for gastroscopy showed significant differences in H. pylori seropositivity between ethnic groups.

AIMS

To determine the prevalence of H. pylori in children and adults in the community in different ethnic groups and to identify risk factors for infection.

METHODS

Serum samples (324) were randomly selected from a cross-sectional survey of 11-12 year old school children with a high proportion of Maori and Pacific Island groups. Serum samples (579) were randomly selected from a cross-sectional workforce survey of 5677 participants aged 40-64 years. Serum samples were tested for H.pylori IgG.

RESULTS

The percentage seropositivity in 11-12 year old children was European 7%, Maori/part Maori 21%, all Pacific Island groups 48% and for the workforce survey 35.8%, 57.4% and 73.2% respectively. Compared with Europeans the increased relative risk of seropositivity for H.pylori in Maori and Pacific Island participants was significant after adjusting for age and socio-economic status (1.43 [1.13, 1.80] and 1.76 [1.43, 2.18]) respectively. The relative risk of H.pylori infection significantly increased with age, lower socio-economic status and lower household income, but was not significantly associated with gender, alcohol or cigarette use.

CONCLUSIONS

The high seroprevalence of H.pylori in Maori and Pacific Island groups is consistent with the differences in incidence of gastric cancer. H.pylori continues to be a common infection in Maori and Pacific Island school children. Ethnicity appears to be a risk factor for H.pylori independent of socio-economic status.

Diagnostic tests for Helicobacter pylori--can they help select patients for endoscopy?

AIM

Dyspepsia is a common symptom and some selection process for endoscopy is required. This study seeks to determine if noninvasive tests for Helicobacter pylori could be useful as a screening test to help select patients for endoscopy.

METHODS

Consecutive patients attending for upper gastrointestinal endoscopy were interviewed prior to endoscopy and the endoscopic diagnoses was recorded. The presence of Helicobacter pylori infection was assessed by serology. Some patients also had a 13C urea breath test or rapid urease test (CLO test).

RESULTS

436 consecutive patients were evaluated. The endoscopy findings were normal in 44%, 29% had reflux oesophagitis, 18% had duodenal ulcer, duodenitis or gastric ulcer and 9% had other diagnoses. 54.8% of patients were positive for Helicobacter serology. Using either the CLO test or 13C urea breath test as the confirmatory test for the diagnosis of Helicobacter pylori, the sensitivity of the serology test was 96% and 91% respectively and the specificity was 66.6 and 82%. Patients with negative serology and no history of recent NSAID or aspirin use comprised 34% of the total with dyspepsia or reflux symptoms. There were no gastric or duodenal ulcers in this group.

CONCLUSION

The serology test may have some potential or the initial evaluation of dyspepsia. These tests need to be prospectively evaluated in general practice.

Angle Class II, division 1 malocclusion treated without premolar extraction

The treatment of an Angle Class II, Division I malocclusion without the extraction of premolars is described. Treatment was accomplished with the standard edgewise appliance using Merrifield directional forces systems.

Diagnostic imagings for primary cardiac fibrosarcoma

Primary tumors of the heart are rare; primary cardiac fibrosarcoma is even rarer. We report a patient with primary cardiac fibrosarcoma widespread metastases presenting with pulmonary metastases initially. The cardiac lesion was identified by bone-imaging localization on bone scan, by hypodense areas in the cardiac chambers of contrast computed tomography of the chest, and by protruding masses in ventricular cavities causing aortic valve outflow-tract obstruction by echocardiogram. At autopsy, a large tumor invaded the interventricular septum and both ventricular cavities of the heart (880 g in weight), and accounted for these imaging findings. While bone-agent localization in the heart does not differentiate malignant from benign conditions, computed tomography and echocardiography of the interatrial and interventricular septal, and right atrial and biventricular cavitary involvement may differentiate fibrosarcoma from myxoma.

Isolation of swine infertility and respiratory syndrome virus (isolate ATCC VR-2332) in North America and experimental reproduction of the disease in gnotobiotic pigs

A recent epizootic of swine infertility and respiratory syndrome (SIRS) in a Minnesota swine herd was investigated. Examination of a sow, neonatal piglets, and stillborn fetuses obtained during the epizootic from the affected herd revealed interstitial pneumonitis, lymphomononuclear encephalitis, and lymphomononuclear myocarditis in the piglets and focal vasculitis in the brain of the sow. Fetuses did not have microscopic lesions. No cause for the infertility and respiratory syndrome was determined. Therefore, attempts were made to experimentally reproduce the disease. Eleven 3-day-old gnotobiotic piglets exposed intranasally to tissue homogenates of piglets from the epizootic became inappetent and febrile by 2-4 days postexposure and had interstitial pneumonitis and encephalitis similar to that seen in the field outbreak. After 2 blind passages in gnotobiotic piglets, tissue homogenates were cultured on continuous cell line CL2621, and a cytopathic virus (ATCC VR-2332), provisionally named SIRS virus, was isolated. Gnotobiotic piglets exposed intranasally to the SIRS virus developed clinical signs and microscopic lesions that were the same as those in piglets exposed to the tissue homogenates, and the virus was reisolated from their lungs. This is the first isolate of SIRS virus in the United States that fulfills Koch's postulates in producing the respiratory form of the disease in gnotobiotic piglets and the first report of isolation and propagation of the virus on a continuous cell line (CL2621). The virus is designated as American Type Culture Collection VR-2332.

Catecholamine content of the preovulatory follicles of the domestic hen

The role of catecholamines in ovarian function of the domestic hen has not been examined extensively. The aim of this study was first to determine the location of catecholamines in the preovulatory follicle of the domestic hen. Second, norepinephrine (NE), epinephrine (EPI) and dopamine (DA) were measured in the isolated theca layer of the five largest preovulatory follicles at specific times during the ovulatory cycle and changes in catecholamine content were correlated with ovarian events. The five largest preovulatory follicles were removed from chickens at 24, 18, 12, 6 and 2 h before ovulation of the largest (F1) follicle. Theca and granulosa layers were isolated, frozen, weighed and prepared for measurements of catecholamines by the double isotope radio-enzymatic assay. Catecholamines were localized primarily in the theca layer with only small amounts present in the granulosa layer. Norepinephrine was present in the theca layer in concentrations 6- and 30-fold those of EPI and DA, respectively. The content of NE and EPI in the theca layer of the F1 follicle was significantly (p less than 0.01) higher at 6 h before ovulation than at other times for the F1 follicle. In contrast, NE and EPI content of the theca layer of second (F2) and third (F3) largest follicles did not change during the ovulatory cycle. The content of DA was elevated (p less than 0.05) at 12 h before ovulation in F1 and F2 follicles. There was a significant reduction in NE in the theca layer of the fifth largest (F5) follicle between 24 and 18 h before ovulation of the F1 follicle.(ABSTRACT TRUNCATED AT 250 WORDS)