DNA replication regulation protein Mcm7 as a marker of proliferation in prostate cancer

BACKGROUND

Recent studies have shown that minichromosome maintenance (MCM) proteins (Mcm2-7) may be useful proliferation markers in dysplasia and cancer in various tissues.

AIMS

To investigate the use of Mcm7 as a proliferation marker in 79 lymph node negative prostate cancers and compare it with Ki-67, a commonly used cell proliferation marker.

METHODS

The percentage of proliferating cells (proliferation index; PI) was calculated for basal and luminal epithelial cells in benign prostate tissue, prostatic intraepithelial neoplasia (PIN), and epithelial cells in adenocarcinoma. The PI for each biomarker was correlated with the preoperative prostate specific antigen concentration, the Gleason score, surgical resection margin status, and the AJCC pT stage for each patient.

RESULTS

The mean PIs for Ki-67 and Mcm7 were: benign luminal epithelium 0.7 and 1.2 and benign basal epithelium 0.8 and 8.2; PIN non-basal epithelium 4.9 and 10.6 and PIN basal epithelium 0.7 and 3.1; adenocarcinoma 9.8 and 22.7, respectively. Mcm7 had a significantly higher mean PI (p<0.0001) than Ki-67 for all cell categories except benign luminal epithelial cells. Mcm7 was a better discriminatory marker of proliferation between benign epithelium, PIN, and invasive adenocarcinoma (p<0.0001) than Ki-67. The drop in Mcm7 mean basal cell PI from benign epithelium to PIN epithelium was significantly larger than for Ki-67 (p<0.0001). Mcm7 had a significantly higher PI than Ki-67 at each risk level.

CONCLUSION

Mcm7 may be a useful proliferation marker in prostatic neoplasia and warrants further evaluation as a complementary tool in the diagnosis of PIN and prostate carcinoma.

Case management in a heterogeneous congestive heart failure population: a randomized controlled trial

BACKGROUND

Both randomized and nonrandomized controlled studies have linked congestive heart failure (CHF) case management (CM) to decreased readmissions and improved outcomes in mostly homogeneous settings. The objective of this randomized controlled trial was to test the effect of CHF CM on the 90-day readmission rate in a more heterogeneous setting.

METHODS

A total of 287 patients admitted to the hospital with the primary or secondary diagnosis of CHF, left ventricular dysfunction of less than 40%, or radiologic evidence of pulmonary edema for which they underwent diuresis were randomized. The intervention consisted of 4 major components: early discharge planning, patient and family CHF education, 12 weeks of telephone follow-up, and promotion of optimal CHF medications.

RESULTS

The 90-day readmission rates were equal for the CM and usual care groups (37%). Total inpatient and outpatient median costs and readmission median cost were reduced 14% and 26%, respectively, for the intervention group. Patients in the CM group were more likely to be taking CHF medication at target doses, but dosages did not increase significantly throughout 12 weeks. Although both groups took their medications as prescribed equally well, the rest of the adherence to treatment plan was significantly better in the CM group. Subgroup analysis of patients who lived locally and saw a cardiologist showed a significant decrease in CHF readmissions for the intervention group (P =.03).

CONCLUSIONS

These results suggest several limitations to the generalizability of the CHF CM-improved outcome link in a heterogeneous setting. One explanation is that the lack of coordinated system supports and varied accessibility to care in an extended, nonnetworked physician setting limits the effectiveness of the CM.

A meta-analysis of the efficacy of over-the-counter nicotine replacement

OBJECTIVE

To determine whether over-the-counter (OTC) nicotine replacement therapy (NRT) is pharmacologically efficacious, whether it produces abstinence rates similar to those in prescription settings, and to estimate the long term (that is, greater than six month) abstinence rate with OTC NRT.

METHOD

Systematic literature review.

DATA SOURCES

Medline, Psych Abstracts, bibliographies, requests of scientists.

STUDY SELECTION

Studies comparing OTC NRT versus OTC placebo or studies comparing OTC NRT versus prescription NRT that reported abstinence rates and for which a full study report was available.

DATA EXTRACTION

Two of the authors independently reviewed studies and compared results.

DATA SYNTHESIS

Meta-analysis was performed by first testing for homogeneity across studies, then combining odds ratios (ORs) weighting by inverse variance and proportions weighting by study sample size.

RESULTS

One OTC NRT versus OTC placebo nicotine gum study was excluded due to small sample size and different setting. The four remaining studies were randomised trials of nicotine versus placebo patch with ORs of 2.1-3.2. These outcomes were homogenous and when combined resulted in an OR favouring NRT of 2.5 (95% confidence interval (CI) 1.8 to 3.6). Among the two randomised and two non-randomised trials of OTC NRT versus prescription NRT, one small study had an OR of 0.3, two others had ORs of 1.0 and 1.4, and a fourth study had an OR of 3.6. These results were not homogenous; however, when combined via a random effects model the estimated OR was not less than 1.0--that is, OR 1.4 (95% CI 0.6 to 3.3). The long term (that is, greater than six months) quit rates for OTC NRT was 1% and 6% in two studies and 8-11% in five other studies. These results were not homogenous; however, when combined the estimated OR was 7% (95% CI 4% to 11%).

CONCLUSIONS

OTC NRT is pharmacologically efficacious and produces modest quit rates similar to that seen in real world prescription practice.

The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: preliminary results

BACKGROUND

By geographic necessity, rural trauma patients must be initially stabilized at local community hospitals before transfer for definitive care. In this study, it was hypothesized that telemedicine consults with trauma surgeons from a Level I trauma center online while the patient was still in the community hospital ED could positively affect care.

METHODS

Four community hospital emergency departments in upstate New York and Vermont were equipped with dual cameras with remote control capability. Three trauma surgeons' homes were wired and equipped with telemedicine systems. Protocols were developed for the initiation of a telemedicine consult.

RESULTS

There were 26 telemedicine consults over an 8-month period. The telemedicine population was significantly more severely injured and had a higher mortality than the general trauma population admitted to the Level I trauma center. In two cases, it was felt that the telemedicine consultation was potentially lifesaving. On follow-up, more than 80% of the referring providers felt that the telemedicine consult improved care.

CONCLUSION

Telemedicine provides a virtual online trauma surgeon to assist with the resuscitation and stabilization of the major trauma patient in a small community hospital. These preliminary results show a positive impact on rural trauma patient care at the local community hospital.

A comparison of recovering alcoholic and non-alcoholic smokers

Whether smokers with a positive past history (PH) of alcohol dependence need more intensive or different treatment than smokers with no such history (NH) is unclear. We surveyed 31 PH smokers and 31 age and sex-matched NH smokers to examine differences in motivations for and barriers to stopping smoking. The final regression model found that PH and NH smokers did not differ in social support, social pressure, readiness to quit or physical consequences of smoking; however, PH smokers were more dependent on nicotine and had more internal (affective) barriers to cessation than NH smokers. Although our results require replication due to our small sample size, they do suggest that PH smokers would especially benefit from medications for nicotine dependence and medications or psychosocial treatments for depression.

Longitudinal Stability of Coagulation, Fibrinolysis, and Inflammation Factors in Stored Plasma Samples

We sought to assess the longitudinal stability of risk factors for atherosclerosis and thrombosis, including several coagulation, fibrinolysis, and inflammation factors, in frozen plasma samples stored at –70° C for months or years. We reviewed data collected on 29 different control pools over periods ranging from 7 to 59 months for two functional assays (factor VII and fibrinogen) and seven antigen measurements (C-reactive protein, D-dimer, plasmin-α 2-antiplasmin complex, plasminogen activator inhibitor-1, protein C, protein S, and tissue plasminogen activator), totaling more than 15,000 data points. Screening of the data using least squares regression revealed only sporadic associations between monthly means and time, with no consistent trends. Analysis by repeated measures and summary measure methods revealed no evidence of sample degradation over time for the factors studied. Our finding of longitudinal stability in the biochemical properties of frozen plasma strengthens the presumption of sample stability on which molecular epidemiologic studies are based.

Subjective effects of oral caffeine in formerly cocaine-dependent humans

Eleven formerly cocaine-dependent (FCD) adults (mean 4 years in recovery) and 11 with no substance dependence history (ND) drank one cup of coffee (caffeine content 0, 50, or 100 mg) per hour for 5 h (for a total of 0, 250, or 500 mg caffeine) in a double-blind, randomized crossover procedure. Participants completed self-report scales before the first cup and 50 min after each cup. Caffeine did not increase cocaine-like effect or desire-for-cocaine ratings among the FCD subjects. Ratings of 'jittery' (P < 0.05) and 'anxious/tense/nervous' (P < 0.10) increased more with caffeine in the FCD group than among ND subjects. Self-report measures of caffeine reinforcement did not differ between FCD and ND groups. These results suggest that, among FCD adults, (a) caffeine does not produce cocaine-like effects, (b) caffeine reinforcement is neither greater nor lesser than that among ND adults, and (c) chronic cocaine use may induce sensitization to some effects of stimulants.

Severe Sepsis Mortality in a Community Teaching. Hospital: 1983–1985 and 1989–1990

Despite better understanding of the pathophysiology and hemodynamic abnormalities of severe sepsis, mortality remains high. We examined the severity-adjusted outcome and use of pulmonary artery catheterization (PAC) in patients with severe sepsis during 1983 to 1985 and 1989 to 1990 in an intensive care unit (ICU) staffed by full-time intensivists. A retrospective chart review was conducted on severe sepsis patients admitted to a multidisciplinary ICU of an 850-bed community teaching hospital. Patients were identified at ICU admission and at 24 and 48 hours after ICU admission. Patients were stratified by severity of illness using the Mortality Probability Model (MPM) and presence or absence of a pulmonary artery catheter within the first 48 hours of ICU admission. In the years 1983 through 1985 and 1989 through 1990, respectively, 245 and 132 patients with severe sepsis were identified. The severity-adjusted outcome and use of PAC was analyzed both within and between these two periods. The severity adjusted mortality from sepsis was unchanged over time (63% in 1983–1985 and 51% in 1989–1990; p = 0.491). Pulmonary artery catheter use increased from 52.2% in 1983 to 1985 to 64.4% in 1989 to 1990 ( p = 0.023). Invasive monitoring with PAC was used in a less severely ill population; during 1983 to 1985, mean severity estimated by MPM was 0.43 compared with an MPM of 0.32 in 1989 to 1990 ( p = 0.003). A significant increase in the therapeutic use of vasoactive drugs (65 vs 81%) to treat severe sepsis was observed over the two periods ( p = 0.0005). Outcome of severe sepsis was unchanged during the two periods. Applying an ICU severity-of-illness adjustment model, early employment of pulmonary artery catheters and increased use of vasopressors did not effect outcome in an intensivist-managed ICU. Insertion of pulmonary artery catheters in patients with less severe illness also did not impact outcome. Use of pulmonary artery catheters to monitor and guide treatment needs further rigorous prospective evaluation to define the specific conditions in severely septic patients for which this intervention is most applicable.

The clinical spectrum of heterozygous protein C deficiency in a large New England kindred

A family with a high incidence of venous thromboembolism was investigated. We performed medical evaluations on 184 of the 411 surviving members of the pedigree, which allowed assignment of individuals into positive, equivocal, or negative categories with respect to their clinical histories of thrombosis. Subjects with antigenic levels of protein C less than 66% of a normal plasma pool were classified as having protein C deficiency. Positive thrombotic histories were found in 13 of the 46 family members determined to be protein-C deficient and in only five of their 138 biochemically unaffected relatives. Statistical analysis of the association between thromboembolic disease and protein-C deficiency was strongly positive chi 2 = 24.95, P less than .0001 with n = 184), indicating that heterozygous protein-C deficiency is an important independent risk factor for the development of thrombotic manifestations in this pedigree. However, the absence of thromboembolic manifestations in many of the protein-C deficient family members to date indicates that other, as yet undefined, factors must play an important role in the clinical expression of this disorder.