Development of a universal connectivity and data management system

Point-of-care testing (POCT) is an increasingly popular method of delivering laboratory testing. Management of POCT is challenging given the variety of devices, locations, and staff that need to be coordinated to ensure quality results and meet regulatory guidelines. Electronic capture and transfer of data are preferred for managing POCT, but there is currently no standard method of connecting different devices. Johns Hopkins Medical Institutions (JHMI) developed a common data management system with interfaces to all of its POCT devices. All POCT data are collected in one database and analyzed in a similar fashion. Where data were once collected by carrying laptops to each nursing unit, the POCT devices can now connect directly to the database over the Internet. Algorithms have been created to automate the data analysis and review process. Over the several years that this software has been used, JHMI has experienced improved quality, accuracy, and management of its POCT program. The labor saved by increased automation of data review is refocused on enhancing the performance and scope of the program. Current connectivity and analysis algorithms have future application to remote consultation, management of home self-monitoring patients, and examination of real-time data.

Association of ARNT splice variants with estrogen receptor-negative breast cancer, poor induction of vascular endothelial growth factor under hypoxia, and poor prognosis

The aryl hydrocarbon receptor nuclear translocator (ARNT) is a basic helix-loop-helix transcription factor that forms heterodimers with the aryl hydrocarbon receptor (AhR) or hypoxia inducible factor-1alpha to activate transcription via xenobiotic response element or hypoxia response element, respectively. Thus, it plays a major role in two key biochemical pathways involved in tumor growth. We previously showed that estrogen receptor (ER)-negative breast cancer cell lines expressed a splice variant of ARNT that was associated with Ah nonresponsiveness. We have now used a sensitive PCR method to analyze the expression of the variant in a series of 92 breast cancers to assess interactions with the ER and prognosis. The splice variant could be detected in all of the cases examined, with high ratios of variant:full-length ARNT (> or =10) characterized in 10 cases. When the patient group was split into quartiles by increasing splice variant ratios, there was an inverse relationship of ER status to ARNT splice-variant ratios (P = 0.01, chi(2)). Univariate analysis showed that cases with high ARNT splice-variant ratios > or =10 had a worse relapse-free and overall survival (P > or = 0.03; hazard ratio, 2.7; and P = 0.006; hazard ratio, 3.9, respectively). In multivariate analysis for relapse-free and overall survival, ARNT splice-variant ratio was the strongest independent factor and, although inversely related to ER, remained a separate risk factor. At least two potential mechanisms could explain this phenomenon: the loss of aryl hydrocarbon receptor-mediated antiestrogenic activity or the blockade of a proapoptotic pathway induced by hypoxia. Because several enzymes involved in drug resistance are induced through a xenobiotic response element, the tumors presenting high ARNT splice-variant ratios may be specifically targeted by drugs normally degraded or inactivated. This study shows the biological importance of ARNT splice variants in the behavior of human breast cancer and suggests that the breast cell lines in which the splice variant was discovered may be useful models for further investigation.

Salvage treatment for local recurrence after breast-conserving surgery and radiation as initial treatment for mammographically detected ductal carcinoma in situ of the breast

BACKGROUND

The purpose of the current study is to evaluate the outcome of salvage treatment for local recurrence after breast-conserving surgery and radiation as initial treatment for mammographically detected ductal carcinoma in situ (DCIS; intraductal carcinoma) of the breast.

METHODS

An analysis was performed of 42 patients with local only first failure (n = 41) or local-regional only first failure (n = 1) after breast-conserving surgery and radiation treatment had been given for DCIS of the breast. Surgical treatment at the time of local recurrence included mastectomy (n = 37; 88%) or excision (n = 5; 12%). Adjuvant systemic therapy at the time of local recurrence was chemotherapy (n = 3; 7%), tamoxifen (n = 8; 19%), both (n = 1; 2%), none (n = 29; 69%), or unknown (n = 1; 2%). The median interval from the time of initial treatment to local recurrence was 4.8 years (range = 1.0-15.2 yrs). The median follow-up after salvage treatment was 4.5 years (range = 0.2-12.8 yrs).

RESULTS

At the time of the local recurrence, 22 patients (52%) had invasive ductal carcinoma, 18 patients (43%) had DCIS, 1 patient (2%) had invasive lobular carcinoma, and 1 patient (2%) had angiosarcoma. After salvage treatment, the rate of overall survival and the rate of cause specific survival for all 42 patients were 92% at both 5- and 8-years after treatment. The rate of freedom from distant metastases was 89% at 5 and 8 years. Favorable prognostic factors after salvage treatment were DCIS as the histology of the local recurrence and mammography only as the method of detection of the local recurrence.

CONCLUSIONS

The results of salvage treatment in the current study demonstrated that local recurrences were salvaged with high rates of survival and freedom from distant metastases. These results support the use of breast-conserving surgery and radiation for initial management of DCIS of the breast.

Prenatal diagnosis of succinic semialdehyde dehydrogenase deficiency: increased accuracy employing DNA, enzyme, and metabolite analyses

Inherited succinic semialdehyde dehydrogenase (SSADH; EC1.2.1.24; McKusick 271980) deficiency is a defect of GABA degradation which leads to accumulation of 4-hydroxybutyric acid (gamma-hydroxybutyric acid; GHB) in physiologic fluids of patients. Prenatal diagnosis (PND) was performed in three at-risk pregnancies employing combinations of: (1) reverse-transcription-polymerase chain reaction (RT-PCR) and genomic DNA amplification followed by sequencing using isolated leukocytes or cultured human lymphoblasts; (2) GHB quantitation in amniotic fluid; or (3) SSADH enzyme assay in chorionic villus (CV) and/or amniocytes. In two pregnancies, all analyses were concordant for prediction of disease status in the fetus. In the third case, enzyme activity in CV (deficient) and metabolite analysis in amniotic fluid (normal) were discordant. For clarification, mutation analysis was undertaken in CV, confirming heterozygosity for the mutation previously identified in the proband. We hypothesize that delayed transit time for shipment of CV between Greece and the United States (8 days) led to enhanced degradation of heterozygous SSADH enzyme activity. Our data demonstrate the importance of combined metabolite, enzyme, and DNA analysis for increased accuracy in the PND of SSADH deficiency.

A health and nutritional profile of rural school children in KwaZulu-Natal, South Africa

A community-based cross-sectional study was undertaken to measure anthropometric indices, micronutrient status and prevalence of parasite infections in 579 rural South African primary school children. Eleven schools were selected randomly from a Magisterial District in southern KwaZulu-Natal (KZN). In each school, all pupils aged between 8 and 10 years were selected. The following outcome measures were obtained: anthropometric--height for age, weight for age and body mass index; micronutrient status--anaemia, serum ferritin and vitamin A; and prevalence of parasite infections--Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium. The observed prevalences were: stunting 7.3%, underweight for age 0.7%, and obesity 3.1%; anaemia 16.5% (Hb < 12 g/dl), vitamin A deficiency 34.7% (serum retinol < 20 micrograms/dl) and 28.1% with reduced serum ferritin (< 12 ng/ml); Trichuris trichiura 53.9%, Ascaris lumbricoides 27.3% and Schistosoma haematobium 24.5%. We conclude that micronutrient deficiency, parasitic infestations and stunting remain significant problems among school-aged children in South Africa. Micronutrient supplementation and de-worming provide opportunities for school-based health promotion and primary health care interventions, and might produce significant health and educational benefits.

A Modern Leg Ulcer Service

Aim:

To define the components and organization of a modern leg ulcer service that is acceptable to patients cost effective and produces high quality outcomes.

Method:

Analysis of data from published literature as well as experience from the organisation of a leg ulcer service in Gloucestershire.

Synthesis:

Assessment of leg ulcers requires the services of a vascular laboratory to assess the venous and arteria systems. Effective systems of compression must be employed. Staff and patients must be educated to understand the principals behind their use. For some patients pinch-grafting may be appropriate. Where arterial disease is present in the lower limb, reconstructive surgery should be used for the lower limb vessels The organisation of such a service must ensure good liaison between General Practitioners, community nurses and hospital specialists. Many patients may be managed in community leg ulcer clinics. In some cases, the advice of specialists such as rheumatologists and dermatologists may be required.

Conclusions:

A national framework for leg ulceir management is needed within which resources are made available in a way that satisfy local needs. Such a framework must be based on management protocols derived from evidence-based practices that have been developed through the experiences of modern leg ulcer services.

The effect of different anthelmintic treatment regimens combined with iron supplementation on the nutritional status of schoolchildren in KwaZulu-Natal, South Africa: a randomized controlled trial

A randomized controlled trial in KwaZulu-Natal (South Africa) of 428 primary-school pupils (stratified into 6 groups by age, sex and intervention) measured the effect of different anthelmintic treatments and iron supplementation regimens provided twice at 6-monthly intervals for 1 year (1996/97). Half the pupils received iron supplementation (ferrous fumarate 200 mg weekly for 10 weeks). Pupils received 2 anthelmintic regimens, either (i) albendazole 400 mg plus praziquantel 40 mg/kg or (ii) albendazole 400 mg on 3 consecutive days plus praziquantel 40 mg/kg or (iii) placebo. Baseline prevalences of Ascaris 55.9%, Trichuris 83.6%, hookworm spp. 59.4%, were reduced after 12 months for single-dose albendazole treatment to Ascaris 17.4% (P < 0.005), Trichuris 61.5% (NS), hookworm spp. 0% (P < 0.005), and for triple-dose albendazole treatment to Ascaris 14.8% (P < 0.005), Trichuris 25.0% (P < 0.01), hookworm 0% (P < 0.005). Schistosoma haematobium 43.4% was reduced among treated groups to 8.3% (P < 0.005). There were no significant changes in the anthropometry of the different treatment groups at either 6 or 12 months post treatment. Twelve months after treatment there was a significant increase in haemoglobin levels (P = 0.02) among pupils receiving triple-dose albendazole, praziquantel and ferrous fumarate; pupils receiving no anthelmintic treatment showed a significant decrease as did pupils who received triple-dose albendazole and praziquantel but no iron. Regular 6-monthly anthelmintic treatment significantly reduced the prevalence of Ascaris, hookworm spp. and S. haematobium infections (P < 0.05). Triple-dose treatment for Trichuris was significantly more effective than a single dose of albendazole 400 mg (P = 0.002). In areas with schistosomiasis, hookworm infection and high prevalence of Trichuris infection, combination treatment with praziquantel, triple-dose albendazole, plus iron supplementation, is likely to improve pupils' health and haemoglobin levels.

Psychological consequences of surgical menopause

More than 250,000 women have a bilateral oophorectomy every year. With surgical menopause, the onset of menopausal symptoms is abrupt and often dramatic. Oophorectomy offers relief from physical conditions for many women; however, those with preexisting psychological and some physical problems tend to experience postsurgical exacerbation of those problems. Loss of estrogenic and androgenic underpinnings may destabilize women with unstable psychiatric axes. Surgically menopausal women may also experience a decline in sexual interest and activity. The relation of surgical menopause to physiologic and sexual well-being is described in this article. The link between hormonal levels and psychological well-being has been well documented. Depression seems to be increased at times of changing hormone levels in women, possibly a result of the effect of estrogen levels on serotonergic activity and its impact on other neurotransmitters. In addition, a sex-specific association with specific psychological disorders has been described in the literature and will be reviewed in this article. The potential benefits of estrogen or estrogen/androgen therapy on libido and mood are discussed, as are findings that estrogen-androgen therapy correlated with less anxiety and hostility and with increased positive feelings when compared with estrogen-only treatment.

The hormone continuum: accrual of women's health benefits

The hormone continuum is a treatment strategy that advocates maintaining hormone continuity, from the reproductive years into menopause and beyond. This entails the use first of oral contraceptives (OCs), which confer well-known health benefits--especially reductions in ovarian and endometrial cancers--besides effective contraception, and later, hormone replacement therapy (HRT), which provides relief of perimenopausal and menopausal symptoms and protects older women from (a) decreasing bone mineral density; (b) cardiovascular disease, according to several studies; and (c) Alzheimer's disease, as suggested by a number of studies. In perimenopause, use of OCs declines by about one-half, and then by a further four-fifths up to menopause. This is unfortunate, because in these later reproductive years women are subject to unintended pregnancy, which in 65% of cases is terminated by abortion. Furthermore, women are thereby deprived also of alleviation of dysmenorrhea and even vasomotor symptoms that often characterize the perimenopause. After menopause is well established, a "seamless" transition to HRT can be made, often with the same progestin that was contained in the OC. This paper discusses risks as well as benefits of hormone therapy, especially of HRT, with an emphasis on patient counseling and individualizing of therapy.

Heterogenous nature of flow-mediated dilatation in human conduit arteries in vivo: relevance to endothelial dysfunction in hypercholesterolemia

Flow-mediated dilatation (FMD) of conduit arteries is dependent on an intact endothelium, although the mechanisms are not fully understood. Using high-resolution ultrasound, we examined the role of endothelial mediators in radial artery dilatation in response to transient (short period of reactive hyperemia) and sustained (prolonged period of reactive hyperemia, hand warming, or an incremental infusion of acetylcholine into the distal radial artery) hyperemia. After short episodes of reactive hyperemia, FMD was abolished by local infusion of the nitric oxide synthesis inhibitor N:(G)monomethyl-L-arginine (5.3+/-1.2% versus 0.7+/-0.7%, P:<0.001). In contrast, basal vessel diameter and dilatation after prolonged episodes of reactive hyperemia, hand warming, and distal infusion of acetylcholine were not attenuated by nitric oxide synthesis inhibition. Inhibition of cyclooxygenase or local autonomic nervous system blockade also had no effect on FMD. Patients with hypercholesterolemia exhibited reduced FMD in response to transient hyperemia, but the response to sustained hyperemia was normal. These data suggest heterogeneity of endothelial responses to blood flow that are dependent on the characteristics of the flow stimulus. Dilatation after brief episodes of hyperemia is mediated by release of nitric oxide, whereas dilatation during sustained hyperemia is unaffected by NO synthesis inhibition. Hypercholesterolemia seems to differentially affect these pathways with impairment of the nitric oxide-dependent pathway and preservation of non nitric oxide-mediated dilatation to sustained flow stimuli.