Valganciclovir for cytomegalovirus prevention in solid organ transplant patients: an evidence-based reassessment of safety and efficacy

BACKGROUND

Several anti-viral drugs have demonstrated efficacy in preventing Cytomegalovirus (CMV) infections in solid organ transplant (SOT) patients. The recently approved valganciclovir is the most commonly used and most expensive drug for CMV prevention. The safety and efficacy data have been drawn from a single trial. We hypothesized that valganciclovir may not be as safe as nor more effective than other therapies for CMV prevention.

METHODS

All experimental and analytical studies that compared valganciclovir with other therapies for prevention of CMV infection after SOT were selected. Based on meta-analytic and multivariate regression methodologies we critically analyzed all available evidence.

FINDINGS

Nine studies were included (N = 1,831). In trials comparing valganciclovir with ganciclovir, the risk for CMV disease is 0.98 (95% Confidence Interval (95%CI) 0.67 to 1.43; P = 0.92; I(2) = 0%). Valganciclovir was significantly associated with the risk of absolute neutropenia (<1,500/mm(3)) compared with all therapies (Odds Ratio (OR) 3.63 95%CI 1.75 to 7.53; P = 0.001; I(2) = 0%); with ganciclovir only (OR 2.88, 95%CI 1.27 to 6.53; P = 0.01; I(2) = 0%); or with non-ganciclovir therapies (OR 8.30, 95%CI 1.51 to 45.58; P = 0.01; I(2) = 10%). For a neutropenia cut-off of <1,000/mm(3), the risk remained elevated (OR 1.97, 95%CI 1.03 to 3.67; P = 0.04; I(2) = 0%). For every 24 patients who receive valganciclovir prophylaxis, one more will develop neutropenia compared to other therapies. The risk of late-onset CMV disease with valganciclovir was similar to ganciclovir and higher than those with non-ganciclovir therapies (OR 8.95, 95%CI 1.07 to 74.83; P = 0.04; I(2) = 0%]. One more patient will develop late-onset CMV disease for every 25 who receive valganciclovir compared to treatment with non-ganciclovir therapies. The risk of CMV tissue-invasive disease in liver recipients receiving valganciclovir was 4.5 times the risk seen with ganciclovir [95%CI 1.00 to 20.14] (p = 0.04). All results remained consistent across different study designs, valganciclovir doses, and CMV serostatus.

CONCLUSIONS

Valganciclovir shows no superior efficacy and significantly higher risk of absolute neutropenia, CMV late-onset disease, and CMV tissue-invasive disease compared to other standard therapies. Due to the availability of efficacious, safer, and lower cost drugs (high-dose acyclovir, valacyclovir, ganciclovir), our results do not favor the use of valganciclovir as a first-line agent for CMV preemptive or universal prophylaxis in SOT patients.

Subantimicrobial-dose doxycycline modulates gingival crevicular fluid biomarkers of periodontitis in postmenopausal osteopenic women

BACKGROUND

We recently demonstrated that a 2-year subantimicrobial-dose doxycycline (SDD) regimen (double-masked, placebo-controlled clinical trial) in postmenopausal (PM) women exhibiting mild systemic bone loss (osteopenia) and local bone loss (periodontitis) reduced the progression of periodontal attachment loss (intent-to-treat analysis) and the severity of gingival inflammation and alveolar bone loss (subgroups) without producing antibiotic side effects. We now describe SDD effects on biomarkers of collagen degradation and bone resorption in the gingival crevicular fluid (GCF) of the same vulnerable subjects.

METHODS

GCF was collected from SDD- and placebo-treated PM subjects (n=64 each) at the baseline and 1- and 2-year appointments; the volume was determined; and the samples were analyzed for collagenase activity (using a synthetic peptide as substrate), relative levels of three genetically distinct collagenases (Western blot), a type-1 collagen breakdown product/bone resorption marker (a carboxyterminal telopeptide cross-link fragment of type I collagen [ICTP]; radioimmunoassay), and interleukin-1beta (enzyme-linked immunosorbent assay). Statistical analyses were performed using generalized estimating equations; primary analyses were intent-to-treat.

RESULTS

Collagenase activity was significantly reduced by SDD treatment relative to placebo based on intent-to-treat (P=0.01). ICTP showed a similar pattern of change during SDD treatment, and GCF collagenase activity and ICTP were positively correlated at all time periods (P<0.001). Matrix metalloproteinase (MMP)-8 accounted for approximately 80% of total collagenase in GCF, with much less MMP-1 and -13, and SDD reduced the odds of elevated MMP-8 by 60% compared to placebo (P=0.006).

CONCLUSION

These observations support the therapeutic potential of long-term SDD therapy to reduce periodontal collagen breakdown and alveolar bone resorption in PM women; effects on serum biomarkers of systemic bone loss in these subjects are being analyzed.

Subantimicrobial dose doxycycline effects on osteopenic bone loss: microbiologic results

BACKGROUND

Based on microbiologic concerns, the safety of a 24-month regimen of subantimicrobial dose doxycycline (SDD; 20 mg twice a day) was evaluated in postmenopausal osteopenic women with periodontitis in a double-blind, placebo-controlled, randomized clinical trial.

METHODS

Subgingival samples were collected from two sites (probing depth > or = 5 mm) in each of 128 subjects at baseline, with the same sites resampled at the conclusion of the 2-year period. The samples were enumerated on selective and non-selective media and on doxycycline (4 microg/ml) medium. Up to five different colonial morphologies were subcultured from the doxycycline medium, identified to species, and susceptibilities determined to doxycycline and five other antibiotics. Data were analyzed for microbial differences in total colony forming units (CFU), periodontal and opportunistic pathogens, and changes in species and in susceptibilities of isolates recovered on doxycycline medium.

RESULTS

There was no significant evidence that changes in total anaerobic counts over the treatment period (P = 0.96) differed between treatment groups. Likewise, periodontal pathogens, opportunistic pathogens, or normal flora did not differ descriptively between groups. Although there was a significant increase (P <0.001) in the total CFU recovered from the 4 microg/ml doxycycline plates at 24 months for SDD versus placebo, the percentage that was clinically resistant to doxycycline (minimal inhibitory concentration [MIC] > or = 16 microg/ml) decreased over the 24-month period in both groups and did not differ between the treatment groups (SDD: 79% to 76%; placebo: 83% to 70%; P = 0.2). There were no significant differences (P >0.28 for each) in the change in cross-resistance between the groups for doxycycline and the other five antibiotics.

CONCLUSIONS

No antimicrobial effect on the subgingival flora was detected following treatment with SDD for 24 months, relative to baseline or to placebo. The increase in initial resistance (at 4 microg/ml) did not translate into a significant increase in the percent resistant to doxycycline (MIC > or = 16 microg/ml) for patients in the SDD group.

The impact of surgical excision in chest wall rhabdomyosarcoma: a report from the Children's Oncology Group

AIMS

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor of childhood. Patient age, size, histologic finding, and site of the tumor are primary determinants of prognosis in RMS. Chest wall RMS is a site in which the limitations of surgical excision are realized. We aim to determine the impact of surgical excision in chest wall RMS.

METHODS

A retrospective chart review was conducted of all 130 pediatric patients enrolled in the Intergroup Rhabdomyosarcoma Study (IRS) with chest wall rhabdomyosarcoma from the first (I) through fourth (IV) IRS with follow-up to June 2005. Median follow-up was 12.1 years (4.6-27.2 years).

RESULTS

There was a significant improvement in failure-free survival (FFS) and overall survival (OS) between the first IRS study, I, and IRS-IV. The estimated FFS and OS at 5 years in IRS I was 30% and 40%, respectively, compared to 68% and 78%, respectively, in IRS-IV (P = .03 and P = .05, respectively). There was no association between histologic finding or size and FFS or OS. However, all patients who presented without metastasis had an FFS and OS of 49% and 61%, respectively, compared with metastatic patients, 7% and 7%, respectively (P < .001). Five-year FFS of group I, II, and III patients was 52%, 52%, and 45%, respectively, and OS was 65%, 60%, and 59%, respectively. There was no significant difference in 5-year FFS or OS in patients who had a complete resection (group I), complete resection with positive microscopic margins (group II), or biopsy or partial resection only (group III). In groups I to III patients, the local and regional failure rate at 5 years is 25% and 6%, respectively.

CONCLUSIONS

The most significant impact on outcome in chest wall RMS patients is metastatic disease at diagnosis. The locoregional failure rate is high but does not appear to impact survival. Alternative treatment strategies are needed for chest wall RMS, but aggressive surgical excision may not be necessary.

Efficacy of sub-antimicrobial dose doxycycline in post-menopausal women: clinical outcomes

AIMS

To determine the clinical efficacy of a 2-year continuous sub-antimicrobial dose doxycycline (SDD; 20 mg bid) in post-menopausal, osteopenic, oestrogen-deficient women on periodontal maintenance.

MATERIALS AND METHODS

One-hundred and twenty-eight subjects were randomized to SDD (n=64) or placebo (n=64). Clinical measurements were performed at posterior interproximal sites at baseline and every 6 months during this 2-year randomized, double-blind, placebo-controlled clinical trial with adjunctive, no-cost 3-4-month periodontal maintenance. Statistical analyses of secondary outcomes from this clinical trial used Generalized Estimating Equations in primarily intent-to-treat analyses.

RESULTS

For the placebo group, 3.4% of the sites showed improvement in clinical attachment levels (CAL) and 2.7% had progressive loss in CAL; for the SDD group, 5.0% of the sites showed an improvement in CAL and 2.2% had progressive loss in CAL. This difference (2.1% of sites) was more favourable in the SDD group than in the placebo [odds ratio (OR)=0.81 [corrected] 95% confidence interval (CI): 0.67-0.97, p=0.03] in these well-maintained patients, whereas probing depths, bleeding on probing and supragingival plaque did not differ significantly between groups (p>0.2). However, in exploratory subgroup analysis of non-smokers, SDD showed reduced bleeding versus placebo (27%versus 33%; p=0.05). In protocol-adherent subjects, the odds of bleeding were 34% lower for SDD (p=0.05).

CONCLUSIONS

Analyses of secondary outcomes of this clinical trial indicated that SDD may be of benefit in reducing progressive attachment loss in post-menopausal females; additional research is needed to confirm these findings. Protocol registered at (ClinicalTrials.gov). Identifier:NCT00066027.

Subantimicrobial dose doxycycline effects on alveolar bone loss in post-menopausal women

AIM

Determine the efficacy of 2-year continuous subantimicrobial dose doxycycline (SDD; 20 mg bid) on alveolar bone in post-menopausal osteopenic, oestrogen-deficient women undergoing periodontal maintenance in a 2-year double-blind, placebo-controlled, randomized clinical trial.

MATERIAL AND METHODS

One-hundred and twenty-eight subjects randomized to SDD or placebo (n=64 each). Posterior vertical bite wings taken at baseline, 1 and 2 years for alveolar bone density (ABD), using radiographic absorptiometry (RA) and computer-assisted densitometric image analysis (CADIA), and alveolar bone height (ABH). Statistical analyses utilized generalized estimating equations; primary analyses were intent to treat (ITT). Results are presented as SDD versus placebo.

RESULTS

Under ITT, there was no statistically significant effect of SDD on ABD loss (RA: p=0.8; CADIA: p=0.2) or ABH loss (p=0.2). Most sites (81-95%) were inactive. For subgroup analyses, mean CADIA was higher with SDD for non-smokers (p=0.05) and baseline probing depths > or =5 mm (p=0.003). SDD was associated with 29% lower odds of more progressive ABH loss in women >5 years post-menopausal (p=0.05) and 36% lower among protocol-adherent subjects (p=0.03).

CONCLUSIONS

In post-menopausal osteopenic women with periodontitis, SDD did not differ overall from placebo. Based on exploratory subgroup analyses, additional research is needed to determine the usefulness of SDD in non-smokers, subjects >5 years post-menopausal and in deeper pockets. Protocol registered at (ClinicalTrials.gov). Identifier: NCT00066027.

Comparing two methods of rehabilitation for risk factor modification after a cardiac event

Because fewer than half of cardiac patients in the United States enroll in cardiac rehabilitation (CR) programs, there is a critical need to test alternative strategies of delivering CR services. This study tested whether a home-based CR (home-CR) program was at least as effective as traditional-CR (trad-CR) in the modification of coronary heart disease risk factors from the beginning of CR (baseline) to 2 and 4 months later. A repeated measures non-inferiority quasi-experimental design was used to examine changes in risk factors. Participants selected which CR program, traditional versus home-based, in which to participate: 37 patients chose trad-CR and 24 patients chose home-CR. The following indicators of risk factors were measured: smoking, blood pressure, frequency of aerobic exercise, cholesterol, amount of dietary fat, frequency of anger, body mass index (BMI), and waist circumference. Home-CR was found to be as effective as trad-CR in modification of cardiac risk factors including BMI, waist circumference, blood pressure, frequency of aerobic exercise, total cholesterol, and a low fat diet. Home-CR was not as effective as trad-CR in reducing the frequency of anger. These findings provide support for an alternative method of delivering cardiac rehabilitation services.

Low-Level Laser Effect on Mandibular Distraction Osteogenesis

PURPOSE

The purpose of this study was to determine whether low-level laser (LLL) application during distraction osteogenesis could accelerate bone regeneration and decrease the length of the consolidation phase and thereby reduce potential patient morbidity.

MATERIALS AND METHODS

Nine adult female New Zealand white rabbits underwent bilateral mandibular corticotomies and placement of unidirectional distraction devices (KLS-Martin LP, Jacksonville, FL). Each rabbit served as its own internal control. After a latency of 1 day, distraction progressed bilaterally at 1 mm per day for 10 days. Immediately after each device activation, the experimental side, chosen randomly, was treated with real LLL (Laser Medical Systems, Hedehusene, Denmark) of 6.0 J x 6 transmucosal sites in the area of the distraction gap. Radiographs were taken presurgically, immediately postsurgically, and weekly until sacrifice, and the bone was analyzed using a semiquantitative 4-point scale (Bone Healing Score [BHS]). Three animals each were sacrificed at 2, 4, and 6 weeks postdistraction, and each hemimandible was prepared for histologic examination in a blinded fashion.

RESULTS

Ten millimeters of distraction was achieved in each rabbit bilaterally. Radiographically, the BHS was higher for the LLL-treated group at all time periods. Histologically, the area of new bone trabeculation and ossification was more advanced for the LLL-treated group, with less intervening fibrovascular intermediate zone in the bony regenerate, at all time periods. The formation of a complete inferior border occurred sooner in the treatment group than in the controls.

CONCLUSIONS

LLL accelerates the process of bone regeneration during the consolidation phase after distraction osteogenesis. The adjunctive use of LLL may allow a shortened period of consolidation and therefore permit earlier device removal, with the avoidance of morbidity associated with prolonged device retention.

Measuring community coalition effectiveness using the ICE instrument

This article presents the development and psychometric testing of the Internal Coalition Effectiveness (ICE) instrument, which was based on the conceptual model Internal Coalition Outcome Hierarchy. Sixty-one items were derived from literature about successful coalitions, and the ICE instrument was tested for reliability and validity. A national panel of eight experts conducted content validity. Remaining tests involved a sample of 61 members and leaders of a large midwestern coalition (77% response rate, n=47). Content validity involved a two-stage process for rigorous item development and quantification (0.88, p<0.05). Internal consistency was based on bivariate Pearson's correlation of 0.30-0.70 for two-item scales and Cronbach's alpha(alpha=0.70). Construct validity was assessed by correlation analysis, independent Student's t tests, and informal coalition feedback. The final 30-item version of ICE is psychometrically sound. Findings were shared with the local coalition, and, in support of the instrument's validity, members and leaders found this information useful for promoting coalition sustainability by identifying internal strengths and areas for improvement. The ICE instrument adds to the body of literature by measuring critical constructs of coalition effectiveness and has significant application for public health nurses working as evaluators for coalitions engaged in community health programming.

Prospective Study of Survival Outcomes in Non-Hodgkin's Lymphoma Patients With Rheumatoid Arthritis

Purpose

Although preliminary studies suggest that non-Hodgkin's lymphoma (NHL) complicating rheumatoid arthritis (RA) may be a clinically distinct entity compared with that occurring in the general population, studies examining the impact of antecedent RA on survival are limited. In this prospective study, we examined the association of RA with survival in patients with NHL.

Patients and Methods

Using two large lymphoma registries, we identified patients with evidence of RA preceding NHL. Survival in RA patients was compared with that of controls using proportional hazards regression, adjusting for the effects of age, sex, lymphoma diagnosis-to-treatment lag time, calendar year, International Prognostic Index score, and NHL grade.

Results

The frequency of NHL subtypes was similar in RA patients (n = 65) and controls (n = 1,530). Compared with controls, RA patients with NHL had similar overall survival (hazard ratio [HR] = 0.95; 95% CI, 0.70 to 1.30) but were at lower risk of lymphoma progression or relapse (HR = 0.41; 95% CI, 0.25 to 0.68) or death related to lymphoma or its treatment (HR = 0.60; 95% CI, 0.37 to 0.98), but were more than twice as likely to die from causes unrelated to lymphoma (HR = 2.16; 95% CI, 1.33 to 3.50).

Conclusion

RA is associated with improved NHL-related outcomes, including a 40% reduced risk of death occurring as a result of lymphoma or its treatment and approximately a 60% lower risk of lymphoma relapse or progression compared with non-RA controls. However, the survival advantage gained in RA from the acquisition of lymphomas with favorable prognoses is negated through an increased mortality from other comorbid conditions.

A Conceptual Model for Understanding Effective Coalitions Involved in Health Promotion Programing

Funding agencies are increasingly focused on community coalitions as effective entities for promoting public health programs. Yet, there has been no conceptual model for understanding how effective coalition infrastructure works to facilitate a learning environment, wherein coalition members and leaders receive ongoing training and technical assistance needed to accomplish their external programming goals. This article presents a conceptual model for measuring the internal effectiveness of coalitions [Internal Coalition Outcome Hierarchy (ICOH)]. The ICOH model served as the basis for development of the evaluation instrument, Internal Coalition Effectiveness, which measures internal coalition effectiveness based on achievement of organizational outcomes at each of the model's seven hierarchical levels. The ICOH conceptual model has broad application for public health nurses who are frequently called on to serve as evaluators for community coalitions engaged in health programming. The model has implications for evaluators to use in teaching coalition members and leaders about their internal strengths and areas for improvement, so that coalitions can develop more effective internal structures and thereby promote long-term sustainability.

Challenges and Opportunities for Combination Therapy in Chronic Obstructive Pulmonary Disease

Advances in the understanding of chronic obstructive pulmonary disease have presented a number of novel therapeutic opportunities. More extensive use of drug combinations is likely, but the development of these therapies presents a number of challenges. In clinical trials, a combination must be tested not only against placebo but also against each of its components, and the false-positive error rate increases rapidly with multiple comparisons. Thus, more groups of subjects must be studied, and more individuals within each group must be studied, in order to ensure statistical significance. Another challenge is that the relatively slow progression of chronic obstructive pulmonary disease and the lack of specificity of commonly used outcome variables complicate the evaluation of all therapies, including combinations. In analogy to genomics and proteomics (evaluation of the pattern of expression of many things simultaneously), it may be more useful to adopt an approach that is here dubbed "clinicomics": consideration of multiple features of chronic obstructive pulmonary disease that are evaluated routinely, for example, with a well-done history and physical examination. The use of a truly multidimensional outcome parameter promises an entirely novel paradigm for the assessment of novel combinations of therapies.

Comparison of CT and dual-energy DEXA using a modified trunk compartment in the measurement of abdominal fat

The quantification of abdominal fat is a marker of health risk. While dual-energy x-ray absorptiometry (DEXA) is easily applied, it measures overall fat, although abdominal fat may be a better indicator of health risk from obesity. We have evaluated whether a subcomponent of DEXA measurements correlates better with computed tomography (CT) for body fat than those traditionally used. Forty-seven healthy adults (22 M/25 F), aged 54.5+/-15.8 yr (mean+/-SD), with BMI of 27.1+/-4.6 kg/m2 participated in a cross-sectional study. Body fat was measured using abdominal CT and DEXA for total fat, trunk fat, and a modified trunk measurement that excludes the chest, termed "lower trunk," and compared. The coefficient of variation for DEXA measurements for trunk, lower trunk, and total body were 1.98, 3.12, and 0.85%, respectively. Mean DEXA for percentage fat ranged from 31.7% to 34.1% for trunk, lower trunk, and total body, compared to 54.2% for abdominal CT (p<0.003 for each pairwise comparison). Lower trunk, whole trunk, and total body DEXA measurements were not different. Measurement of subcomponents of fat content by DEXA is not superior to whole body measurements and remains consistently lower than measurements by CT.

Subjective Outcomes Following Sural Nerve Harvest

PURPOSE

The goal of this study was to assess subjective patient recovery of donor site sensory deficit following sural nerve harvest for trigeminal nerve repair surgery.

PATIENTS AND METHODS

A review of 42 consecutive sural nerve graft patient records yielded 26 patients, at least 20 months following sural nerve grafting for trigeminal nerve repair, who participated in a telephone questionnaire survey to assess subjective outcomes. The association between donor site outcome and other factors, including nerve graft recovery, age, gender, pain, cold sensitivity, scar cosmesis and tactile sensitivity, and legal involvement were analyzed, and presurgical and present levels of donor and nerve graft site sensibility were compared.

RESULTS

The perceived area of donor site sensory deficit decreased significantly over time. Postoperative donor site pain and cold sensitivity at low levels were reported by few patients, and the majority have completely resolved. Most patients reported no problems with scar cosmesis or pain. There was a moderate agreement between donor site recovery and nerve graft recovery (kappa = 0.32). Few patients reported satisfaction with one site and not the other or complete dissatisfaction with both sites. Other factors such as age, gender, or legal involvement were not found to correlate with satisfaction level.

CONCLUSIONS

The use of a questionnaire for subjective assessment of neurosensory recovery following nerve graft repair yields outcomes information that is generally not considered in the traditional clinical patient assessment. The majority of patients tolerate sural nerve harvest without significant donor site morbidity.

Alcohol intake is associated with altered pulmonary function

Little is known about the effect of moderate alcohol intake on lung function in the general population. Because moderate alcohol intake appears to reduce cardiovascular disease risk, we hypothesized that moderate alcohol intake is associated with better pulmonary function. To test this hypothesis, we examined the association between alcohol intake and pulmonary function, measured by spirometry, in a representative sample of U.S. adults who participated in the Third National Health and Nutrition Examination Survey. A stratified multistage clustered probability design was used to select a population-based sample. Data analyzed included alcohol intake, smoking status, education, body mass, sex, age, race, diabetes status, and CHF status. The Third National Health and Nutrition Examination Survey was conducted from 1988 to 1994 by the National Center for Health Statistics of the Centers for Disease Control and Prevention, Atlanta, GA. We analyzed data from 15,294 study participants who completed extensive questionnaires in the household and a comprehensive physical examination, including pulmonary function testing, either in the household or at a specially equipped mobile examination center. Low-to-moderate alcohol intake was not associated with reduced odds of obstructive lung function. In fact, increased odds for obstructive lung pattern were observed only in former heavy drinkers. In contrast, low-to-moderate alcohol intake was associated with better forced vital capacity and forced exhaled volume in 1s in the absence of obstruction, consistent with reduced odds for lung restriction. Using a logistic regression model, we found that individuals reporting alcohol consumption had a lower risk of lung restriction both before and after adjusting for confounding factors including smoking (P< or =.001). Alcohol intake-related reduced risk for restriction was associated with lower risk of CHF, diabetes, obesity, and lower markers of inflammation (white blood cell, fibrinogen, and C-reactive protein) consistent with less lung congestion, external restriction, and/or lung inflammation. Our analyses indicate that alcohol consumption, even at very modest intake levels, is associated with less lung restriction.

Association of rheumatoid arthritis treatment response and disease duration with declines in serum levels of IgM rheumatoid factor and anti-cyclic citrullinated peptide antibody

OBJECTIVE

To examine the association of treatment response and disease duration with changes in rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody levels among patients with rheumatoid arthritis (RA).

METHODS

The study sample included 66 RA patients who completed double-blind, randomized clinical protocols and for whom baseline and followup serum samples were available. Anti-CCP and RF levels were measured using commercially available assay kits. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were used to describe the association of response and disease duration with declines in antibody levels.

RESULTS

Patients had a mean +/- SD age of 49.9 +/- 12.0 years and were predominantly female (n = 51; 77%). The mean +/- SD duration between the times at which the baseline and followup serum samples were obtained was 13.7 +/- 8.6 months. Among the 64 subjects with positive antibody at baseline, 33 (52%) experienced a > or =25% reduction in the anti-CCP antibody level during the course of treatment, and 35 patients (55%) had a > or =25% reduction in RF. After adjustment for the baseline anti-CCP antibody level, only a shorter disease duration (< or =12 months) was significantly associated with a decline in the level of anti-CCP antibody (OR 3.0, 95% CI 1.0-8.8), and no association with treatment response was observed. Conversely, treatment response was the only significant determinant of a decrease in RF levels (OR 3.6, 95% CI 1.2-10.4).

CONCLUSION

Shorter disease duration predicts greater declines in anti-CCP antibody levels with treatment in RA. Although treatment response is a robust determinant of a decrease in RF, it does not appear to be associated with declines in the anti-CCP antibody level.

Results of treatment of fifty-six patients with localized retroperitoneal and pelvic rhabdomyosarcoma: a report from The Intergroup Rhabdomyosarcoma Study-IV, 1991-1997

BACKGROUND

We reviewed 56 IRS-IV patients with localized rhabdomyosarcoma [RMS] of the retroperitoneum/pelvis to assess outcome and prognostic factors, including the value of initially excising >or=50% of the tumor (debulking) before chemotherapy.

METHODS

Patients had embryonal RMS [N=38], alveolar RMS [N = 7], RMS not otherwise specified [NOS, N = 7], or undifferentiated sarcoma [N = 4]. Fifteen patients were debulked; 41 patients were biopsied. All received VAC; most received radiotherapy.

RESULTS

Estimated 5-year failure-free survival [FFS] and overall survival rates were 70 and 75%, respectively. FFS rates were better for patients <10 years old and those with embryonal RMS compared to alveolar RMS/undifferentiated sarcoma. After adjusting for age and histological differences, FFS was better for patients whose tumor was debulked prior to beginning therapy [P = 0.02].

CONCLUSIONS

These results are superior to those of previous protocols for patients with RMS of the retroperitoneum/pelvis. Initial excision of >or=50% of the tumor may be associated with increased FFS.

Multicenter experience with upper gastrointestinal polyps in pediatric patients with familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis (FAP) is a hereditary cancer syndrome that includes gastro-duodenal involvement, polyposis, and a propensity to adenocarcinoma necessitating endoscopic surveillance. There are few data describing pediatric upper gastrointestinal FAP resulting in conflicting screening recommendations.

OBJECTIVES

To characterize pediatric gastroduodenal FAP and to investigate the association between symptoms at endoscopy and APC mutation analysis with endoscopic-histologic findings warranting surveillance.

METHOD

A retrospective chart review was performed, including all children with FAP who underwent upper endoscopy (EGD) at two institutions; (UNMC: 1992-2002, JHH: 1983-2002), all biopsies were reviewed and the APC mutations present in the cohort of patients were correlated to the pattern of severity of endoscopic findings and the frequency of APC mutations identified through commercially available testing for FAP (Labcorp: 1998-2002).

RESULTS

Twenty-four patients from 21 families underwent 49 EGDs. Eighty-three percent were asymptomatic at the time of endoscopy. The most common finding was fundic gland polyposis (FGP) (51%), of which 42% and 15% harbored dysplasia and changes indefinite for dysplasia, respectively. Periampullary duodenal adenomata were present in 41% of patients with one patient necessitating ampullectomy. Symptoms at endoscopy were not predictive of premalignant changes. In 15 patients where the APC mutation was known patients with dysplastic FGP, gastric, or duodenal adenoma were more likely to harbor a mutation between codons 1225-1694 than the reference population (p= 0.006).

CONCLUSIONS

All pediatric patients with FAP warrant upper gastrointestinal screening and surveillance endoscopy from the time of initial colonoscopy irrespective of referable symptoms. Patients with APC mutation between codon 1225-1694 may be more susceptible to aggressive gastroduodenal involvement in FAP.

The significance of social network in a geriatric assessment population

BACKGROUND AND AIMS

There has long been speculation that socially-involved individuals suffer less illness, overcome sickness more readily, and experience better health outcomes than more socially isolated persons. This study describes social network characteristics, and determines whether social network affects health outcomes in the geriatric population.

METHODS

Data from 1270 consecutive patients seen in the outpatient Geriatric Assessment Clinic (GAC) of the University of Nebraska Medical Center between August 1988 and May 1999 were analyzed. Social network was measured by the Social Network Index (SNI).

RESULTS

Younger age, higher income and higher education were related to a broader social network. A larger social network was generally associated with lower caregiver burden, higher functional status and better cognition. Men with the smallest social networks were found to be at significantly higher risk of death than women with larger social networks (HR 4). After adjusting for age (HR 1.04, CI 1.03-1.06), income (HR 1.00, CI 1-1), education (HR, NS), IADL (HR 0.97, CI 0.95-0.99), CIRS (HR 1.08, CI 1.05-1.10) and informal service use (HR, NS), the risk of death for subjects based on SNI is only significant in the comparison between SNI III and SNI I (HR 0.67, CI 0.50-0.91).

CONCLUSIONS

SNI I males are at significantly increased risk of death compared with all other groups. The average number of years from initial visit to death for SNI I males is only 2.8 years. These results are consistent with the literature, which suggests men are more affected by social isolation and have decreased survival compared with females. The influence of SNI on mortality in this frail, elderly group appears to be diluted by the presence of functional disability and a high degree of comorbid illness.

Incidence, duration, and prevalence of Escherichia coli O157:H7 fecal shedding by feedlot cattle during the finishing period

The objective was to describe variability in prevalence, incidence, and duration of fecal shedding of naturally occurring E. coli O157:H7 by a group of feedlot cattle over time. One hundred steers, randomly assigned to 10 pens, were fed a high-concentrate finishing diet for 136 days (19 weeks). Rectal feces from each animal were tested for E. coli O157:H7 every week for 19 weeks. E. coli O157:H7 was recovered from each animal that completed the study and was detected from at least one animal every week. Average pen prevalence of cattle shedding E. coli O157:H7 varied significantly over time (P < 0.0001) and across pens (P < 0.0001), ranging from 1 to 80%. Pairwise comparisons of mean pen prevalence of E. coli O157:H7 between weeks and estimation of the predicted probability of an incident case of E. coli O157:H7 over time allowed the definition of three distinct phases--namely, the preepidemic, epidemic, and postepidemic periods. Average pen prevalence varied significantly over time (P < 0.01) and across pens (P < 0.001) for all time periods. The odds of an incident case were significantly greater during epidemic and postepidemic periods relative to the preepidemic period (P = 0.0002 and P = 0.03, respectively). Duration of infection was significantly longer for first or second infections that began during epidemic or postepidemic periods relative to the preepidemic period (P < 0.001). Both incidence and duration of shedding peaked during the epidemic period. Pen-level prevalence of cattle shedding E. coli O157:H7 was affected by both incidence and duration of shedding and could be explained by time- or pen-dependent risk factors, or both.

A Method for Identifying Places in Rural America at Risk of Not Being Able to Support Adequate Health Services

CONTEXT

Public policymakers and their advisers struggle with the problem of specifying criteria by which health care providers in rural areas are eligible for special consideration in payment policies and for special grant programs. A means of designating places can provide a basis for assistance and can help target public resources for any providers who deliver services in those places.

PURPOSE

This paper provides the details underlying a place-based approach to identifying rural areas that are at risk for not being able to provide requisite health services.

METHODS

A population size criterion is utilized first to eliminate metropolitan areas and other large agglomerations from consideration. Any territory not included in a place of 3500 or more people, including a 25-mile buffer around that place, is a priori considered to be at risk. All places, including buffers, that have populations between 3500 and 100,000 are further analyzed using population compositional data and principal components analysis.

FINDINGS

In 10 states and 24 bordering states selected for developing and testing the method, there were 1907 block groups outside the boundaries of any place with a population of at least 3500. In addition, the analysis suggested that 66 out of 236 places and buffers with populations between 3500 and 100,000 also should be classified as vulnerable.

CONCLUSIONS

The results are discussed in regard to how a place-based approach can advance the study of rural health needs. By focusing on the needs of the people residing in a defined area, as determined from the aggregate characteristics of the population, a model is generated that can be used to predict special circumstances confronting any service provider. The public policy implications of the findings are also considered. Special payment policies could be written on the basis of place instead of provider characteristics, and grant programs providing technical assistance could be targeted to places of greatest need.

Patterns of adherence to antiretroviral medications: the value of electronic monitoring

OBJECTIVE

To investigate the patterns of intra-subject (between medication) adherence to antiretroviral therapy.

DESIGN

A prospective, observational, 3-month study of adherence to antiretroviral therapy at an inner-city clinic in 40 HIV-infected subjects.

METHODS

Adherence was monitored monthly by the use of medication event monitoring system (Aprex) caps placed on each antiretroviral drug in a subject's regimen. Agreement between different drug classes and dosing schedules, for each subject, was quantified by estimating the mean difference in adherence, with 95% limits of agreement. An analysis of variance model was used to estimate the variance of the differences. Individual dosing calendars were examined for each subject.

RESULTS

The dosing schedule was a strong predictor of intra-subject adherence. Regardless of the subject's overall adherence rate, high or low, when subjects missed a dose of one medication, they missed a dose of both medications taken at that dosing time. Conversely, when medications were scheduled to be taken together, regardless of the drug class, the medications were taken at the same times. The majority of the subjects took medications at obviously incorrect times. Problematical adherence was related to thrice-daily dosing and food restrictions.

CONCLUSION

This is the first report objectively to quantify intra-subject adherence to antiretroviral therapy and report the findings in detail. We observed clear patterns of drug-taking behavior among the subjects in our study. To the extent that medication scheduling is a controllable factor, our report provides an insight into specific patterns of behavior that may be targets for adherence counseling.

All-digital image capture and whole-field analysis of ciliary beat frequency

We hypothesized that a high-speed all-digital video imaging system, with computerized analysis, would precisely capture and measure ciliary beat frequency (CBF) and would shorten the time from data capture to data analysis. We compared a conventional analog video system with a new high-speed digital system we developed for CBF analysis. Using ciliated primary bovine bronchial epithelial cells we made simultaneous analog and digital CBF measurements of the same region of interest (ROI) while temperature was varied. This yielded nearly identical data over a wide range of frequencies (7-15 Hz) using either system. Unlike the digital system however, the analog system did not accurately detect CBF above 15 Hz (temperatures higher than 30 degrees C). We also compared ROI analysis with a new analysis algorithm we have named whole-field analysis (WFA). WFA measurement of CBF agreed with ROI and reduced operator time required to analyse data by more than 90% compared with the analog system. We conclude that all-digital computerized CBF analysis correlates closely with standard video methods, markedly speeds up data analysis and provides new ways, including WFA, to analyse entire fields of motile cilia simultaneously. We have termed this system 'Sisson-Ammons Video Analysis' (SAVA).

Resolution of depression among victims of intimate partner violence: is cessation of violence enough?

The objective of this article is to assess the effect of abuse cessation on depressive symptoms among women abused by a male intimate partner. This prospective cohort study of Seattle women with a history of intimate partner violence (IPV) who were classified by history of abuse and abuse status at 3 month, 9 month, and 2 year follow-up interviews. Relative risks (RR) were calculated using generalized estimating equations. Among subjects with a history of psychological abuse only, cessation of abuse was associated with a nonsignificant reduction in the likelihood of depression compared to subjects whose abuse continued (aRR = 0.88; 95%CI: 0.75,1.03). Among subjects with a history of physical/sexual abuse and psychological abuse, cessation of physical/sexual abuse only was associated with a 27% decline, and cessation of both types of abuse was associated with a 35% decline in the likelihood of depression (aRR = 0.73, 95%CI: 0.63,0.86; and aRR = 0.65; 95%CI: 0.55,0.76; respectively). Cessation of abuse among victims of IPV is associated with a decreased prevalence of depression.

Ethanol consumption decreases the synthesis of the mannose 6-phosphate/insulin-like growth factor II receptor but does not decrease its messenger RNA

The mannose 6-phosphate/insulin-like growth factor II receptor (M6P/IGF-IIR) is a protein that facilitates the transport of acid hydrolases into the lysosome. We have shown that chronic ethanol consumption lowers the M6P/IGF-IIR content in rat hepatocytes. Here, we determined the steady-state level of mRNA encoding M6P/IGF-IIR, as well as the rate of receptor synthesis, to ascertain whether the ethanol-elicited reduction in receptor protein content is related to changes in either or both of these parameters. Rats were pair-fed the normal carbohydrate (NC) or low carbohydrate high-fat (LC) liquid diets containing either ethanol or isocaloric maltose-dextrin for 7-8 weeks. RNA was isolated from hepatocytes and from whole livers of these animals and subjected to reverse transcription-polymerase chain reaction (RT-PCR) to determine the mRNA levels encoding M6P/IGF-IIR. Hepatocytes isolated from these animals were also radiolabeled with Pro-mix L-[35S] in vitro cell labeling mix to measure incorporation into total cellular protein and the immunoprecipitated M6P/IGF-IIR protein. The steady-state levels of M6P/IGF-IIR mRNA in both hepatocytes and whole livers from ethanol-fed rats were the same as those from their respective controls regardless of whether they were fed the NC or the LC diets. Hepatocytes from ethanol-fed rats showed a 36% lower rate of total protein synthesis and an even greater reduction (70%) in receptor synthesis. When the relative rate of receptor synthesis was calculated, hepatocytes from ethanol-fed rats had a 53% lower relative rate of receptor synthesis compared with controls. Autoradiographic analysis of the immunoprecipitated receptor protein from ethanol-fed rats also indicated a 79% decline in the total M6P/IGF-IIR protein synthetic rate compared with pair-fed controls. We conclude that the ethanol-elicited reduction of M6P/IGF-IIR content was, in part, related to a concomitant reduction of receptor protein synthesis but not to a decline in its mRNA level. Thus, the ethanol-elicited decline in receptor protein synthesis may be due to defective M6P/IGF-IIR mRNA translation.

Evaluation of friction during sliding tooth movement in various bracket-arch wire combinations

Frictional forces during simulated sliding tooth movement were measured with a model that was representative of the clinical condition. The model allowed tipping of the tooth until contact was established between the arch wire and diagonally opposite corners of the bracket wings; it also allowed rotation until the wire contacted opposite corners of the ligature tie, or the buccal shield with self-ligating brackets, and the base of the slot. Conventional and self-ligating stainless steel brackets as well as conventional ceramic brackets, and ceramic brackets with a stainless steel slot, all with 0.022 inch bracket slot, were tested with 0.019 x 0.025 inch arch wires of stainless steel, nickel titanium, and beta titanium. Each of the 12 bracket-arch wire combinations was tested 10 times. No significant interaction was detected between brackets and arch wires (P = .89), but the bracket and arch wire effects were significant (P < .001). The pairwise differences between conventional and self-ligating stainless steel brackets and ceramic brackets with stainless steel slot were not significant. However, the conventional ceramic brackets generated significantly higher friction than the other brackets tested. Beta titanium arch wires produced higher frictional forces than nickel titanium arch wires, but no significant differences were found between each of the two and stainless steel arch wires. Attempts to identify differences in surface scratches of the arch wires produced by the different brackets were unsuccessful.

Factors used by program directors to select residents

A national, stratified random sample of 405 graduate medical education program directors was surveyed on the way they selected their residents. The results from the 237 respondents reaffirm earlier studies which found that the interview was the most important selection variable. The results indicate that the recent increase in competition for residency positions has increased the importance of academic variables. For example, 86 percent of the respondents stated that they would not rank a candidate who had not passed the National Board of Medical Examiners Part I examination. Because 86 percent also stated that they give preference in ranking students to those who have done well in an elective at their hospitals, the senior year of medical school may be used as a "residency chase" rather than for the general professional education of the physician.