P1-10-07: Comparing Breast Cancer Screening Guidelines: A Stage-Survival-Cost Model in a Public Hospital

Background: Despite advances in diagnosis and treatment of breast cancer in the United States, racial disparities in survival persist. Female breast cancer represented the costliest cancer site in 2010 with further increases projected to 2020. Mammography screening guidelines reflect the inherent difficulty in reconciling mortality reduction with potential harms to patients and cost-effectiveness concerns. Controversy still surrounds the 2009 updated USPSTF recommendations, as critics and advocates alike evaluate lives saved, costs, and how best to compare screening strategies. This study simulates USPSTF and ACS guidelines’ effects on stage, 5-year survival, and cost of treatment vs. usual practice in women treated in an urban public hospital.

Methods: Charts of 84 patients diagnosed with Stage I-III breast cancer in 2008 were reviewed. Published tumor doubling times guided a retrospective model to predict size at diagnosis by simulated ACS or USPSTF guidelines. AJCC-7 stages were then assigned to produce 3 distributions: 1) actual stage; 2) stage under ACS; and 3) stage under USPSTF. Survival estimates by stage and year from diagnosis were drawn from NCDB statistics and applied to each stage distribution, yielding average predicted survival for the actual and hypothetical scenarios. Finally, treatment costs for women continuously enrolled in Medicaid for 18 months were calculated from merged claims and registry data and similarly applied.

Results: Study patients averaged 55 years; 85% were African American. Forty-nine percent were covered by Medicaid and 23% by Medicare. Comparing actual and predicted stages at diagnosis showed significant shifts in stage distribution between all three scenarios (Table 1).

Working together as a catalyst for change: the development of a peer mentoring model for the prevention of chronic disease in Australian Indigenous communities

This paper outlines the development of a model for an Indigenous peer mentoring program. The aim of this program is to improve the health of Indigenous people living in the western suburbs of Melbourne, Australia. Although the benefits of peer mentoring are well documented, particularly in relation to disease prevention, little has been written about the specific benefits for Indigenous people. While developing this model, it became apparent that to be successful, peer mentoring programs for Indigenous people need to be flexible, informal and draw on the knowledge and skills of the local community in partnership with local services.

Plasma methoxytyramine: a novel biomarker of metastatic pheochromocytoma and paraganglioma in relation to established risk factors of tumour size, location and SDHB mutation status

BACKGROUND

There are currently no reliable biomarkers for malignant pheochromocytomas and paragangliomas (PPGLs). This study examined whether measurements of catecholamines and their metabolites might offer utility for this purpose.

METHODS

Subjects included 365 patients with PPGLs, including 105 with metastases, and a reference population of 846 without the tumour. Eighteen catecholamine-related analytes were examined in relation to tumour location, size and mutations of succinate dehydrogenase subunit B (SDHB).

RESULTS

Receiver-operating characteristic curves indicated that plasma methoxytyramine, the O-methylated metabolite of dopamine, provided the most accurate biomarker for discriminating patients with and without metastases. Plasma methoxytyramine was 4.7-fold higher in patients with than without metastases, a difference independent of tumour burden and the associated 1.6- to 1.8-fold higher concentrations of norepinephrine and normetanephrine. Increased plasma methoxytyramine was associated with SDHB mutations and extra-adrenal disease, but was also present in patients with metastases without SDHB mutations or those with metastases secondary to adrenal tumours. High risk of malignancy associated with SDHB mutations reflected large size and extra-adrenal locations of tumours, both independent predictors of metastatic disease. A plasma methoxytyramine above 0.2nmol/L or a tumour diameter above 5cm indicated increased likelihood of metastatic spread, particularly when associated with an extra-adrenal location.

CONCLUSION

Plasma methoxytyramine is a novel biomarker for metastatic PPGLs that together with SDHB mutation status, tumour size and location provide useful information to assess the likelihood of malignancy and manage affected patients.

Measurements of plasma methoxytyramine, normetanephrine, and metanephrine as discriminators of different hereditary forms of pheochromocytoma

BACKGROUND

Pheochromocytomas are rare catecholamine-producing tumors derived in more than 30% of cases from mutations in 9 tumor-susceptibility genes identified to date, including von Hippel-Lindau tumor suppressor (VHL); succinate dehydrogenase complex, subunit B, iron sulfur (Ip) (SDHB); and succinate dehydrogenase complex, subunit D, integral membrane protein (SDHD). Testing of multiple genes is often undertaken at considerable expense before a mutation is detected. This study assessed whether measurements of plasma metanephrine, normetanephrine, and methoxytyramine, the O-methylated metabolites of catecholamines, might help to distinguish different hereditary forms of the tumor.

METHODS

Plasma concentrations of O-methylated metabolites were measured by liquid chromatography with electrochemical detection in 173 patients with pheochromocytoma, including 38 with multiple endocrine neoplasia type 2 (MEN 2), 10 with neurofibromatosis type 1 (NF1), 66 with von Hippel-Lindau (VHL) syndrome, and 59 with mutations of SDHB or SDHD.

RESULTS

In contrast to patients with VHL, SDHB, and SDHD mutations, all patients with MEN 2 and NF1 presented with tumors characterized by increased plasma concentrations of metanephrine (indicating epinephrine production). VHL patients usually showed solitary increases in normetanephrine (indicating norepinephrine production), whereas additional or solitary increases in methoxytyramine (indicating dopamine production) characterized 70% of patients with SDHB and SDHD mutations. Patients with NF1 and MEN 2 could be discriminated from those with VHL, SDHB, and SDHD gene mutations in 99% of cases by the combination of normetanephrine and metanephrine. Measurements of plasma methoxytyramine discriminated patients with SDHB and SDHD mutations from those with VHL mutations in an additional 78% of cases.

CONCLUSIONS

The distinct patterns of plasma catecholamine O-methylated metabolites in patients with hereditary pheochromocytoma provide an easily used tool to guide cost-effective genotyping of underlying disease-causing mutations.

Frequency of abdominal wall hernias: is classical teaching out of date?

Objectives

Abdominal wall hernias are common. Various authors all quote the following order (in decreasing frequency): inguinal, femoral, umbilical followed by rarer forms. But are these figures outdated? We investigated the epidemiology of hernia repair (retrospective review) over 30 years to determine whether the relative frequencies of hernias are evolving.

Design

All hernia repairs undertaken in consecutive adult patients were assessed. Data included: patient demographics; hernia type; and operation details. Data were analysed using Microsoft Excel 2007 and SPSS.

Setting

A single United Kingdom hospital trust during three periods: 1985–1988; 1995–1998; and 2005–2008.

Main outcome measures

Frequency data of different hernia types during three time periods, patient demographic data.

Results

Over the three time periods, 2389 patients underwent 2510 hernia repairs (i.e. including bilateral and multiple hernias in a single patient). Inguinal hernia repair was universally the commonest hernia repair, followed by umbilical, epigastric, para-umbilical, incisional and femoral, respectively. Whereas femoral hernia repair was the second commonest in the 1980s, it had become the fifth most common by 2005–2008. While the proportion of groin hernia repairs has decreased over time, the proportion of midline abdominal wall hernias has increased.

Conclusion

The current relative frequency of different hernia repair type is: inguinal; umbilical; epigastric; incisional; para-umbilical; femoral; and finally other types e.g. spigelian. This contrasts with hernia incidence figures quoted in common reference books.

Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis

BACKGROUND

Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is becoming widely used for mediastinal lymph node staging in patients with known or suspected lung cancer. While a substantial number of case series have evaluated test performance of this investigation, the small sample sizes limited the ability to accurately evaluate the precision of EBUS-TBNA as a staging modality. A systematic review was performed of published studies evaluating EBUS-TBNA for mediastinal lymph node staging to ascertain the pooled sensitivity and specificity of this investigation.

METHODS

A literature search was constructed and performed by a professional medical librarian to identify the literature from 1960 to February 2008. Pooled specificity and sensitivity was estimated from the extracted data with an exact binomial rendition of the bivariate mixed-effects regression model.

RESULTS

Of 365 publications, 25 were identified in which EBUS-TBNA was specifically focused on mediastinal node staging. Of these, only 10 had data suitable for extraction and analysis. The overall test performance was excellent with an area under the summary receiver operating characteristics curve of 0.99 (95% CI 0.96 to 1.00); similarly, EBUS-TBNA had excellent pooled specificity of 1.00 (95% CI 0.92 to 1.00) and good pooled sensitivity of 0.88 (95% CI 0.79 to 0.94).

CONCLUSIONS

EBUS-TBNA has excellent overall test performance and specificity for mediastinal lymph node staging in patients with lung cancer. The results compare favourably with published results for computed tomography and positron emission tomography.

Update on pediatric pheochromocytoma

Pheochromocytomas are rare tumors in children arising from chromaffin cells of adrenal medullary or extra-adrenal paraganglionic tissue. The tumors are characterized by synthesis, metabolism, and secretion of catecholamines. The formerly used guidelines for pheochromocytoma have been changed by recent discoveries, implementation of new approaches, and understanding of biochemistry, genetics, imaging, pathophysiology, and nomenclature of these tumors. In children, pheochromocytomas are more frequently familial, extra-adrenal, bilateral, and multifocal than in adults. Because of a highly variable clinical presentation, pheochromocytoma is often referred to as the great mimic. Measurements of plasma or urinary fractionated metanephrines are recommended as first-line biochemical tests for diagnosis, with optimum diagnostic sensitivity to be preferred over specificity. In general, localization studies must be used secondary to clinical and biochemical evidence. Adequate preoperative treatment with alpha-blockade is mandatory, including for pheochromocytomas that do not secrete but only synthesize catecholamines. Because approximately 40% of pheochromocytomas in children have a hereditary basis, proper genetic testing should be performed, with appropriate implications for future follow-up and treatment options. The risk for development of malignant disease depends highly on the underlying mutation, which may also impact recommendations concerning screening and surgical or systemic treatment. This article reviews recent advances in biochemistry, genetics, and imaging and outlines recommendations for improved evaluation and treatment of children with benign or malignant pheochromocytomas.

Two common mitochondrial DNA polymorphisms are highly associated with migraine headache and cyclic vomiting syndrome

Mitochondrial dysfunction is a hypothesized component in the multifactorial pathogenesis of migraine without aura (MoA, 'common migraine') and the related condition of cyclic vomiting syndrome (CVS). In this study, the entire mitochondrial genome was sequenced in 20 haplogroup-H CVS patients, a subject group studied because of greater genotypic and phenotypic homogeneity. Sequences were compared against haplogroup-H controls. Polymorphisms of interest were tested in 10 additional CVS subjects and in 112 haplogroup-H adults with MoA. The 16519C-->T polymorphism was found to be highly disease associated: 21/30 CVS subjects [70%, odds ratio (OR) 6.2] and 58/112 migraineurs (52%, OR 3.6) vs. 63/231 controls (27%). A second polymorphism, 3010G-->A, was found to be highly disease associated in those subjects with 16519T: 6/21 CVS subjects (29%, OR 17) and 15/58 migraineurs (26%, OR 15) vs. 1/63 controls (1.6%). Our data suggest that these polymorphisms constitute a substantial proportion of the genetic factor in migraine pathogenesis, and strengthen the hypothesis that there is a component of mitochondrial dysfunction in migraine.

Development, impact and outcomes of the Hull Bacteraemia Service

BACKGROUND

Bacteraemia is a significant cause of mortality and healthcare expenditure. Evidence suggests that consultation by an infection specialist may improve outcomes.

AIM

To review the characteristics and outcomes of patients seen by a newly implemented bacteraemia service.

METHODS

Retrospective review of data collected at time of consultation. Economic analyses and benchmarking of outcomes were also performed.

RESULTS

One hundred and fifty-one patients were seen by the service over an 18-month period. Staphylococcus aureus was the most common isolate and central venous lines the most common source. Antibiotics were changed and additional investigations suggested in 62% and 61% of patients, respectively. The 30-day mortality was 19%. Implementation and delivery of the service over the 18-month study period cost pound 22,663 (pound 15,109 per year). The cost per change in antibiotic prescription was pound 244. The cost per 'near-miss' detected was pound 1193. Overall mortality was no higher and possibly lower than in published studies.

CONCLUSION

We believe that this model of care may be suitable for the management of patients with bacteraemia. A study assessing the cost-effectiveness of this approach is required.

Another look at breast projection after breast reduction

A controversy exists between vertical mammoplasty and the "traditional" keyhole\inferior pedicle method of breast reduction. This article examines factors affecting breast projection by considering the difference in concept between vertical mammaplasty (using the modification proposed by Hall-Findley as an example) and the inferior pedicle\keyhole pattern. This article is not about "how to do" but rather about "why" things are done in a certain way. The emphasis is on understanding what is done and its effects rather than on technique. The breast can be considered a cone. Breast projection then is the ratio between the nipple projection and the breast base. Two key concepts need to be considered: the orientation of the ellipses during excision of breast tissue in breast reduction and the role of the breast base\inframammary fold. Breast projection is not determined by the scars. After an examination of each technique, methods to enhance projection are discussed.

Method: ‘Are you Aboriginal and/or Torres Strait Islander?’: improving data collection at BreastScreen Victoria

OBJECTIVE

To evaluate the ascertainment and recording of clients' Indigenous status at BreastScreen Victoria (BSV) by assessing: staff compliance with best practice recommendations in ascertaining Indigenous status data collection practices; and the consistency of recording of Indigenous status between visits.

METHODS

The Australian Bureau of Statistics/Australian Institute of Health and Welfare best practice recommendations for collecting Indigenous status data were compared against BSV practices. One hundred and thirty-three BSV staff were also surveyed about their practices of ascertaining Indigenous status. An audit of the consistency of recording Indigenous status at first and most recent visit to BSV was also conducted.

RESULTS

Current ascertainment and recording of Indigenous status by BSV staff does not comply with best practice recommendations. A high proportion of staff were not ascertaining Indigenous status (34%), and/or perceived they were prevented from asking women whether they were Indigenous (53%). The consistency of recording of Indigenous status between women's visits was also low.

IMPLICATIONS

Our findings are likely to be found in other services where collection of Indigenous status data occurs. To improve data collection, services need to: ensure questions regarding Indigenous status comply with best practice recommendations; provide staff training regarding the importance of collecting the information; and improve Indigenous participation and control of data collection and dissemination.

Distribution of in vivo and in vitro range of motion following 1-level arthroplasty with the CHARITE artificial disc compared with fusion

OBJECT

One of the goals of lumbar arthroplasty is to restore and maintain range of motion (ROM) and to protect adjacent levels from abnormal motion, which may be a factor in transition syndrome following arthrodesis. In this study, in vitro ROM results were compared with in vivo, 2-year postoperative radiographic ROM evaluations.

METHODS

Radiographs of patients enrolled in the CHARITE investigational device exemption study were analyzed at baseline and at 2 years postoperatively. The ROM in flexion/extension at the implanted and adjacent levels was measured, normalized, and compared with ROM results obtained using cadaver (in vitro) evaluations.

RESULTS

Preoperative ROM distributions in patients enrolled for arthroplasty or fusion at the L4-5 level was as follows: 28% motion was observed at L3-4, 35% at L4-5 and 37% at L5-S1. Following a one-level arthroplasty at L4-5, the in vivo ROM distribution from L-3 to S-1 at the 2-year time point was 36% at L3-4, 30% at L4-5 and 35% at L5-S1. Following a one-level fusion with BAK and pedicle screws at L4-5, the in vivo ROM distribution from L-3 to S-1 at the 2-year time point was 45% at L3-4, 9% at L4-5 and 46% at L5-S1.

CONCLUSIONS

The baseline as well as the 2-year in vivo data confirmed previously published in vitro data. One-level arthroplasty was shown herein to replicate the normal distribution of motion of the intact spine.

ABC; An AGITG trial of fixed dose rate (FDR) gemcitabine (gem) and cisplatin for patients (pts) with advanced biliary tract cancer (ABC)

15015

Background: No standard regimen exists for pts with ABC. Previous studies suggest that FDR optimises gem activity. This study evaluated the activity of FDR gem with low dose cisplatin using a previously identified schedule. Methods: Single arm, multi- centre phase II trial, planned to enrol 45 pts > 18 years, ECOG PS = 2, with previously untreated histologically / cytologically confirmed, inoperable locally advanced or metastatic ABC. Treatment consisted of FDR gem 1000 mg/m2 (10 mg/m2/min) and cisplatin 20 mg/m2 days 1& 8 q21 days until progression or intolerable toxicity. The primary end point was response rate (RR) by RECIST. Secondary end points included tolerability and safety, progression free and overall survival (PFS, OS) and response duration (RD). Results: 50 pts were enrolled from Feb 05 to Oct 06. Mean age was 60y (39–78); 88% had ECOG PS 0–1; 54% were female. Primary sites were gall bladder 45%, biliary tree 51%, ampulla 4%. Distant metastases were present in 63%. Past treatments included biliary stent in 29%, bypass in 6%, and an external drain in 4%. With a minimum follow-up of 12 weeks, best response was a confirmed PR in 11 pts (RR 22%, 95% CI 11 - 36) and SD (after 4 cycles) in 11 pts (22%), 1 (2%) unevaluable. CA19–9 responses occurred in 6 of 33 pts (18%). Median OS was 7 mo (0.3–13), PFS 4.4 mo (0.3–13), and RD 8 mo (5–12). One year survival rate was 30%. The median number of cycles was 4 (1–16). Treatment was delayed at least once in 45% of pts; mean delay 9d. Grade 3/4 (NCI/CTC) toxicities included infection 9%, fatigue 9%, anorexia/nausea 11%, vomiting 9%, anaemia 9%, neutropenia 28%, thrombocytopenia 15%, abnormal ALP 25%, GGT 47%, AST 6%. There was 1 treatment related death (hematemesis with grade 4 thrombocytopenia). Exploratory analysis of CA 19–9 and its association with response assessment and overall survival will be presented in June. Conclusions: This combination was well tolerated. The observed response rate is consistent with the expected 35% rate and may be superior to that expected with gem monotherapy. Further testing of this dose and scheduling is warranted. The authors thank Lilly for an unrestricted grant to conduct this study.

[Table: see text]

The Role of Glucagon in Regulating Chicken Hepatic Malic Enzyme and Histidase Messenger Ribonucleic Acid Expression In Response to an Increase in Dietary Protein Intake

Increased dietary protein intake rapidly (3 h) decreases hepatic malic enzyme and increases hepatic histidase mRNA expression in broiler chicks. A series of experiments was conducted to determine the role that glucagon or a specific mixture of dietary amino acids might have in regulating the rapid changes in mRNA expression of these enzymes, when dietary protein intake is increased. Three hours after the injection of glucagon (240 microg/kg of BW) into the brachial vein of broiler chicks, hepatic malic enzyme mRNA expression was significantly lower and hepatic histidase mRNA expression was significantly greater than the level detected in saline-injected chicks. In addition, broiler chicks fed a high (40 g/ 100 g of diet) protein diet had significantly higher plasma glucagon levels at 1 and 3 h after initial access to this diet than broiler chicks fed a basal (22 g/100 g of diet) protein diet. The plasma glucagon concentration, however, was not different between the chicks fed the 2 dietary protein levels at 2 h after the initial access to the 2 diets. When a mixture of indispensable or dispensable amino acids was added to the basal diet to equal the concentrations of the individual indispensable or dispensable amino acids in the high protein diet, hepatic mRNA expression of malic enzyme and histidase were intermediate to the expression found in chicks fed the basal and high protein diet. The results indicate that glucagon may mediate the changes in the mRNA expression of malic enzyme and histidase in response to dietary protein intake and that total amino acid intake rather than the ingestion of specific amino acids regulates the mRNA expression of malic enzyme and histidase in chicks.

Combined use of a cytoprotectant and rehabilitation therapy after severe intracerebral hemorrhage in rats

After moderate intracerebral hemorrhage (ICH), both hypothermia (HYPO) and constraint-induced movement therapy (CIMT) improve recovery and reduce the volume of brain injury. We tested the hypothesis that more severe ICH requires both cytoprotection and rehabilitation to significantly improve recovery. Rats were subjected to a unilateral striatal ICH via collagenase infusion. Rats remained normothermic or were subjected to mild HYPO ( approximately 2 days) starting 12 h later. Fourteen days after ICH, half of the rats received CIMT (7 days of restraint of the less affected limb plus daily exercises); the remainder were untreated. Walking, limb use and skilled reaching were assessed up to 60 days, at which time animals were euthanized and the volume of tissue lost was determined. The HYPO treatment alone did not improve outcome, whereas CIMT alone provided significant benefit on the limb use asymmetry test. In the staircase test, the greatest benefit was achieved with the combination of HYPO and CIMT treatments. The volume of tissue lost after ICH was similar among groups arguing against cytoprotection as a mechanism of functional recovery. Finally, these findings suggest that, at least under the present circumstances (e.g., severe striatal ICH), CIMT provides superior benefit to HYPO and that combination therapy will sometimes further improve recovery.

A prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part II: evaluation of radiographic outcomes and correlation of surgical technique accuracy with clinical outcomes

STUDY DESIGN

A prospective, randomized, multicenter, Food and Drug Administration-regulated, investigational device exemption clinical trial.

OBJECTIVES

To compare the safety and effectiveness of lumbar total disc replacement (TDR) with the CHARITE artificial disc (DePuy Spine, Raynham, MA) to anterior lumbar interbody fusion for the treatment of single-level degenerative disc disease from L4-S1 unresponsive to nonoperative treatment. In addition, to evaluate the radiographic outcomes of lumbar artificial disc replacement at either L4-L5 or L5-S1 with the CHARITE artificial disc as compared to anterior lumbar interbody fusion with cylindrical cages and iliac crest bone graft; and to determine if a correlation exists between clinical outcomes and surgical accuracy of TDR placement within the disc space.

SUMMARY OF BACKGROUND DATA

Prior investigators have reported excellent radiographic results with the CHARITE artificial disc for the treatment of lumbar degenerative disc disease. These encouraging results are the product of retrospective reviews without a control. Very few studies have reported on the segmental motion of an intervertebral level implanted with an artificial disc, and no studies have reported a correlation of radiographic and clinical outcomes.

METHODS

A prospective, randomized, multicenter, US Food and Drug Administration, investigational device exemption study with 24-month follow-up was performed at 14 centers throughout the United States. A total of 304 subjects were randomized in a 2:1 ratio, with 205 in the investigational group (TDR with the CHARITE artificial disc) and 99 in the control group (anterior lumbar interbody fusion with BAK cages and iliac crest bone graft). A total of 71 TDR training cases were performed (up to 5 at each site) before randomization beginning at each site. Plain radiographs were analyzed for each subject in both groups regarding range of motion (ROM) in flexion/extension, restoration of disc space height, and subsidence. Prosthesis placement in the coronal and midsagittal planes was analyzed for the 276 patients with TDR. Correlations were performed between prosthesis placement and clinical outcomes.

RESULTS

Patients in the investigational group had a 13.6% mean increase, and those in the control group an 82.5% decrease in mean flexion/extension ROM at 24 months postoperatively compared to baseline. Patients in the investigational group had significantly better restoration of disc height than the control group (P < 0.05). There was significantly less subsidence in the investigational group compared to the control group (P < 0.05). The surgical technical accuracy of CHARITE artificial disc placement was divided into 3 groups: I, ideal (83%); II, suboptimal (11%); and III, poor (6%), and correlated with clinical outcomes. The flexion/extension ROM and prosthesis function improved with the surgical technical accuracy of radiographic placement (P = 0.003).

CONCLUSIONS

Preoperative ROM in flexion/extension was restored and maintained in patients receiving a TDR. TDR with the CHARITE artificial disc resulted in significantly better restoration of disc space height, and significantly less subsidence than anterior interbody fusion with BAK cages. Clinical outcomes and flexion/extension ROM correlated with surgical technical accuracy of CHARITE artificial disc placement. In the majority of cases, placement of the CHARITE artificial disc was ideal.

Card agglutination test for trypanosomiasis (CATT) end-dilution titer and cerebrospinal fluid cell count as predictors of human African Trypanosomiasis (Trypanosoma brucei gambiense) among serologically suspected individuals in southern Sudan

The diagnosis of human African trypanosomiasis (HAT) due to Trypanosoma brucei gambiense relies on an initial serologic screening with the card agglutination test for trypanosomiasis (CATT) for T. b. gambiense, followed by parasitologic confirmation in most endemic areas. Unfortunately, field parasitologic methods lack sensitivity and the management of serologically suspected individuals (i.e., individuals with a positive CATT result but negative parasitology) remains controversial. In Kajo-Keji County in southern Sudan, we prospectively collected sociodemographic and laboratory data of a cohort of 2,274 serologically suspected individuals. Thirty-three percent (n = 749) attended at least one follow-up visit and HAT was confirmed in 64 (9%) cases. Individuals with lower initial CATT-plasma (CATT-P) end-dilution titers had lowest risks (10.4 and 13.8/100 person-years for 1:4 and 1:8 titers, respectively) that significantly increased for higher dilutions: relative risks = 5.1 (95% confidence interval [CI] = 2.6-9.5) and 4.6 (95% CI = 2.8-9.8) for 1:16 and 1:32 titers, respectively. The cumulative yearly risk was also high (76%) in individuals found with 11-20 cells in the cerebrospinal fluid, but this involved only eight patients. Adjustment for potential confounders did not affect the results. In conclusion, treatment with pentamidine should be considered for all serologically suspected individuals with a CATT-P end-dilution titer >/= 1:16 in areas of a moderate to high prevalence of HAT.

Indomethacin therapy for patent ductus arteriosus in premature infants: efficacy of a dosing strategy based on a second-dose peak plasma indomethacin level and estimated plasma indomethacin levels

The objective of this study was to determine the rate of patent ductus arteriosus (PDA) closure in premature infants using an adjustable indomethacin (INDO) dosing strategy, based on a second-dose peak plasma INDO level. We conducted a retrospective review of the medical records of premature infants that were treated with INDO for a PDA, had a second dose peak plasma NDO levels, and followed predetermined guidelines for INDO dosing adjustments, over a 4-year period (1995 to 1998). Of 103 infants treated with the adjustable INDO dosing strategy, 66 (64%) achieved PDA closure whereas 37 (36%) did not. No differences in the second-dose peak plasma INDO levels (830 +/- 339 versus 702 +/- 381 ng/mL), day of life treatment was started (4 +/- 3 versus 4 +/- 2 days), or the number of doses of INDO received (4 +/- 1 versus 5 +/- 2 dose) were observed between responders and nonresponders. However, fourth-dose peak plasma INDO levels, which were available from 38 of 66 (57%) of the responders and 20 of 37 (54%) of the nonresponders, were lower in nonresponders (1553 +/- 413 versus 1829 +/- 609 ng/mL, p < 0.05). Patient demographics, including birth weight and gestational age, were similar between these groups. Using an adjustable INDO dosing strategy, based on a second-dose peak plasma INDO level and estimated plasma levels, PDA closure rates of 64% can be achieved. Although a clear relationship between INDO plasma levels and PDA closure was evident form this study, the rate of PDA closure in our study was lower than has been observed in studies with serial plasma INDO level monitoring.

Prematurity is the major risk factor for late-onset group B streptococcus disease

A case-control study was conducted in the greater Houston area to determine risk factors for late-onset group B streptococcus (GBS) disease (onset of disease or first positive culture between 7 and 180 days after birth). Characteristics of 122 case patients diagnosed during 1995-2000 were compared with control subjects matched for birth hospital and date of birth. Half the case patients were preterm infants, 84% of whom were born at <34 weeks of gestation. The risk for late-onset GBS disease increased by a factor of 1.34 (95% confidence interval [CI], 1.15-1.56) for each week of decreasing gestation, by 3.70 (95% CI, 1.35-10.1) for infants of black mothers, and by 4.15 (95% CI, 1.27-13.60) for infants of mothers with a positive GBS screening. These risk factors are similar to that of early-onset GBS disease. However, prematurity is the major risk factor for late-onset GBS disease.

Composition and distribution of pythium communities in wheat fields in eastern washington state

ABSTRACT Pythium spp. were isolated from a mixture of soil and roots collected from 80 wheat fields in eastern Washington in the summer of 2000 from an area encompassing approximately 27,000 km(2). These sites covered a range of soil textures (coarse to fine, silty loess), average annual precipitation (200 to 600 mm), and average annual temperatures (7 to 11 degrees C). Soil type and annual precipitation run in an east-west gradient, while temperature has a north-south gradient. Species were identified using classical methods and by sequencing the internal transcribed spacer (ITS)-1 region of the rDNA and comparing these sequences to a database from a worldwide collection of Pythium spp. The species with the highest frequency of occurrence among all the sites were P. abappressorium sp. nov. (A) (50%), P. rostratum (R) (40%), P. debaryanum (D) (37.5%), P. heterothallicum (H) (33.7%), P.oligandrum (O) (31.2%), an unidentified P. sp. (aff. echinulatum) (E) (25%), and P. ultimum (U) (18%). P. intermedium, P. irregulare, P. paroecandrum, P. sylvaticum, P. dissimile, and P. dissoticum were isolated at a low frequency. From one to six species were isolated at each site, and there were 46 different species combinations detected. The species presence/absence data from all sites were analyzed with Jaccard's similarity coefficient hierarchical cluster analysis. Six communities were identified (species within each community designation in order of frequency among the sites within the community)-AD, AOU, AR, DEH, HE, and RU. In general, P. abappressorium was evenly distributed over all zones. AOU was more prevalent in zones with lower precipitation and coarser soil, while DEH and HE were associated with zones with higher precipitation and finer-textured soils on the basis of comparison of frequency distributions with the expected distribution over all the sites. The RU community was more prevalent in higher temperature zones. Canonical correspondence analysis was performed to examine the relationship between species and environmental variables. Soil type and precipitation were highly correlated with each other and with axis 1, which separated P. ultimum and P. abappressorium (lower variable values) from P. heterothallicum (higher variable values). Axis 2 and 3 were most correlated with temperature, and these axes separated P. oligandrum (higher value) from P. debaryanum (lower value) and P. ultimum-P. rostratum from the other species. The results suggest that Pythium species composition, distributions, and associations on a given crop may be influenced by environmental factors at a mesoscale level (100 to 1,000,000 ha).

Necrotizing enterocolitis and gastrointestinal complications after indomethacin therapy and surgical ligation in premature infants with patent ductus arteriosus

BACKGROUND

Indomethacin is the most frequently used pharmacological agent for closure of a patent ductus arteriosus (PDA) in premature infants. However, reports of complications, particularly, necrotizing enterocolitis (NEC) and isolated gastrointestinal perforation have generated concerns about the use of this medication.

OBJECTIVES

A retrospective study to compare the incidence of NEC, NEC-related gastrointestinal complications and isolated gastrointestinal perforation among premature infants treated for a PDA with either, indomethacin alone (I), surgical ligation alone (L), or indomethacin followed by surgical ligation (I-L).

METHODS

The medical records of 224 infants that underwent treatment, either pharmacological or surgical, for a PDA, confirmed by echocardiography, over a 4-year period (1995 to 1998) were analyzed. Treatment history and gastrointestinal complications were reviewed.

RESULTS

Of the 224 infants, 108 (48.2%) were treated with I, 50 (22.3%) by L, 66 (29.5%) with I-L. The clinical characteristics of the three treatment groups were similar and no differences in the incidence of NEC were observed between groups. NEC occurred in 14 (13%) of the I group, seven (14%) of the L group, and eight (12%) of the I-L group. The rate of NEC related gastrointestinal complications and isolated gastrointestinal perforation were also similar among groups.

CONCLUSION

In this large retrospective study, indomethacin treatment for a significant PDA in premature infants was not associated with a greater risk for NEC or NEC-related gastrointestinal complications than surgical ligation.