Some statistical methods useful in circulation research

Some statistical techniques for analyzing the kinds of studies typically reported in Circulation Research are described. Particular emphasis is given to the comparison of means from more than two populations, the joint effect of several experimentally controlled variables, and the analysis of studies with repeated measurements on the same experimental units.

A national survey of physician-assisted suicide and euthanasia in the United States

BACKGROUND

Although there have been many studies of physician-assisted suicide and euthanasia in the United States, national data are lacking.

METHODS

In 1996, we mailed questionnaires to a stratified probability sample of 3102 physicians in the 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide or euthanasia. We weighted the results to obtain nationally representative data.

RESULTS

We received 1902 completed questionnaires (response rate, 61 percent). Eleven percent of the physicians said that under current legal constraints, there were circumstances in which they would be willing to hasten a patient's death by prescribing medication, and 7 percent said that they would provide a lethal injection; 36 percent and 24 percent, respectively, said that they would do so if it were legal. Since entering practice, 18.3 percent of the physicians (unweighted number, 320) reported having received a request from a patient for assistance with suicide and 11.1 percent (unweighted number, 196) had received a request for a lethal injection. Sixteen percent of the physicians receiving such requests (unweighted number, 42), or 3.3 percent of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7 percent (unweighted number, 59), said that they had administered at least one lethal injection.

CONCLUSIONS

A substantial proportion of physicians in the United States report that they receive requests for physician-assisted suicide and euthanasia, and about 7 percent of those who responded to our survey have complied with such requests at least once.

"We don't carry that"--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

BACKGROUND

We have observed that many black and Hispanic patients receiving palliative care at a major urban teaching hospital are unable to obtain prescribed opioids from their neighborhood pharmacies. In this study, we investigated the availability of commonly prescribed opioids in New York City pharmacies.

METHODS

We surveyed a randomly selected sample of 30 percent of New York City pharmacies to obtain information about their stock of opioids. For each pharmacy, U.S. Census estimates for 1997 were used to determine the racial and ethnic composition of the neighborhood (defined as the area within a 0.4-km [0.25-mile] radius of the pharmacy) and the proportion of residents who were more than 65 years old. Data on robberies, burglaries, and arrests involving illicit drugs in 1997 were obtained for the precinct in which each pharmacy was located. We used a generalized linear model to examine the relation between the racial or ethnic composition of neighborhoods and the opioid supplies of pharmacies, while controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level.

RESULTS

Pharmacists representing 347 of 431 eligible pharmacies (81 percent) responded to the survey. A total of 176 pharmacies (51 percent) did not have sufficient supplies of opioids to treat patients with severe pain. Only 25 percent of pharmacies in predominantly nonwhite neighborhoods (those in which less than 40 percent of residents were white) had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of pharmacies in predominantly white neighborhoods (those in which at least 80 percent of residents were white) (P<0.001).

CONCLUSIONS

Pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain adequately.

Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial

IMPORTANCE

Family caregivers of patients with chronic critical illness experience significant psychological distress.

OBJECTIVE

To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.

INTERVENTIONS

At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.

MAIN OUTCOMES AND MEASURES

The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival.

RESULTS

Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different.

CONCLUSIONS AND RELEVANCE

Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01230099.

Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study

BACKGROUND

More than 50,000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities.

METHODS

In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27,449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud).

FINDINGS

9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders.

INTERPRETATION

9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population.

FUNDING

Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health.

Sublingual absorption of selected opioid analgesics

Ongoing interest in the improvement of pain management with opioid analgesics had led to the investigation of sublingual opioid absorption. The present report determined the percent absorption of selected opioid analgesics from the oral cavity of normal subjects under conditions of controlled pH and swallowing when a 1.0 ml aliquot of the test drug was placed under the tongue for a 10-minute period. Compared with morphine sulfate at pH 6.5 (18% absorption), buprenorphine (55%), fentanyl (51%), and methadone (34%) were absorbed to a significantly greater extent (p less than 0.05), whereas levorphanol, hydromorphone, oxycodone, heroin, and the opioid antagonist naloxone were not. Overall, lipophilic drugs were better absorbed than were hydrophilic drugs. Plasma morphine concentration-time profiles indicate that the apparent sublingual bioavailability of morphine is only 9.0% +/- 11.9% (SD) of that after intramuscular administration. In the same subjects the estimated sublingual absorption was 22.4% +/- 9.2% (SD), indicating that the sublingual absorption method may overestimate apparent bioavailability. When the oral cavity was buffered to pH 8.5, methadone absorption was increased to 75%. Thus, an alkaline pH microenvironment that favors the unionized fraction of opioids increased sublingual drug absorption. Although absorption was found to be independent of drug concentration, it was contact time dependent for methadone and fentanyl but not for buprenorphine. These results indicate that although the sublingual absorption and apparent sublingual bioavailability of morphine are poor, the sublingual absorption of methadone, fentanyl, and buprenorphine under controlled conditions is relatively high.

Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study

We examined the neonatal mortality rates of low-birth-weight infants (501 to 2250 g) born between 1976 and 1978 in three kinds of hospitals in New York City: those with newborn-intensive-care units (Level 3), those with capabilities for the care of most premature infants (Level 2), and those without any special facilities for premature newborns (Level 1). Among 13,560 singleton low-birth-weight infants, the adjusted neonatal mortality rate for Level 3 hospitals was 128.5 per thousand live births - significantly lower (P less than 0.001) than the rates for both level 2 (168.1) and Level 1 units (163.0). The association of level of care with mortality could not be accounted for by differences between groups in social or demographic status, in prenatal care, or in medical complication of pregnancy. We infer that birth at a Level 3 center lowers neonatal mortality in low-birth-weight infants. However, only 34 per cent of the patients in this study were born in such units.

Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline

Interdisciplinary teams are important in providing care for older patients, but interdisciplinary teamwork is rarely a teaching focus, and little is known about trainees' attitudes towards it. To determine the attitudes of second-year post-graduate (PGY-2) internal medicine or family practice residents, advanced practice nursing (NP), and masters-level social work (MSW) students toward the value and efficiency of interdisciplinary teamwork and the physician's role on the team, a baseline survey was administered to 591 Geriatrics Interdisciplinary Team Training participants at eight U.S. academic medical centers from January 1997 to July 1999. Most students in each profession agreed that the interdisciplinary team approach benefits patients and is a productive use of time, but PGY-2s consistently rated their agreement lower than NP or MSW students. Interprofessional differences were greatest for beliefs about the physician's role; 73% of PGY-2s but only 44% to 47% of MSW and NP trainees agreed that a team's primary purpose was to assist physicians in achieving treatment goals for patients. Approximately 80% of PGY-2s but only 35% to 40% of MSW or NP trainees agreed that physicians have the right to alter patient care plans developed by the team. Although students from all three disciplines were positively inclined toward medical interdisciplinary teamwork, medical residents were the least so. Exposure to interdisciplinary teamwork may need to occur at an earlier point in medical training than residency. The question of who is ultimately responsible for the decisions of the team may be an "Achilles heel," interfering with shared decision-making.

The Chinese herbal medicine formula FAHF-2 completely blocks anaphylactic reactions in a murine model of peanut allergy

BACKGROUND

Peanut allergy is potentially life threatening. There is no curative therapy for this disorder. We previously found that an herbal formula, food allergy herbal formula (FAHF)-1, blocked peanut-induced anaphylaxis in a murine model when challenged immediately posttherapy.

OBJECTIVE

To test whether FAHF-2, an improved herbal formula, from which 2 herbs, Zhi Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata) and Xi Xin (Herba Asari), were eliminated, is equally effective to FAHF-1, and if so, whether protection persists after therapy is discontinued.

METHODS

Mice allergic to peanut treated with FAHF-2 for 7 weeks were challenged 1, 3, or 5 weeks posttherapy. Anaphylactic scores, core body temperatures, vascular leakage, and plasma histamine levels after peanut challenge were determined. Serum peanut-specific antibody levels and splenocyte cytokine profiles were also measured.

RESULTS

After challenges, all sham-treated mice developed severe anaphylactic signs, significant decrease in rectal temperatures, significantly increased plasma histamine levels, and marked vascular leakage. In contrast, no sign of anaphylactic reactions, decrease in rectal temperatures, or elevation of plasma histamine levels was observed in FAHF-2-treated mice in 5 separate experiments. IgE levels were significantly reduced by FAHF-2 treatment and remained significantly lower as long as 5 weeks posttherapy. Splenocytes from FAHF-2-treated mice showed significantly reduced IL-4, IL-5, and IL-13, and enhanced IFN-gamma production to recall peanut stimulation in vitro .

CONCLUSION

FAHF-2 treatment completely eliminated anaphylaxis in mice allergic to peanut challenged as long as 5 weeks posttherapy. This result was associated with downregulation of T H 2 responses. FAHF-2 may be a potentially effective and safe therapy for peanut allergy.

Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women

Our purpose in this study was to determine the prevalence of undetected disorders of bone and mineral metabolism in women with osteoporosis and to identify the most useful and cost-efficient screening tests to detect these disorders. A cross-sectional study was conducted among 664 postmenopausal women with osteoporosis at the Osteoporosis and Metabolic Bone Disease Program at the Mount Sinai Hospital in New York between January 1992 and June 1996. Women without a history of diseases or medications known to adversely affect bone who completed extensive laboratory testing including complete blood count, chemistry profile, 24-h urinary calcium, 25(OH)vitamin D, and PTH were included. Among 173 women who met the inclusion criteria for the study, previously undiagnosed disorders of bone and mineral metabolism were identified in 55 women (32%). Disorders of calcium metabolism and hyperparathyroidism were the most frequent diagnoses. A testing strategy involving measurement of 24-h urine calcium, serum calcium, and serum PTH for all women and serum TSH among women on thyroid replacement therapy would have been sufficient to diagnose 47 of these 55 women (85%) at an estimated cost of $75 per patient screened. Previously undiagnosed disorders affecting the skeleton are common in otherwise healthy women with low bone density. A simple testing strategy is likely to identify most such disorders.

Efficacy and tolerability of anti-asthma herbal medicine intervention in adult patients with moderate-severe allergic asthma

BACKGROUND

Chinese herbal medicine has a long history of human use. A novel herbal formula, anti-asthma herbal medicine intervention (ASHMI), has been shown to be an effective therapy in a murine model of allergic asthma.

OBJECTIVE

This study was undertaken to compare the efficacy, safety, and immunomodulatory effects of ASHMI treatment in patients with moderate-severe, persistent asthma with prednisone therapy.

METHODS

In a double-blind trial, 91 subjects underwent randomization. Forty-five subjects received oral ASHMI capsules and prednisone placebo tablets (ASHMI group) and 46 subjects received oral prednisone tablets and ASHMI placebo capsules (prednisone group) for 4 weeks. Spirometry measurements; symptom scores; side effects; and serum cortisol, cytokine, and IgE levels were evaluated before and after treatment.

RESULTS

Posttreatment lung function was significantly improved in both groups as shown by increased FEV(1) and peak expiratory flow findings (P<.001). The improvement was slightly but significantly greater in the prednisone group (P<.05). Clinical symptom scores, use of beta(2)-bronchodilators, and serum IgE levels were reduced significantly, and to a similar degree in both groups (P<.001). T(H)2 cytokine levels were significantly reduced in both treated groups (P<.001) and were lower in the prednisone-treated group (P<.05). Serum IFN-gamma and cortisol levels were significantly decreased in the prednisone group (P<.001) but significantly increased in the ASHMI group (P<.001). No severe side effects were observed in either group.

CONCLUSION

Anti-asthma herbal medicine intervention appears to be a safe and effective alternative medicine for treating asthma. In contrast with prednisone, ASHMI had no adverse effect on adrenal function and had a beneficial effect on T(H)1 and T(H)2 balance.

Reduced oxidant stress and extended lifespan in mice exposed to a low glycotoxin diet: association with increased AGER1 expression

Aging is accompanied by increased oxidative stress (OS) and accumulation of advanced glycation end products (AGEs). AGE formation in food is temperature-regulated, and ingestion of nutrients prepared with excess heat promotes AGE formation, OS, and cardiovascular disease in mice. We hypothesized that sustained exposure to the high levels of pro-oxidant AGEs in normal diets (Reg(AGE)) contributes to aging via an increased AGE load, which causes AGER1 dysregulation and depletion of anti-oxidant capacity, and that an isocaloric, but AGE-restricted (by 50%) diet (Low(AGE)), would decrease these abnormalities. C57BL6 male mice with a life-long exposure to a Low(AGE) diet had higher than baseline levels of tissue AGER1 and glutathione/oxidized glutathione and reduced plasma 8-isoprostanes and tissue RAGE and p66(shc) levels compared with mice pair-fed the regular (Reg(AGE)) diet. This was associated with a reduction in systemic AGE accumulation and amelioration of insulin resistance, albuminuria, and glomerulosclerosis. Moreover, lifespan was extended in Low(AGE) mice, compared with Reg(AGE) mice. Thus, OS-dependent metabolic and end organ dysfunction of aging may result from life-long exposure to high levels of glycoxidants that exceed AGER1 and anti-oxidant reserve capacity. A reduced AGE diet preserved these innate defenses, resulting in decreased tissue damage and a longer lifespan in mice.

Communication about chronic critical illness

BACKGROUND

Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met.

METHODS

In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3-7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items.

RESULTS

Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively.

CONCLUSIONS

Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.

The natural history of type B Niemann-Pick disease: results from a 10-year longitudinal study

OBJECTIVES

Type B Niemann-Pick disease (NPD-B) caused by acid sphingomyelinase deficiency is a rare, autosomal recessive, lysosomal storage disorder with a broad range of disease severity. The objectives of this study were to document the natural history of the disease in a large, clinically heterogeneous patient population that was followed for a period of 10 years and to determine how genotype influences phenotype.

METHODS

Twenty-nine patients with NPD-B had serial evaluations at least 9 months apart. Organ volumes, hematologic indices, lipid concentrations, pulmonary function, and hepatic activity were studied, and individual phenotypic severity was compared with genotype.

RESULTS

All patients with intact spleens had splenomegaly (mean value: 12.7 multiples of normal [MN]; range: 4.5-27.3 MN), and all but 1 had hepatomegaly (mean volume: 1.91 MN; range: 0.93-3.21 MN). At initial visit, 39% had thrombocytopenia and 3% had leukopenia. At final visit, the percentages increased to 54% and 34%, respectively. Mean annual decreases in platelet count and leukocyte count were 7 x 10(3) and 0.2 x 10(3) per mm3, respectively. The typical atherogenic lipid profile was worse in older patients. A total of 69% of patients had low diffusion capacity for carbon monoxide, and more than one third had low forced expiratory volume in 1 second, forced vital capacity, and forced expiratory volume in 1 second/forced vital capacity at initial visit. All measurements of pulmonary function showed a gradual deterioration over time. Liver dysfunction was characterized by stable elevation of hepatic transaminases and bilirubin. Homozygotes for DeltaR608, P323A, and P330R had milder disease than patients with all other genotypes.

CONCLUSIONS

The natural history of NPD-B is characterized by hepatosplenomegaly with progressive hypersplenism, worsening atherogenic lipid profile, gradual deterioration in pulmonary function, and stable liver dysfunction.

A test for detection of clustering over time

The use of the scan statistic in testing for clustering in time is discussed with particular reference to a reported clustering of trisomies in spontaneous abortions in New York City. The scan statistic is the maximum number of observed cases in an interval of preselected length, as the interval is allowed to scan, or slide along, the time frame of interest. A table of the lower tail of the distribution of this statistic is given.

Creatine kinase-MB elevation after coronary intervention correlates with diffuse atherosclerosis, and low-to-medium level elevation has a benign clinical course: implications for early discharge after coronary intervention

OBJECTIVES

The study evaluated the incidence and predictors of creatine kinase-MB isoenzyme (CK-MB) elevation after successful coronary intervention using current devices, and assessed the influence on in-hospital course and midterm survival.

BACKGROUND

The CK-MB elevation after coronary intervention predominantly using balloon angioplasty correlates with late cardiac events of myocardial infarction (MI) and death. Whether CK-MB elevation after nonballoon devices is associated with an adverse short and midterm prognosis is unknown.

METHODS

The incidence and predictors of CK-MB elevation after coronary intervention were prospectively studied in 1,675 consecutive patients and were followed for in-hospital events and survival.

RESULTS

CK-MB elevation was detected in 313 patients (18.7%), with 1-3x in 12.8%, 3-5x in 3.5% and >5x normal in 2.4% of patients. Procedural complications or electrocardiogram changes occurred in only 49% of the CK-MB-elevation cases; CK-MB elevation was more common after nonballoon devices (19.5% vs. 11.5% after percutaneous transluminal coronary angioplasty; p < 0.01). Predictors of CK-MB elevation on multivariate analysis were diffuse coronary disease (p = 0.02), systemic atherosclerosis (p = 0.002), stent use (p = 0.04) and absence of beta-blocker therapy (p = 0.001). Adverse in-hospital cardiac events were more frequent in patients with >5x CK-MB elevation, with no significant difference between 1-5x CK-MB elevation versus normal CK-MB group. During a mean follow-up of 13 +/- 3 months, the incidence of death in the CK-MB-elevation group was 1.6% versus 1.3% in the normal CK-MB group (p = NS).

CONCLUSIONS

The CK-MB elevation after coronary intervention was observed even in the absence of discernible procedural complications and was more common in patients with diffuse atherosclerosis. In-hospital clinical events requiring prolonged monitoring were higher in >5x CK-MB-elevation patients only. Midterm survival of CK-MB-elevation patients was similar to those with normal CK-MB. Our prospective analysis shows a lack of adverse in-hospital cardiac events and suggests that early discharge of stable 1-5x normal CK-MB-elevation patients after successful coronary intervention is safe.

Calcium, vitamin D, and parathyroid hormone status in young white and black women: association with racial differences in bone mass

The etiology of the racial disparity in bone mass and fracture rate is unknown. Since the PTH-vitamin D endocrine system is a major regulator of calcium metabolism and bone turnover, this cross-sectional study examined the relationship of radial and lumbar bone density to vitamin D metabolite and PTH concentrations and to calcium intake and excretion in 67 white and 70 black highly comparable, healthy, premenopausal women. Bone density at both radial and lumbar sites was higher in blacks than in whites. Serum 25-hydroxyvitamin D was slightly but not statistically significantly (P = 0.08), lower in blacks than in whites, but there were no racial differences in 1,25-dihydroxyvitamin D, PTH, or renal tubular maximum for reabsorption of phosphate. The mean 25-hydroxyvitamin D concentration in blacks was well within the normal range and was not associated with evidence of secondary hyperparathyroidism. There were no correlations of bone density to vitamin D or PTH concentrations. Although there were no racial differences in dietary intake of calcium and vitamin D or in sodium excretion, 24-h urinary calcium excretion was significantly lower in blacks than in whites, and calcium excretion was inversely associated with radial bone density. In contrast to previous reports, in healthy, normal weight, premenopausal black women there is no evidence of vitamin D deficiency or secondary hyperparathyroidism, suggesting that factors other than the vitamin D-PTH axis are responsible for racial differences in bone mass.

PRO 2000 elicits a decline in genital tract immune mediators without compromising intrinsic antimicrobial activity

OBJECTIVE

Vaginal microbicides should protect against infection without disrupting the mucosal environment or its mediators of host defense. The objective of this study was to examine the effect of 14 daily applications of 0.5% PRO 2000 or placebo gel on mediators of mucosal immunity and intrinsic antimicrobial activity.

DESIGN AND METHODS

A randomized, prospective, double-blind, placebo-controlled study was conducted among 24 healthy, abstinent women. Levels of cytokines, chemokines, defensins, and other protective factors and intrinsic antimicrobial activity were determined in cervicovaginal lavage samples collected on study days 0, 7, 14, and 21.

RESULTS

No increase in pro-inflammatory cytokines was observed. Rather cytokines and protective factors including interleukin (IL)-1 receptor antagonist, immunoglobulins and human beta-defensin 2 were lower in the drug compared with the placebo group. All of the mediators returned towards baseline on day 21. Women who were cycling had lower levels of most proteins on study days 7 and/or 14 compared with women on oral contraceptives; however, the magnitude of decline was greater in women who received PRO 2000 compared with placebo gel. The reduction in protective factors was not associated with a loss in the intrinsic anti-viral (HIV or herpes simplex virus) activity or anti-bacterial activity (Escherichia coli or Staphylococcus aureus).

CONCLUSION

In contrast to experience with nonoxynol-9, PRO 2000 did not trigger an inflammatory response in cervicovaginal secretions. There was a modest reduction in mucosal immune mediators, but this loss was not associated with a reduction in intrinsic antimicrobial activity.

Suicide clusters: an examination of age-specific effects

The age specificity of time-space clusters of suicide was examined using National Center for Health Statistics data for 1978-84. Significant clustering of suicide occurred primarily among teenagers and young adults, with minimal effect beyond 24 years of age. Clustering was two to four times more common among adolescents and young adults than among other age groups.

Higher incidence of diabetes in liver transplant recipients with hepatitis C

We assessed the clinical and biochemical parameters associated with the development of posttransplantation diabetes (PTDM) in 52 liver transplant recipients followed up for 1 year. Diabetes was present before transplantation in 9.6% (5 of 52) of patients, and PTDM occurred in 23% (11 of 47) of the remaining liver transplant recipients. Of the 13 patients who had hepatitis C as the cause of their liver failure (HC-LD), 8 (62%) developed PTDM; of the 34 patients with other causes of liver failure, 3 (9%) developed PTDM (p < 0.001). Posttransplantation diabetes was also associated with the development of early posttransplantation hyperglycemia, a higher number of liver rejection episodes, and lower serum albumin levels at 6 months. The association of PTDM with HC-LD remained significant in a logistic regression model after adjustment for potential confounding variables. We conclude that PTDM is common in liver transplant recipients. Associated clinical parameters predictive of PTDM include a diagnosis of HC-LD before transplantation, the development of early hyperglycemia after transplantation, multiple episodes of posttransplantation liver rejection and low serum albumin levels at 6 months. The fact that HC-LD remained an independent risk factor for the development of PTDM may suggest a direct or immune-mediated pancreatic effect of the virus.

Time-space clustering of teenage suicide

The occurrence of time-space clusters was examined in national mortality data on suicide among adolescents aged 15-19 years obtained from the National Center for Health Statistics Mortality Detail Files for 1978-1984. The analyses indicated that overall significant time-space clustering occurred among 15-19 year olds. The authors thus believe that they have documented for the first time that outbreaks of suicide occur more frequently than expected by chance alone. The occurrence of suicide clusters among teenagers appeared to vary considerably by state and year of investigation. There is some indication that there has been an increase in teenage clusters in more recent years.

Cancer incidence in world trade center rescue and recovery workers, 2001-2008

BACKGROUND

World Trade Center (WTC) rescue and recovery workers were exposed to a complex mix of pollutants and carcinogens.

OBJECTIVE

The purpose of this investigation was to evaluate cancer incidence in responders during the first 7 years after 11 September 2001.

METHODS

Cancers among 20,984 consented participants in the WTC Health Program were identified through linkage to state tumor registries in New York, New Jersey, Connecticut, and Pennsylvania. Standardized incidence ratios (SIRs) were calculated to compare cancers diagnosed in responders to predicted numbers for the general population. Multivariate regression models were used to estimate associations with degree of exposure.

RESULTS

A total of 575 cancers were diagnosed in 552 individuals. Increases above registry-based expectations were noted for all cancer sites combined (SIR = 1.15; 95% CI: 1.06, 1.25), thyroid cancer (SIR = 2.39; 95% CI: 1.70, 3.27), prostate cancer (SIR = 1.21; 95% CI: 1.01, 1.44), combined hematopoietic and lymphoid cancers (SIR = 1.36; 95% CI: 1.07, 1.71), and soft tissue cancers (SIR = 2.26; 95% CI: 1.13, 4.05). When restricted to 302 cancers diagnosed ≥ 6 months after enrollment, the SIR for all cancers decreased to 1.06 (95% CI: 0.94, 1.18), but thyroid and prostate cancer diagnoses remained greater than expected. All cancers combined were increased in very highly exposed responders and among those exposed to significant amounts of dust, compared with responders who reported lower levels of exposure.

CONCLUSION

Estimates should be interpreted with caution given the short follow-up and long latency period for most cancers, the intensive medical surveillance of this cohort, and the small numbers of cancers at specific sites. However, our findings highlight the need for continued follow-up and surveillance of WTC responders.

"Sarcoid like" granulomatous pulmonary disease in World Trade Center disaster responders

BACKGROUND

More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of "sarcoid like" granulomatous pulmonary disease in other WTC responders.

METHODS

Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only "definite" cases are reported.

RESULTS

Thirty-eight patients were classified as "definite" cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality.

CONCLUSIONS

Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected.

Incidence and timing of germinal matrix/intraventricular hemorrhage in low birth weight infants

Incidence and time of onset of germinal matrix/intraventricular hemorrhage (GM/IVH) were prospectively ascertained in 1,105 infants weighing < or = 2,000 g at birth, a cohort comprising about 85% of all births of that weight born from September 1984 to June 1987 in the central New Jersey counties of Ocean, Monmouth, and Middlesex. Cranial ultrasonography was performed as nearly as possible to age 4 hours, 24 hours, and 7 days. Each scan was reviewed by two independent readers and, if necessary, a third; consensus was achieved on scan of first diagnosis of GM/IVH in 965 of the 1,079 infants with assessable scans. The cumulative incidence of GM/IVH in the first week of life was 24.6% (265/1,079). In the 965 infants with consensus diagnoses, the first scan, at 4.9 +/- 2.2 hours, yielded the highest incidence--10.6% (95/899). Incidence by the second scan (25.1 +/- 4.9 hours) was 6.0% (49/813), and by the third scan (7.2 +/- 0.8 days), 9.0% (64/715). The iterative algorithm for interval-censored data developed by Turnbull (J R Stat Soc [B] 1976;8:290-5) was used to estimate the most likely time of onset based on time of first diagnosis. From 34% to 44% of hemorrhages were present at the first opportunity to scan, which in these data was at age 1 hour. At least a third of GM/IVH in infants < or = 2,000 g appears to be of congenital or immediate postnatal onset.