Concordance between childhood injury diagnoses from two sources: an injury surveillance system and a physician billing claims database

OBJECTIVES

(1) To determine the concordance between injury diagnoses (head injury (HI), probable HI, or orthopedic injury) for children visiting an emergency department for an injury using two

DATA SOURCES

an injury surveillance system (Canadian Hospitals Injury Research and Prevention Program, CHIRPP) and a physician billing claims database (Regie de l'assurance maladie de Quebec, RAMQ), and (2) to determine the sensitivity and specificity of diagnostic and procedure codes in billing claims for identifying HI and orthopedic injury among children.

DESIGN

In this cross sectional cohort, data for 3049 children who sought care for an injury (2000-01) were obtained from both sources and linked using the child's personal health insurance number.

METHODS

The physician recorded diagnostic codes from CHIRPP were used to categorize the children into three groups (HI, probable HI, and orthopedic), while an algorithm, using ICD-9-CM diagnostic and procedures codes from the RAMQ, was used to classify children into the same three groups.

RESULTS

Concordance between the data sources was "substantial" (weighted Kappa 0.66; 95% CI 0.63 to 0.69). The sensitivity of diagnostic and procedure codes in the RAMQ database for identifying HI and for orthopedic injury were 0.61 (95% CI 0.57 to 0.64) and 0.97 (95% CI 0.96 to 0.98), respectively. The specificity for identifying HI and for orthopedic injury were 0.97 (95% CI 0.96 to 0.98) and 0.58 (95% CI 0.56 to 0.63), respectively.

CONCLUSION

Combining diagnostic and procedures codes in a physician billing claims database (the RAMQ database) may be a valid method of estimating injury occurrence among children.

Comparison between tests of fatigue and force for trunk flexion

STUDY DESIGN

A quasi-experimental study was conducted.

OBJECTIVE

To compare intraindividual differences between trunk flexion isometric force, fatigue during isometric contraction (isometric fatigue), and fatigue during sit-ups (dynamic fatigue).

SUMMARY OF BACKGROUND DATA

Trunk flexion force and trunk flexion fatigue commonly are used to assess trunk flexion fitness. The use of one test is appropriate only if the tests are highly correlated.

METHODS

This study measured force and either isometric fatigue (time to task failure, n = 79) or dynamic fatigue (number of sit-ups in 2 minutes, n = 73) in self-selected, healthy secondary school (I-III) subjects. In 15 subjects, both isometric and dynamic fatigue were measured.

RESULTS

After control was used for upper body mass, the R2(adj) was 0.34 between isometric force and isometric fatigue, 0.31 between isometric force and dynamic fatigue was, and 0.27 between dynamic fatigue and isometric fatigue. Including gender in the model did not affect the results.

CONCLUSIONS

The lack of a high correlation between trunk flexion isometric fatigue, dynamic fatigue, and isometric force suggests that health care professionals should be careful to select the test that answers their particular needs or question.

The role of vitamin D and retinoids in controlling prostate cancer progression

Prostate cancer is a leading cause of cancer-related deaths in many countries. Premalignant lesions and invasive cancer occur more frequently in the prostate than in any organ other than the skin. Yet, the incidence of clinically detected prostate cancer is much lower than the histopathological incidence. The slow growth of prostate cancer and the low incidence of clinically manifest disease in some geographical locations or racial/ethnic groups suggest that prostate cancer can be controlled, perhaps by dietary factors. Vitamin D and retinoids have emerged as leading candidates both to prevent and to treat prostate cancer. Many of the activities of these compounds, established from epidemiological studies, research with cell culture and animal models, and clinical trials, are consistent with tumor suppressor effects. However, retinoids may have additional tumor enhancer properties that balance or negate anti-cancer activity. This perhaps explains the overall lack of protective effects of vitamin A compounds against prostate cancer found in epidemiological studies, and the minimal efficacy of retinoids in clinical trials to treat prostate cancer. While current efforts focus on developing strategies to use vitamin D compounds to control prostate cancer, the possibility exists that prostate cancer cells may become resistant to tumor suppressor effects of vitamin D. Analyses of experimental model systems show that prostate cancer cells become less sensitive to vitamin D through loss of receptors or signaling molecules that mediate vitamin D's actions, or through changes in metabolic enzymes that synthesize or degrade vitamin D compounds. The potential promise of exploiting vitamin D to control prostate cancer is tempered by the possibility that prostate cancer, perhaps even at early stages, may develop mechanisms to escape tumor suppressor activities of vitamin D and/or retinoids.

A comparison of the therapeutic efficacy and tolerability of etoricoxib and diclofenac in patients with osteoarthritis

OBJECTIVE

To evaluate and compare the efficacy and tolerability of etoricoxib and diclofenac in patients with osteoarthritis of the knee or hip.

METHODS

In this 6-week double-blind, active comparator controlled, parallel-group study eligible osteoarthritis patients were randomised to receive either etoricoxib 60 mg once daily (n = 256) or diclofenac 50 mg three times daily (n = 260). The primary study endpoint was the Western Ontario McMaster osteoarthritis index (WOMAC) pain subscale. Other endpoints included were the WOMAC stiffness and physical function subscales, and the Patient's Global Assessment of Response to Therapy (PGART) questionnaire. Early efficacy was evaluated using WOMAC first question (pain walking on a flat surface) and PGART 4 h after the morning dose of each drug on days 1 and 2. Rescue medication (paracetamol) used was also recorded. The study was designed to show comparable efficacy between etoricoxib 60 mg once daily and diclofenac 50 mg three times daily with respect to the primary endpoint and was conducted outside the United States at 67 centres in 29 countries.

RESULTS

Etoricoxib (60 mg once daily) was comparable in efficacy to diclofenac (150 mg daily) on all the above parameters. The one exception was in the assessment of early efficacy where etoricoxib demonstrated significantly greater benefit within 4 h of taking the first dose on the first day of therapy (p = 0.007) as evaluated by the percentage of patients with good or excellent (PGART) responses. The treatment effects of both drugs were similar by the time day 2 was reached and were sustained throughout the 6 weeks of therapy. Both treatments were generally well tolerated.

CONCLUSIONS

Etoricoxib is clinically effective in the therapy of osteoarthritis providing a magnitude of effect comparable to that of the maximum recommended daily dose of diclofenac. The onset of clinical benefit with etoricoxib on day one is more rapid than that of diclofenac. Both drugs were generally well tolerated.

Extensive polymorphism in the plasmodium vivax merozoite surface coat protein MSP-3alpha is limited to specific domains

Plasmodium merozoites are covered by a complex coat of surface proteins. Several of the Merozoite Surface Proteins (MSPs) that make up this coat have been proposed as vaccine candidates although some of the MSPs are known to be highly polymorphic. We present here the first survey and analysis of the polymorphism in the recently characterized P. vivax surface protein PvMSP-3alpha. Full length or partial sequences were obtained for the Pvmsp-3alpha gene from isolates originating in Central and South America, Asia and the Pacific. The Pvmsp-3alpha sequence is remarkably diverse, but this extensive diversity is largely restricted to certain domains of the encoded protein. An acidic C-terminal domain and a smaller hydrophilic N-terminus are relatively conserved, while a central domain containing coiled-coil heptad repeats is highly polymorphic and in some isolates of P. vivax is partially deleted. Unlike other MSPs, there is no evidence of allelic families of PvMSP-3alpha gene sequences, and no evidence that certain patterns of polymorphism group within isolates of similar geographical origin. The distribution and nature of polymorphism suggest that there are functional restrictions on mutations in this gene, and have implications for inclusion of PvMSP-3alpha as a candidate in a P. vivax vaccine.

New HLA-B alleles identified and sequences extended in potential bone marrow donors: B*5804, B*4418, B*1558, and B*4805

Nucleic acid-based methods for allele identification have revealed more than 470 polymorphic variants at the HLA-B locus. Screening of potential bone marrow donors with sequence specific primer polymerase chain reactions and sequence specific oligonucleotide probe hybridization assays revealed apparent variants within the B*58, *44, *15, and *48 allele groups. DNA sequencing of cloned DNA identified the new alleles B*5804, B*4418, and B*1558 within these groups and observed new sequence information for the previously reported allele B*4805. These findings further extend our knowledge of the substantial genetic variation present at the HLA-B locus within human populations.

Identification and sequencing of HLA-B*0714 and B*2718 alleles and novel exon 1 sequences of B*0709 and B*2714 alleles in potential bone marrow donors

Sequence specific oligonucleotide probe hybridization and sequence specific primer PCR typing of volunteer bone marrow donors suggested the presence of variants of known HLA-B alleles in two individuals. PCR products encompassing HLA-B locus exons 1, 2, and 3 were prepared, subcloned and sequenced. A Hispanic individual had a novel B*07 allele (B*0714) and a Chinese individual had a novel B*27 allele (B*2718). In two other individuals, a previously unknown sequence of exon 1 was determined for HLA-B*0709 (African American) and B*2714 (Native American). These findings further illustrate the substantial genetic variation present at the HLA-B locus within human populations. We discuss the structural variation in the protein sequence for these HLA-B alleles and its potential functional effects.

Diaminoindanes as microsomal triglyceride transfer protein inhibitors

The synthesis and biological activities of biarylamide-substituted diaminoindanes as microsomal triglyceride transfer protein (MTP) inhibitors are described. One of the more potent compounds, 8aR, inhibited both the secretion of apoB from Hep G2 cells and the MTP-mediated transfer of triglycerides between synthetic acceptor and donor liposomes with IC(50) values of 0.7 and 70 nM, respectively. In normolipidemic rats and dogs, oral administration of 8aR dose-dependently reduced both plasma triglycerides and total cholesterol. Moreover, in rats and dogs, 8aR also prevented the postprandial rise in plasma triglycerides following a bolus administration of a fat load. Because MTP inhibitors decrease very low density lipoprotein assembly in the liver, the potential for hepatic lipid accumulation was evaluated. In normolipidemic rats, hepatic cholesterol and triglyceride contents were dose-dependently increased by 8aR. However, hepatic lipid accumulation resulted in negligible change in total liver weight and was reversible after withdrawal of the compound.

Retrospective study of Chlamydia trachomatis using the polymerase chain reaction on archival Papanicolaou-stained cytologic smears

OBJECTIVE

To detect chlamydial DNA on archived Papanicolaou-stained (Pap) smears using the polymerase chain reaction (PCR) technique.

STUDY DESIGN

A PCR assay was designed to identify chlamydial DNA using consensus sequences unique to the genus Chlamydia in the 16S rRNA gene. This assay produced a 109 base pair product containing a single Pvu II restriction site. One hundred cervicovaginal Pap smears from a teen clinic population were processed for DNA isolation and PCR. Amplifiable DNA was isolated from 93 of the 100 cases as determined by a human growth hormone gene. These specimens were subjected to chlamydial PCR.

RESULTS

PCR analysis of the 93 samples yielded 6 that were positive for the chlamydial 16S rRNA sequence. The six positive chlamydial amplicons were purified and subjected to Pvu II restriction enzyme analysis to validate their identity. The analysis confirmed the identity of the products, as a single Pvu II restriction site resulted in 41 base pair and 68 base pair products, as predicted.

CONCLUSION

PCR testing for Chlamydia trachomatis can be performed on DNA isolated from archival Pap smears. Using this methodology, 6.5% of young women in our teen clinic population were positive for chlamydial DNA.

A double-blind, randomized, controlled study of amitriptyline, nortriptyline and placebo in patients with fibromyalgia. An analysis of outcome measures

OBJECTIVE

To study the efficacy and tolerability of amitriptyline and nortriptyline in a Brazilian population with fibromyalgia and to evaluate the instruments used to measure the efficacy of the treatment.

METHODS

A total of 118 fibromyalgia patients were randomly assigned to 3 groups: amitriptyline (AM, n = 40), nortriptyline (NOR, n =38) and placebo (PL, n = 40), and were blindly given 25 mg at bedtime of the assigned treatment for 8 weeks. Clinical evaluation before and at the end of the study included the number of tender points (NTP), FIQ score (FIQ), and global improvement as reported by the patients on a verbal scale (VSGI).

RESULTS

The 3 groups were comparable at baseline for all the parameters studied. After 8 weeks, the 3 groups improved in all parameters: (36.5% AM, 26.7% NOR and 24% PL patients improved on FIQ; 13.9% AM, 19.5% NOR and 8.57% PL patients improved on NTP; 86.5% AM, 72.2% NOR and 57.6% PL patients improved on VSGI). Only the AM group differed from the PL group on VSGI. Side effects were noted among the groups, but none were serious (16 in the AM group, 31 in the NOR group, and 25 in the PL group).

CONCLUSION

All three groups improved after treatment. Only the patient's subjective global assessment of improvement differed between the AM patients and the PL group (p < or = 0.03). In fibromyalgia, placebo groups are important in drug trials. Different measures of therapeutic effect are not better than the patient's self assessment.

The development of androgen-independent prostate cancer

The normal prostate and early-stage prostate cancers depend on androgens for growth and survival, and androgen ablation therapy causes them to regress. Cancers that are not cured by surgery eventually become androgen independent, rendering anti-androgen therapy ineffective. But how does androgen independence arise? We predict that understanding the pathways that lead to the development of androgen-independent prostate cancer will pave the way to effective therapies for these, at present, untreatable cancers.

The cognitive neuroscience paradigm: a unifying metatheoretical framework for the science and practice of clinical psychology

The emerging discipline of cognitive neuroscience (CN) enjoins the efforts of cognitive psychologists, neuroscientists, computer scientists, clinical neurologists, neurophilosophers, and many others working collaboratively across traditional disciplinary boundaries to elucidate the manner in which the physical operations of the brain give rise to the vast panoply of human mental and behavioral events. The present article describes the foundational tenets of the CN metatheoretical framework and contends that the CN framework is capable of providing a coherent, unifying scientific paradigm for the discipline of clinical psychology. Clinical psychology's adoption of the CN paradigm would facilitate (a) its consilient linkage with the natural sciences, (b) resolution of long-standing internecine theoretical schisms, and (c) enhanced understanding and treatment of numerous forms of psychopathology. Nevertheless, psychology's historically influential radical behavioral (RB) perspective is not easily reconciled with the CN paradigm. However, unlike CN, RB (a) is not fully consilient with the natural sciences, (b) fails to articulate the proximal causal mechanisms that mediate environment-behavior relations, and (c) engages in "greedy reductionism" in its disavowal of informational levels of complexity in the patterning of neural activity. The article concludes with a discussion of the possibility of theoretical rapprochement between CN and RB.

On mental events, disciplinary boundaries, and reductionism: a reply to Plaud

Plaud's (2001) radical behavioral manifesto suggests that a psychological science based exclusively upon the study of environment-behavior functional contingencies would yield a discipline unencumbered by mentalism, vaguely delineated disciplinary boundaries, or inappropriate reductionism. In reply, we note that: (a) mental events-e.g., thoughts and feelings-are increasingly accessible to objective investigation, and provide an observable proximal causal mechanism for the environmental selection of behavior; (b) the call for pristine disciplinary boundaries is anachronistic, inasmuch as progress in the natural sciences has engendered disciplinary boundaries that are increasingly porous; (c) cognitive neuroscience facilitates a comprehensive understanding of complex human behavior by mapping out the relationship between such behavior and underlying brain events, thereby engaging in an appropriate form of reductionism (constitutive reductionism) that has become a hallmark of the natural sciences; and (d) ironically, it is radical behaviorism, in its disavowal of the informational level of complexity instantiated in brain events, that engages in inappropriate eliminative reductionism (i.e., reducing neural information to "nothing but" its underlying bring states).

Vascular complications after percutaneous coronary interventions following hemostasis with manual compression versus arteriotomy closure devices

OBJECTIVES

We evaluated the vascular complications after hemostasis with arteriotomy closure devices (ACD) versus manual compression after percutaneous coronary interventions (PCI).

BACKGROUND

Previous clinical studies have indicated that ACD can be used for achievement of hemostasis and early ambulation after PCI. This study investigated the safety of ACD in achieving hemostasis after PCI compared with manual compression in a large cohort of consecutive patients.

METHODS

A total of 5,093 patients were followed after PCI was performed with the transfemoral approach. Univariate and multivariate analysis were used to identify the predictors of vascular complications with ACD (n = 516) or with manual compression (n = 5,892) as a hemostasis option after sheath removal.

RESULTS

The use of ACD was associated with a more frequent occurrence of hematoma compared with manual compression (9.3 vs. 5.1%, p < 0.001). There was also a higher rate of significant hematocrit drop (>15%) with ACD versus manual compression (5.2% vs. 2.5%, p < 0.001). Similar rates of pseudoaneurysm and arteriovenous fistulae were noted with either hemostasis technique. Vascular surgical repair at the access site was required more often with ACD versus manual compression (2.5 vs. 1.5%, p = 0.03).

CONCLUSIONS

In this early experience with ACD after PCI, their use was associated with higher vascular complication rates than hemostasis with manual compression.

Radioimaging of implants in rats using Tc-99m-MDP

Radiopharmaceutical isotopes are widely used clinically to detect tumors of osteogenic origin. One example is Technetium-99m methylene diphosphonate (Tc-99m-MDP). When viewed with a gamma camera, the concentration of the isotope (increased gamma activity) indicates an area of increased bone activity. This technology provides an opportunity to measure bone growth around implants in vivo. The purpose of this study was to measure Tc-99m-MDP activity around titanium alloy implants placed in the tibiae of rats. Some implant sites were treated with a growth factor; other sites served as controls. The hypothesis tested was that implants placed with a growth factor would have greater associated Tc-99m-MDP activity. Twelve adult male Sprague-Dawley rats were anesthetized and surgical access to the medial proximal tibiae was obtained. Titanium alloy screw implants were placed in six animals along with 65 microgram of acidic fibroblast growth factor (FGF-1); the other six animals received implants only and served as controls. After five days, rats were injected with 1500 microCi of Tc-99m-MDP. After 3 hours, rats were imaged with a gamma camera. The Tc-99m-MDP intensity associated with each implant was quantified and the means for each group were compared using ANOVA. Implants treated with FGF-1 demonstrated significantly more Tc-99m-MDP activity than implants alone. This suggests that Tc-99m-MDP analysis may be a useful tool for determining bone growth around implants in laboratory animals in vivo.

A Rationale for Treatment of Hereditary Vitamin D-resistant Rickets with Analogs of 1α,25-Dihydroxyvitamin D3

Hereditary vitamin D-resistant rickets (HVDRR) is caused by heterogeneous inactivating mutations in the vitamin D receptor (VDR). Treatment of HVDRR patients with high doses of oral calcium and supraphysiologic doses of 1 alpha,25-dihydroxyvitamin D(3) (1,25D(3)) has had limited success. In this study we explored the use of vitamin D analogs as a potential therapy for this disorder. The rationale for the use of vitamin D analogs is that they bind the VDR at different amino acid residues than 1,25D(3), and their ability to modulate VDR functions differs from that of the natural hormone. In this report, we examined the VDR from three HVDRR patients with mutations in the ligand-binding domain of the VDR (histidine 305 to glutamine, arginine 274 to leucine, and phenylalanine 251 to cysteine) for their responses to two vitamin D analogs, 20-epi-1,25D(3) and 1 beta-hydroxymethyl-3-epi-16-ene-26a,27a-bishomo-25D(3) (JK-1626-2). Our results reveal that vitamin D analogs partially or completely restore the responsiveness of the mutated VDR. Analog treatment seemed to be more successful when the mutation affects the amino acids directly involved in ligand binding rather than amino acids that contribute to a functional VDR interface with dimerization partners or coactivators of transcription.