Ecological momentary assessment of temptation and lapse in dieting

Although some research attention has been given to the factors associated with temptation and lapse in dieting, the majority of research has focused on individuals in weight loss clinical trials and relied heavily on retrospective self-report data. The present study sought to overcome these limitations by using ecological momentary assessment (EMA) techniques to examine situations of dietary temptation, lapse, and minimal dietary consequence with a sample of overweight dieters (N=30) attempting to lose weight on their own. Results support and extend previous research findings on dietary temptation and lapse. In general, results indicate that recent consumptive activity, location, mood state, type of activity, and abstinence violation effects were related to moments of temptation and/or lapse. Education on the factors associated with dietary temptation and lapse and strategies for addressing these factors is imperative for both dieters in formal programs and those attempting to lose or maintain weight on their own.

An integrated doctoral educational model for developing researchers in health care strategic management

Doctoral education varies according to how students that graduate from a particular program are prepared for various type of careers. PhD programs principally work to develop researchers; researchers produce and disseminate new knowledge in a given area of expertise. This manuscript looks specifically at a PhD program designed to produce researchers in healthcare strategic management. This program is based in a business school and builds on general business principles to produce strategists that do research in the healthcare context. The business school program (type B) will be analyzed according to the areas (or potential areas) of research done by its graduates. The different areas are shown in a table where one axis is research content (i.e., specifically what the functional area of research is) and the other axis is publication outlet (i.e., what journal the research is disseminated in). Advantages of the type B program are compared to advantages of a PhD program based in a healthcare administration or healthcare management school (type H program) in terms of publications in these different areas.

Scavenger-receptor-mediated endocytosis of lipopolysaccharide in Atlantic cod (Gadus morhua L.)

The mechanism of elimination of blood-borne Vibrio salmonicida lipopolysaccharide (LPS) from Atlantic cod (Gadus morhua L.) was studied. The anatomical distribution of LPS was determined using both morphological and radiotracing methods. Immunohistochemistry performed on tissue specimens after injection of LPS disclosed that the endocardial endothelial cells (EECs) represented the cellular site of uptake in heart. Co-injection of trace amounts of [125I]LPS together with excess amounts of formaldehyde-treated albumin (FSA), a ligand for the scavenger receptor, significantly inhibited the accumulation of the radiotracer in heart only. Studies on purified monolayer cultures of atrial EECs showed that fluorescein-labelled LPS was taken up in structures reminiscent of endosomal/lysosomal vesicles. Incubation of cultures with [125I]LPS together with excess amounts of FSA, fucoidan and dextran sulphate, molecules known to compete for endocytosis via the scavenger receptor, reduced uptake of the probe by 80 %. Mannan, a ligand for the mannose receptor, did not compete for uptake. Kinetic studies on the uptake and degradation of [125I]LPS in cultured atrial endocardial cells revealed no degradation after 48 h of culture. In conclusion, we have shown that the EECs of cod remove V. salmonicida LPS from the circulation by scavenger-receptor-mediated endocytosis.

Diagnosing antisocial personality disorder among substance abusers: the scid versus the MCMI-II

There is much controversy among social scientists and clinicians over the proper measurement of antisocial personality disorder (ASPD). The degree to which various diagnostic measures differ in their assessment of ASPD among substance abusers is not known. This study assessed the degree of agreement between a semistructured clinical interview and a self-report inventory on a diagnosis of ASPD among substance abusers. The Structured Clinical Interview for DSM-III-R (SCID-II), a clinically generated instrument, and the Millon Clinical Multiaxial Inventory (MCMI-II), a self-report inventory, were administered to 275 clients randomly assigned to two therapeutic communities (TCs). Based on the limited existing literature, it was hypothesized that there would be minimal agreement between the diagnosis of ASPD by the two scales. This hypothesis was supported. The kappa statistic indicated low agreement between the scales (kappa = 0.27), with the MCMI-II diagnosing ASPD more often than the SCID-II. The low agreement on a diagnosis of ASPD may be due to the different types of information collected by the two scales. The SCID-II emphasizes observable behavioral criteria, while the MCMI-II emphasizes pathological personality traits. The focus of the MCMI-II on pathological personality traits may more accurately diagnose ASPD in substance-abusing populations in which the majority of the clients have extensive criminal histories. Definite conclusions regarding the proper measurement of ASPD in substance-abusing samples is difficult without additional empirical evidence.

Structure-Based design, synthesis and sAR of a novel series of thiopheneamidine urokinase plasminogen activator inhibitors

The serine protease urokinase plasminogen activator (uPA) is thought to play a central role in tumor metastasis and angiogenesis. Molecular modeling studies suggest that 5-thiomethylthiopheneamidine inhibits uPA by binding at the S1 pocket of the active site. Further structure based elaboration of this residue resulted in a novel class of potent and selective inhibitors of uPA.

Integrated voice recognition and picture archiving and communication system: development and early experience

Voice recognition (VR) and picture archiving and communication system (PACS) both have advantages and disadvantages in radiologic practice. We describe a fully integrated VR/PACS system running on a single platform. Integration optimizes the positive features of both systems and creates a synergy that is not otherwise realized. The planning and development of the system is described, as well as a number of challenges that were addressed. Radiologists have viewed the process changes very positively during initial use.

Development of a computerized screening system to identify substance abuse in primary care

The Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC), developed under a contract from the National Institute on Drug Abuse, is a comprehensive screening system developed for quickly identifying and addressing substance abuse and related problems in a primary care setting. The DAPA-PC system includes a two-level screening instrument, resources for scoring and reporting results, motivational messages, treatment referrals, and informative links, which together address the multifaceted needs of patients dealing with addiction problems and their providers. The need for such a system, preliminary reactions to the instrument, and future course of research are discussed.

Nitrofurantoin quadruple therapy for Helicobacter pylori infection: effect of metronidazole resistance

BACKGROUND

Antibiotic resistance has increasingly been recognized as the major cause of treatment failure for Helicobacter pylori infection. New therapies for patients with metronidazole- or clarithromycin-resistant H. pylori are needed.

AIM

To investigate the role of nitrofurantoin quadruple therapy for the treatment of H. pylori.

METHODS

Patients with confirmed H. pylori infection received nitrofurantoin (100 mg t.d.s.), omeprazole (20 mg b.d.), Pepto-Bismol (two tablets t.d.s.), and tetracycline (500 mg t.d.s.) for 14 days. Four or more weeks after the end of therapy, outcome was assessed by repeat endoscopy with histology and culture or urea breath testing.

RESULTS

Thirty patients were entered, including 25 men and five women; the mean age was 54.9 years. The most common diagnoses were duodenal ulcer (23%) and GERD (18%). The intention-to-treat cure rate was 70% (95% CI: 50.6-85%). Nitrofurantoin quadruple therapy was more effective with metronidazole-sensitive strains (88%; 15 out of 17) than with metronidazole-resistant strains (33%; three out of nine; P=0.008). Two of the treatment failures had pre-treatment isolates susceptible to metronidazole, which were resistant after therapy.

CONCLUSIONS

Because nitrofurantoin quadruple therapy performed inadequately in the presence of metronidazole resistance, we conclude that nitrofurantoin is unlikely to find clinical utility for the eradication of H. pylori.

Developing a taxonomy for research in adverse drug events: potholes and signposts

Computerized decision support and order entry shows great promise for reducing adverse drug events (ADEs). The evaluation of these solutions depends on a framework of definitions and classifications that is clear and practical. Unfortunately the literature does not always provide a clear path to defining and classifying adverse drug events. While not a systematic review, this paper uses examples from the literature to illustrate problems that investigators will confront as they develop a conceptual framework for their research. It also proposes a targeted taxonomy that can facilitate a clear and consistent approach to the research of ADEs and aid in the comparison to results of past and future studies. The taxonomy addresses the definition of ADE, types, seriousness, error, and causality.

Distracting painful injuries associated with cervical spinal injuries in blunt trauma

Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography.

OBJECTIVE

To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography.

METHODS

This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries.

RESULTS

Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography.

CONCLUSIONS

A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.

Peginterferon alfa-2a in patients with chronic hepatitis C and cirrhosis

BACKGROUND

Chronic hepatitis C virus (HCV) infection in patients with cirrhosis is difficult to treat. In patients with chronic hepatitis C but without cirrhosis, once-weekly administration of interferon modified by the attachment of a 40-kd branched-chain polyethylene glycol moiety (peginterferon alfa-2a) is more efficacious than a regimen of unmodified interferon. We examined the efficacy and safety of peginterferon alfa-2a in patients with HCV-related cirrhosis or bridging fibrosis.

METHODS

We randomly assigned 271 patients with cirrhosis or bridging fibrosis to receive subcutaneous treatment with 3 million units of interferon alfa-2a three times weekly (88 patients), 90 microg of peginterferon alfa-2a once weekly (96), or 180 microg of peginterferon alfa-2a once weekly (87). Treatment lasted 48 weeks and was followed by a 24-week follow-up period. We assessed efficacy by measuring HCV RNA and alanine aminotransferase and by evaluating liver-biopsy specimens. A histologic response was defined as a decrease of at least 2 points on the 22-point Histological Activity Index.

RESULTS

In an intention-to-treat analysis, HCV RNA was undetectable at week 72 in 8 percent, 15 percent, and 30 percent of the patients treated with interferon alfa-2a and with 90 microg and 180 microg of peginterferon alfa-2a, respectively (P=0.001 for the comparison between 180 microg of peginterferon alfa-2a and interferon alfa-2a). At week 72, alanine aminotransferase concentrations had normalized in 15 percent, 20 percent, and 34 percent of patients, respectively (P=0.004 for the comparison between 180 microg of peginterferon alfa-2a and interferon alfa-2a). In the subgroup of 184 patients with paired liver-biopsy specimens, the rates of histologic response at week 72 were 31 percent, 44 percent, and 54 percent, respectively (P=0.02 for the comparison between 180 microg of peginterferon alfa-2a and interferon alfa-2a). All three treatments were similarly tolerated.

CONCLUSIONS

In patients with chronic hepatitis C and cirrhosis or bridging fibrosis, 180 microg of peginterferon alfa-2a administered once weekly is significantly more effective than 3 million units of standard interferon alfa-2a administered three times weekly.

Peginterferon alfa-2a in patients with chronic hepatitis C

BACKGROUND

Covalent attachment of a 40-kd branched-chain polyethylene glycol moiety to interferon alfa-2a results in a compound (peginterferon alfa-2a) that has sustained absorption, a slower rate of clearance, and a longer half-life than unmodified interferon alfa-2a. We compared the clinical effects of a regimen of peginterferon alfa-2a with those of a regimen of interferon alfa-2a in the initial treatment of patients with chronic hepatitis C.

METHODS

We randomly assigned 531 patients with chronic hepatitis C to receive either 180 microg of peginterferon alfa-2a subcutaneously once per week for 48 weeks (267 patients) or 6 million units of interferon alfa-2a subcutaneously three times per week for 12 weeks, followed by 3 million units three times per week for 36 weeks (264 patients). All the patients were assessed at week 72 for a sustained virologic response, defined as an undetectable level of hepatitis C virus RNA (<100 copies per milliliter).

RESULTS

In the peginterferon group, 223 of the 267 patients completed treatment and 206 completed follow-up. In the interferon group, 161 of the 264 patients completed treatment and 154 completed follow-up. In an intention-to-treat analysis in which patients who missed the examination at the end of treatment or follow-up were considered not to have had a response at that point, peginterferon alfa-2a was associated with a higher rate of virologic response than was interferon alfa-2a at week 48 (69 percent vs. 28 percent, P=0.001) and at week 72 (39 percent vs. 19 percent, P=0.001). Sustained normalization of serum alanine aminotransferase concentrations at week 72 was also more common in the peginterferon group than in the interferon group (45 percent vs. 25 percent, P=0.001). The two groups were similar with respect to the frequency and severity of adverse events, which were typical of those associated with interferon alfa.

CONCLUSIONS

In patients with chronic hepatitis C, a regimen of peginterferon alfa-2a given once weekly is more effective than a regimen of interferon alfa-2a given three times weekly.

Evaluation of a method using Proteus mirabilis and Pseudomonas aeruginosa to experimentally induce dual infection of the urinary bladder in dogs

OBJECTIVE

To evaluate a method using Proteus mirabilis and Pseudomonas aeruginosa to experimentally induce dual infection of the urinary bladder in dogs.

ANIMALS

6 healthy mixed-breed dogs.

PROCEDURE

Dogs were anesthetized, and cystitis was induced by infusing a solution of salicylic acid in ethanol into the bladder, followed by an inoculum containing field isolates of P. mirabilis and P. aeruginosa. Dogs were examined daily for 21 days after induction of cystitis. On day 21, dogs were euthanatized, and urinary bladder, renal pelvis, and prostate specimens were submitted for bacterial culture.

RESULTS

After induction of cystitis, all dogs had evidence of thickening of the bladder wall, dysuria, tenesmus, and hematuria. Urinalysis revealed proteinuria, hematuria, and pyuria. All urine samples obtained on day 21 yielded growth of P. mirabilis, but P. aeruginosa was not cultured from any of these samples. Proteus mirabilis was isolated from bladder, renal pelvis, or prostate specimens from 4 dogs; P. aeruginosa was not isolated from any of the tissue specimens.

CONCLUSION

Results suggest that the method used in the present study fails to induce dual infection of the urinary bladder with P. mirabilis and P. aeruginosa. The inability to establish a persistent dual infection with this method may have been a result of insufficient pathogenicity of the Pseudomonas isolate or an inadequacy of the experimental design.

Nitric oxide synthase and postischemic liver injury

The objective of this study was to determine what roles the endothelial cell and inducible isoforms of nitric oxide synthase (eNOS, iNOS) play in ischemia and reperfusion (I/R)-induced liver injury in vivo in mice genetically deficient in each isoform of NOS. We found that 45 min of partial (70%) liver ischemia and 5 h of reperfusion induced substantial liver injury as assessed by the release of large and significant amounts of the liver-specific enzyme alanine aminotransferase (ALT) into the serum of wild-type (wt) mice. The enhanced ALT levels were not due to increased recruitment of potentially damaging PMNs, which could mediate hepatocyte injury, as neither histopathological inspection nor quantitative MPO determinations revealed the presence of PMNs in the liver at this time point. In addition, we observed a significant enhancement in liver injury in eNOS-deficient but not iNOS-deficient mice subjected to liver I/R compared to postischemic wt mice. Taken together, these data suggest that eNOS- but not iNOS-derived NO plays an important role in limiting or downregulating I/R-induced liver injury in vivo following 5 h of reperfusion.

Accuracy of the extent of axillary nodal positivity related to primary tumor size, number of involved nodes, and number of nodes examined

PURPOSE

While a number of studies have evaluated the minimum number of axillary nodes that need to be examined to accurately determine nodal positivity or negativity, there is little information on the number of nodes which must be examined to determine the extent of nodal positivity. This study attempts to determine for patients with 1-3 positive nodes the probability that the number of positive nodes reported is the true number of positive nodes as well as the probability that 4 or more nodes could be positive based on primary tumor size and number of nodes examined.

MATERIALS AND METHODS

From 1979 to 1998, 1652 women with Stages I-II invasive breast cancer underwent an axillary dissection as part of their breast conservation therapy and had more than 10 lymph nodes examined. The mean and median number of nodes identified in the dissection was 19 and 17 (range, 11-75). The median age was 55 years. A total of 1155 women had T1 tumors and 497 had T2 tumors. Of the 459 node-positive women, 72% had 1-3 positive nodes, 18% had 4-9 positive nodes, and 10% had 10 or more positive nodes. A mathematical model based on tumor size and number of nodes examined was created using the hypergeometric distribution and Bayes Theorem. The resulting model was used to estimate the accuracy of the reported number of positive nodes and the probability of 4 or more positive nodes based on various observed sampling combinations.

RESULTS

For patients with T1 tumors and 1, 2, or 3 positive nodes, the minimum number of nodes examined needed for a 90% probability of accuracy is 19, 20, and 20. For T2 tumors and 1, 2, or 3 positive nodes, a minimum of 20 nodes is required. The probability of 4 or more positive nodes increases as tumor size and the number of reported positive nodes increase and as the number of examined nodes decreases. For a 10% or less probability of 4 or more positive nodes, a patient with a T1 tumor and 1, 2, or 3 observed positive nodes would require a minimum of 8, 15, and 20 nodes removed. For a T2 tumor and 1, 2, or 3 observed positive nodes, the corresponding numbers are 10, 16, and 20.

CONCLUSION

The accuracy of the extent of axillary nodal positivity is influenced by the number of observed positive nodes, tumor size, and the number of nodes examined. Underestimation of the number of positive nodes will result in errors in the assessment of an individual's risk for locoregional recurrence, distant disease, and breast cancer death and will adversely impact on treatment recommendations. This model provides the clinician with a means for assessing the accuracy of the number of positive nodes reported in patients with 1-3 positive nodes.

Internal mammary node irradiation neither decreases distant metastases nor improves survival in stage I and II breast cancer

PURPOSE

To compare outcome for ipsilateral breast tumor recurrence (IBTR), or regional node recurrence, initial and subsequent distant metastases, and overall and cause-specific survival in women treated with conservative surgery and radiation based on whether or not radiation was targeted to the internal mammary nodes (IMN).

METHODS AND MATERIALS

From 1979-1994, 1383 women with Stage I-II breast cancer underwent wide excision, axillary node dissection with >/=10 nodes removed, and radiation. Median follow-up was 6 years; median age was 55 years. A total of 114 women had radiation targeted to the IMN with deep tangents and 1269 did not. Women who received IMN treatment were more often axillary node-positive (40% vs. 25%, p = 0. 002), had central or inner quadrant tumors (61% vs. 40%, p = 0.001), and had T2 tumors (47% vs. 31%, p = 0.001). All axillary node-positive women received adjuvant chemotherapy and/or tamoxifen. For axillary node-negative women, 13% of the IMN treatment group received adjuvant systemic therapy compared to 37% of the no treatment group (p = 0.001). Radiation was directed to the breast only in 97% of the axillary node-negative women who had IMN treatment and 99% of the no IMN treatment group. For axillary node-positive women, 98% of the IMN-treated group had radiation to the breast and supraclavicular nodes +/- a posterior axillary field compared to 77% of the no IMN treatment group (p = 0.001). There were no significant differences between the two groups for median age, menopausal status, histology, final surgical margin, estrogen and progesterone receptor status, or the number of positive nodes.

RESULTS

There were no significant differences in the 5- and 10-year cumulative incidence of an IBTR, regional node recurrence, initial or total distant metastases for the two groups. Similarly 5- and 10-year actuarial overall and cause-specific survival were not significantly different. However, subset analysis revealed a statistically significant increase in initial (29% vs. 15% at 10 yr, p = 0.002) and total (30% vs. 17% at 10 yr, p = 0.01) distant metastases and a significant decrease in cause-specific survival (76% vs. 89% at 10 yr, p = 0.02) for postmenopausal women who received IMN treatment. These findings could not be attributed to differences in the use of systemic therapy or the number of positive nodes. Axillary node-positive patients did not experience a significant decrease in initial (36% vs. 22% at 10 yr, p = 0.21) or total distant metastases (37% vs. 28% at 10 yr, p = 0.62) or a significant improvement in cause-specific survival (72% vs. 76% at 10 yr, p = 0.76) with IMN treatment regardless of whether the tumor was lateral or medial/central in location. IMN treatment was not associated with an increase in non-breast cancer deaths during this period of observation.

CONCLUSIONS

This retrospective series was unable to identify a significant benefit for IMN irradiation in terms of distant metastases or cause-specific survival for the entire patient population, and in particular, for patients with positive axillary nodes and medially located lesions. The results of the proposed or ongoing prospective randomized trials will further address this controversial issue.

Metronidazole containing quadruple therapy for infection with metronidazole resistant Helicobacter pylori: a prospective study

BACKGROUND

Metronidazole remains a key component of H. pylori infection therapy. It has been suggested that despite resistance, metronidazole may be effective when given at high dose with bismuth, tetracycline, and a proton pump inhibitor (quadruple therapy).

AIM

To prospectively evaluate metronidazole quadruple therapy for treatment of metronidazole resistant H. pylori infection in the United States.

METHODS

Patients infected with metronidazole resistant H. pylori were prospectively prescribed 14 days of quadruple therapy consisting of metronidazole 500 mg t.d.s., tetracycline 500 mg q.d.s., two bismuth subsalicylate tablets q.d.s., and omeprazole 20 mg o.d.

RESULTS

A total of 26 patients were entered into the study; 22 for their first treatment and four as re-treatment for failed therapy. Of the 26 patients, 24 were cured (cure rate 92%; 95% CI: 78-99%). Both treatment failures reported full compliance to 14 days of therapy. Side-effects were common and resulted in premature discontinuation of therapy in 31%. Premature discontinuation did not reduce the cure rate.

CONCLUSION

Quadruple metronidazole combination therapy is effective despite the presence of metronidazole resistance and should be considered as either first line therapy or for failures of twice-a-day combination therapies.

Homelessness and gender in out-of-treatment drug users

This study examines 5225 out-of-treatment crack users and drug injectors drawn from five different geographic areas to examine selected factors associated with homelessness. Of these crack users, 27% considered themselves undomiciled, and 60% had previously entered some type of drug treatment. Logistic regression found that substance abusers who were married, female, and persons of color were less likely to be without a home when other variables were controlled. Trading sex for money and perceived chance of getting acquired immunodeficiency syndrome (AIDS) were associated positively with homelessness, while participating in methadone detoxification and methadone maintenance programs seemed to offer some protection from homelessness.

Microinvasive breast carcinoma: clinicopathologic analysis of a single institution experience

BACKGROUND

Microinvasive breast carcinoma (MIC) has a good prognosis but specific definitions have varied in the past, making the clinical significance of MIC a subject of debate.

METHODS

Microscopic slides of 59 cases of breast carcinoma originally diagnosed as MIC were reviewed retrospectively. Histologic parameters were correlated with clinical findings and outcome to define diagnostic criteria better.

RESULTS

On review, the 59 cases were recategorized as follows: pure DCIS (N = 16), DCIS with foci equivocal for microinvasion (N = 7), DCIS with > or =1 focus of microinvasion (N = 11), T1 invasive carcinomas with > or =90% DCIS (N = 18), and T1 tumors with <90% DCIS (N = 7). The MIC cases in the current study averaged 3 separate foci of early infiltration outside the basement membrane, each one not >1.0 mm. The mean follow-up was 95 months. Six patients (10%) had only local recurrence: 1 case each in patients with equivocal microinvasion, microinvasion, and T1 tumors with <90% DCIS and 3 cases among the patients with T1 tumors with > or = 90% DCIS. Four patients, all with T1 tumors with > or =90% DCIS, had distant failure (7%). In the MIC group, only one patient developed a local recurrence after breast conservation. No patient had axillary lymph node metastasis. For the entire series, factors associated with local recurrence were younger age, breast conservation versus mastectomy, and close surgical margins. The only factor associated with distant failure was the size of the DCIS component. Seven patients with T1 tumors with > or =90% DCIS experienced local or distant failure and 5 of these (71%) developed progressive disease or died of disease. All other patients who developed a recurrence were disease free at last follow-up. In a retrospective series, poorer outcome in carcinomas with > or =90% DCIS may be related to the greater likelihood of missed larger areas of invasive carcinoma. Therefore, meticulous and extensive sampling of these carcinomas is required.

CONCLUSIONS

MIC as defined has a good prognosis. It has a different biology than T1 invasive carcinoma with > or =90% DCIS, which may progress and cause death. Large tumors with multiple foci of microinvasion may have metastatic potential.

Fertility drug therapies: past, present, and future

Throughout the last 30 years there has been an evolution of drug therapies aimed at the treatment of infertility. These agents primarily address the induction of ovulation or enhancing ovulation by allowing more oocytes to mature simultaneously. As this evolution has progressed, drugs have moved away from human products to the advent of the recombinant or genetically engineered technology. The drugs have not cured infertility, but they have affected positively the quest of families confronted by infertility.

Furazolidone combination therapies for Helicobacter pylori infection in the United States

BACKGROUND

Antibiotic resistance has begun to impair the ability to cure Helicobacter pylori infection.

AIM

To evaluate furazolidone as a component of combination therapies for treatment of H. pylori infection in the United States.

METHODS

Patients with active H. pylori infection received furazolidone combination therapy for 14 days (furazolidone 100 mg and tetracycline 500 mg t.d.s.; omeprazole 20 mg o.d. in the morning and, depending on the pre-treatment antimicrobial susceptibility pattern, 500 mg of metronidazole or clarithromycin t.d.s.).

RESULTS

A total of 27 patients received the metronidazole containing combination (cure rate 100%) and seven received the clarithromycin combination (cure rate 86%). Overall the cure rates for intention-to-treat was 97% (95% CI: 85% to 100%). The single failure took the clarithromycin containing combination for only 2 days (per protocol cure rate = 100%). Side-effects were common and led to discontinuation of therapy in 26% of patients. An attempt to eliminate metronidazole and clarithromycin and use furazolidone, tetracycline, and lansoprazole b.d. produced an unsatisfactory cure rate of 72%.

CONCLUSION

Furazolidone combination therapy appears to be effective. Additional studies with different antimicrobial combinations and duration of therapy are warranted.

An integrated genetic linkage map with 1,137 markers constructed from five F2 crosses of autoimmune disease-prone and -resistant inbred rat strains

The rat (Rattus norvegicus) is an important experimental model for many human diseases including arthritis, diabetes, and other autoimmune and chronic inflammatory diseases. The rat genetic linkage map, however, is less well developed than those of mouse and human. Integrated rat genetic linkage maps have been previously reported by Pravenec et al. (1996, Mamm. Genome 7: 117-127) (500 markers mapped in one cross), Bihoreau et al. (1997, Genome Res. 7: 434-440) (767 markers mapped in three crosses), Wei et al. (1998, Mamm. Genome 9: 1002-1007) (562 markers mapped in two crosses), Brown et al. (1998, Mamm. Genome 9: 521-530) (678 markers mapped in four crosses), and Nordquist et al. (1999, Rat Genome 5: 15-20) (330 markers mapped in two crosses). The densest linkage map combined with a radiation hybrid map, reported by Steen et al. (1999, Genome Res. 9: AP1-AP8), includes 4736 markers mapped in two crosses. Here, we present an integrated linkage map with 1137 markers. We have constructed this map by genotyping F2 progeny of five crosses: F344/NHsd x LEW/NHsd (673 markers), DA/Bkl x F344/NHsd (531 markers), BN/SsN x LEW/N (714 markers), DA/Bkl x BN/SsNHsd (194 markers), and DA/Bkl x ACI/SegHsd (245 markers). These inbred rat strains vary in susceptibility/resistance to multiple autoimmune diseases and are used extensively for many types of investigation. The integrated map includes 360 loci mapped in three or more crosses. The map contains 196 new SSLP markers developed by our group, as well as many SSLP markers developed by other groups. Two hundred forty genes are incorporated in the map. This integrated map should allow comparison of rat genetic maps from different groups and thereby facilitate genetic studies of rat autoimmune and related disease models.

Outcomes of patients receiving radiation for carcinoma of the rectum. Results of the 1988-1989 patterns of care study

BACKGROUND

Clinical trials of surgical adjuvant treatment for patients with rectal carcinoma (RC) indicate that postoperative radiation therapy with concurrent chemotherapy (CRT) is superior to postoperative radiation alone (RT) or surgery alone. Whether preoperative treatment is superior to postoperative treatment is controversial. This Patterns of Care Study (PCS) surveyed patients with RC treated with radiation during the years 1988-1989 to determine the national practice standards and outcomes and to compare these results with those of clinical trials.

METHODS

A national survey of 73 institutions was conducted using 2-stage cluster sampling, and specific information on 406 patients with RC who received radiation at 69 facilities was collected. Follow-up information on 215 patients was subsequently collected by mail survey. There were no significant differences between the known prognostic indicators or treatment-related variables for patients for whom follow-up was available compared with the variables for patients for whom follow-up was not available. Follow-up ranged from 0 to 8.44 years with a median of 4 years. One hundred fifty-four patients (71%) received postoperative treatment, either RT (37%) or CRT (34%); and 40 (18%) received preoperative treatment, either RT (15%) or CRT (3%). Ninety-six patients (45%) received chemotherapy, and for 86% of those patients chemotherapy was administered concurrently with radiation.

RESULTS

Survival was stage-dependent (85% Stage I, 69% Stage II, and 54% Stage III at 5 years, P = 0.04). Survival was also substage-dependent, and patients with C(1) cancer had significantly higher 5-year survival than those with C(2)/C(3) cancer (89% vs. 48%, P = 0.008). Local failure was similar for Stage II and Stage III patients (10% vs. 11% at 5 years, respectively). In multivariate analyses, only stage and use of chemotherapy were significant to survival (Stage III vs. Stage I and II, relative risk [RR] = 2.52, and chemotherapy vs. no chemotherapy, RR = 0.46). A significantly higher 5-year survival rate was seen with postoperative CRT than with postoperative RT (69% vs. 50%, P = 0. 011). Preoperative radiation resulted in a significantly higher 5-year survival rate than postoperative radiation (85% vs. 50%, P = 0.0006), but not compared with postoperative CRT. Survival and local failure did not differ according to radiation therapy interruption or the interval between surgery and radiation.

CONCLUSIONS

Stage is an important prognostic indicator for survival, and among patients with Stage III malignancies survival in the substage C(1) is significantly higher than in the substages C(2) and C(3). As has been demonstrated in randomized trials, adjuvant postoperative CRT is superior to postoperative RT for patients with RC in this national study. These nationwide results of adjuvant treatment are comparable to those reported in randomized trials. The use of CRT was the only treatment-related factor that resulted in a significant reduction in the risk of death.

Fas-deficient lpr mice are more susceptible to graft-versus-host disease

The Fas/Fas ligand (FasL) pathway is involved in a variety of regulatory mechanisms that could be important for the development of graft-vs-host disease (GVHD) after bone marrow transplantation (BMT), such as cytolysis of target cells by cytotoxic T cells, regulation of inflammatory responses, peripheral deletion of autoimmune cells, costimulation of T cells, and activation-induced cell death. To further evaluate the role of Fas/FasL in the complex pathophysiology of GVHD, we used Fas-deficient B6.lpr mice as recipients in a MHC-matched minor histocompatibility Ag-mismatched murine model for GVHD after allogeneic BMT (C3H.SW-->B6). We found a significantly higher morbidity and mortality from GVHD compared with control B6 recipients. In contrast, B6.lpr recipients had very little hepatic GVHD, although all other specific GVHD target organs (skin, intestines, and thymus) were more severely affected than in the control B6 recipients. B6.lpr recipients with GVHD demonstrated intact donor lymphoid engraftment and an increase in expansion of donor T cells and monocytes/macrophages compared with control B6 recipients. Serum levels of IFN-gamma and TNF-alpha were higher in B6.lpr recipients than in control B6 recipients, and monocytes/macrophages in B6.lpr recipients appeared more sensitized. B6.lpr recipients had more residual peritoneal macrophages after BMT, and peritoneal macrophages from B6.lpr mice could induce a greater proliferative response from C3H.SW splenocytes. This study demonstrates that the expression of Fas in the recipient is required for GVHD of the liver, but shows unexpected consequences when host tissues lack the expression of Fas for the development of GVHD in other organs and systemic GVHD.

Biological markers of risk in nipple aspirate fluid are associated with residual cancer and tumour size

We previously demonstrated that nipple aspirate fluid (NAF) can be obtained from virtually all non-Asian women between the ages of 30 and 72. The focus of this report is to (1) determine the association of candidate markers of breast cancer risk in NAF obtained from fresh mastectomy specimens with residual breast carcinoma, and (2) evaluate the association of the markers with breast tumour progression. Nipple aspiration was performed on 97 specimens. Cytology, DNA index (including % hypertetraploid cells), cell cycle parameters (S phase fraction, % cells in G2/M), prostate-specific antigen (PSA), epidermal growth factor (EGF), testosterone, carcinoembryonic antigen (CEA) and prostaglandin D synthase (PGDS) were evaluated in NAF for their association with (1) residual ductal carcinoma in situ (DCIS) or invasive cancer, and (2) pathologic tumour size. NAF was obtained from 99% (96/97) of specimens. Atypical and malignant NAF cytology were significantly associated with residual DCIS or invasive cancer (P = 0.001) and with larger tumours (P = 0.004). One hundred per cent and 88% of subjects with malignant and atypical NAF cytology, respectively, had residual carcinoma. The percentage of cells in G2/M and DNA index were associated both with risk of residual carcinoma (P = 0.01 for each) and larger tumour size (DNA index, P = 0.03; G2/M, P = 0.05), although neither biomarker improved the ability of NAF cytology, to predict residual breast cancer. Higher DNA index was associated with atypical cytology (P = 0.0001). In summary, atypical and malignant NAF cytology are associated with larger tumour size, and are highly predictive of residual carcinoma after needle or excisional biopsy of the breast.

Ordered bicontinuous nanoporous and nanorelief ceramic films from self assembling polymer precursors

Three-dimensional ceramic nanostructured films were produced from silicon-containing triblock copolymer films exhibiting the double gyroid and inverse double gyroid morphologies (space group Ia3d). A one-step room-temperature oxidation process that used ozonolysis and ultraviolet irradiation effected both the selective removal of the hydrocarbon block and the conversion of the silicon-containing block to a silicon oxycarbide ceramic stable to 400 degrees C. Depending on the relative volume fraction of the hydrocarbon block to the silicon- containing block, either nanoporous or nanorelief structures were fabricated with calculated interfacial areas of approximately 40 square meters per gram and pore or strut sizes of approximately 20 nanometers.

Outcomes of patients receiving radiation for carcinoma of the rectum. Results of the 1988-1989 patterns of care study

BACKGROUND

Clinical trials of surgical adjuvant treatment for patients with rectal carcinoma (RC) indicate that postoperative radiation therapy with concurrent chemotherapy (CRT) is superior to postoperative radiation alone (RT) or surgery alone. Whether preoperative treatment is superior to postoperative treatment is controversial. This Patterns of Care Study (PCS) surveyed patients with RC treated with radiation during the years 1988-1989 to determine the national practice standards and outcomes and to compare these results with those of clinical trials.

METHODS

A national survey of 73 institutions was conducted using 2-stage cluster sampling, and specific information on 406 patients with RC who received radiation at 69 facilities was collected. Follow-up information on 215 patients was subsequently collected by mail survey. There were no significant differences between the known prognostic indicators or treatment-related variables for patients for whom follow-up was available compared with the variables for patients for whom follow-up was not available. Follow-up ranged from 0 to 8.44 years with a median of 4 years. One hundred fifty-four patients (71%) received postoperative treatment, either RT (37%) or CRT (34%); and 40 (18%) received preoperative treatment, either RT (15%) or CRT (3%). Ninety-six patients (45%) received chemotherapy, and for 86% of those patients chemotherapy was administered concurrently with radiation.

RESULTS

Survival was stage-dependent (85% Stage I, 69% Stage II, and 54% Stage III at 5 years, P = 0.04). Survival was also substage-dependent, and patients with C(1) cancer had significantly higher 5-year survival than those with C(2)/C(3) cancer (89% vs. 48%, P = 0.008). Local failure was similar for Stage II and Stage III patients (10% vs. 11% at 5 years, respectively). In multivariate analyses, only stage and use of chemotherapy were significant to survival (Stage III vs. Stage I and II, relative risk [RR] = 2.52, and chemotherapy vs. no chemotherapy, RR = 0.46). A significantly higher 5-year survival rate was seen with postoperative CRT than with postoperative RT (69% vs. 50%, P = 0. 011). Preoperative radiation resulted in a significantly higher 5-year survival rate than postoperative radiation (85% vs. 50%, P = 0.0006), but not compared with postoperative CRT. Survival and local failure did not differ according to radiation therapy interruption or the interval between surgery and radiation.

CONCLUSIONS

Stage is an important prognostic indicator for survival, and among patients with Stage III malignancies survival in the substage C(1) is significantly higher than in the substages C(2) and C(3). As has been demonstrated in randomized trials, adjuvant postoperative CRT is superior to postoperative RT for patients with RC in this national study. These nationwide results of adjuvant treatment are comparable to those reported in randomized trials. The use of CRT was the only treatment-related factor that resulted in a significant reduction in the risk of death.

Emergency department evaluation and treatment of the shoulder and humerus

The shoulder girdle is a versatile anatomic structure with a wide range of mobility and function. Its soft tissue and skeletal components are subject to a variety of injuries spanning from overuse syndromes to acute trauma. This article reviews the key historical and physical examination techniques of the shoulder, and special attention is paid to proper imaging in the emergency department, which aids in the diagnosis of specific disorders. This article also reviews the various therapeutic options, including surgery.

Rural hospitals and the local economy: a needed extension and refinement of existing empirical research

The relationship between the health care sector and the rural economy is of increasing importance. Much additional research is needed to fully understand this relationship and to address some of the limitations of the modest amount of research that already exists. In this study, data from Nebraska were used to create a four-part typology of rural hospitals. Input-output analysis was used to assess the economic effects of each type of hospital on the local economy and to simulate the effects of three different changes or scenarios: an increase or decrease in hospital utilization; the elimination of local purchases of nonlabor inputs; and a change in the mix or configuration of services provided. While the hospital is an important contributor to local economies, this contribution is not constant across hospital types. The total job-related effects ranged from 77 jobs for the smallest type of rural hospital to 1,332 for the largest type. Service and trade (retail plus wholesale) are the two sectors of the local economy most heavily influenced by the presence of a hospital. In today's changing and challenging environment, there is a great need for researchers to create and evaluate the economic effects of a variety of relevant and realistic scenarios (other than hospital closure).

Varicella complicated by group A streptococcal sepsis and osteonecrosis

A 5-year-old boy presented with primary varicella zoster virus infection, group A streptococcal sepsis, toxic shock, and multisite osteonecrosis. An association between osteonecrosis and group A streptococcal sepsis has not been previously reported. Clinical recognition with supportive radiologic and pathologic findings are presented. Therapeutic guidelines are suggested.

Patients with early stage invasive cancer with close or positive margins treated with conservative surgery and radiation have an increased risk of breast recurrence that is delayed by adjuvant systemic therapy

PURPOSE

The association between a positive resection margin and the risk of ipsilateral breast tumor recurrence (IBTR) after conservative surgery and radiation is controversial. The width of the resection margin that minimizes the risk of IBTR is unknown. While adjuvant systemic therapy may decrease the risk of an IBTR in all patients, its impact on patients with positive or close margins is largely unknown. This study examines the interaction between margin status, margin width, and adjuvant systemic therapy on the 5- and 10-year risk of IBTR after conservative surgery and radiation.

METHODS AND MATERIALS

A series of 1,262 patients with clinical Stage I or II breast cancer were treated by breast-conserving surgery, axillary node dissection, and radiation between March 1979 and December 1992. The median follow-up was 6.3 years (range 0.1-15.6). The median age was 55 years (range 24-89). Clinical size was T1 in 66% and T2 in 34%. Seventy-three percent of patients were node-negative. Only 5 % of patients had tumors that were EIC-positive. Forty-one percent had a single excision, and 59% had a reexcision. The final margins were negative in 77%, positive in 12%, and close (< or = 2 mm) in 11%. The median total dose to the tumor bed was 60 Gy with negative margins, 64 Gy with close margins, and 66 Gy with positive margins. Chemotherapy +/- tamoxifen was used in 28%, tamoxifen alone in 20%, and no adjuvant systemic therapy in 52%.

RESULTS

The 5-year cumulative incidence (CI) of IBTR was not significantly different between patients with negative (4%), positive (5%), or close (7%) margins. However, by 10 years, a significant difference in IBTR became apparent (negative 7%, positive 12%, close 14%, p = 0.04). There was no significant difference in IBTR when a close or positive margin was involved by invasive tumor or DCIS. Reexcision diminished the IBTR rate to 7% at 10 years if the final margin was negative; however, the highest risk was observed in patients with persistently positive (13%) or close (21%) (p = 0.02) margins. The median interval to failure was 3.7 years after no adjuvant systemic therapy, 5.0 years after chemotherapy +/- tamoxifen, and 6.7 years after tamoxifen alone. This delay to IBTR was observed in patients with close or positive margins, with little impact on the time to failure in patients with negative margins. The 5-year CI of IBTR in patients with close or positive margins was 1% with adjuvant systemic therapy and 13% with no adjuvant therapy. However, by 10 years, the CI of IBTR was similar (18% vs. 14%) due to more late failures in the patients who received adjuvant systemic therapy.

CONCLUSION

A negative margin (> 2 mm) identifies patients with a very low risk of IBTR (7% at 10 years) after conservative surgery and radiation. Patients with a close margin (< or = 2 mm) are at an equal or greater risk of IBTR as with a positive margin, especially following a reexcision. A margin involved by DCIS or invasive tumor has the same increased risk of IBTR. A reexcision of an initially close or positive margin that results in a negative final margin reduces the risk of IBTR to that of an initially negative margin. A close or positive margin is associated with an increased risk of IBTR even in patients who are EIC-negative or receiving higher boost doses of radiation. The median time to IBTR is delayed; however, the CI is not significantly decreased by adjuvant systemic therapy in patients with close or positive margins-the 5 year results in these patients underestimate their ultimate risk of recurrence.

Dose monitoring in Partial Liquid Ventilation by infrared measurement of expired perfluorochemicals

Patients undergoing Partial Liquid Ventilation (PLV) with the perfluorochemical liquid perflubron (PFB) continuously evaporate the drug from the lung during ventilatory expiration. In this study, two infrared (IR) devices, a modified industrial analyzer ("experimental prototype") and a custom-designed device suitable for use in a clinical environment ("clinical prototype"), were calibrated and validated on the bench to measure a range of PFB concentrations (CPFB) in a gas stream. PFB loss from the lung (area under the CPFB-vs-time-curve) could be correlated during PLV simulation with changes in tidal volume, breathing rate, and variable CPFB-vs-time profiles. The two IR devices produced nearly identical measurements for the same CPFB standards (maximum deviation = 1.5%). The experimental IR prototype was tested in 17 anesthetized, paralyzed, and ventilated swine (42-53 kg) to quantify the total amount and rate of evaporate loss of PFB over 12 hours of PLV, both with and without periodic supplemental PFB doses. The residual PFB volumes in the animal lungs at the end of the study, as determined by a gravimetric postmortem lung method, were found to agree on average for all animals to within 10% of the residual PFB volume as predicted by the IR approach. Furthermore, the IR signal of CPFB does not appear to correlate with the absolute amount of PFB in the lungs, but may reflect the relative proportion of PFB-wetted airway and alveolar surface. The authors conclude that IR quantitation of PFB evaporative loss is acceptably accurate for extended periods of PLV and may be a useful tool in the clinic for PFB dose monitoring and maintenance, thereby helping to optimize PLV treatment.

A closed rebreathing system for dose maintenance during Partial Liquid Ventilation

Partial Liquid Ventilation (PLV), a treatment for acute respiratory failure in which the lungs are filled, either partially or to functional residual capacity (FRC), with perfluorochemical (PFC) liquid while the patient is on mechanical gas ventilation, has progressed to clinical trials using the PFC perflubron (PFB). Because gas expired during PLV is laden with PFB vapor, PFB is lost via evaporation, which increases dose consumption and necessitates periodic redosing. A device has been developed to minimize evaporative loss by confining PFC vapor to a gas volume breathed by the patient, which is isolated from the ventilator. This closed rebreathing system works with the ventilator such that after the lung is filled with PFB, the patient is connected to the rebreathing system, with breathing still "driven" by the ventilator. The rebreathing system consists of two gas circuits, or compartments, separated by a flexible bag (in a box) partition. One compartment is in gas communication with the lung, while the second communicates with the ventilator. The O2 level on the patient side is matched to that on the ventilator side by sensing gas concentrations and by feedback control of O2 introduction. Similarly, air is introduced into the patient side under pressure-based feedback control to maintain a constant gas volume. On inspiration, the ventilator delivers the tidal volume (breath) into the box surrounding the bag, which, in turn, is transmitted through the bag to the lung. On expiration, the process is reversed. Unidirectional circulation of gas in the rebreathing circuit is achieved via check valves, and expired CO2 is removed by a barium hydroxide lime cartridge. Airway humidification is maintained by captive water vapor in the system and water vapor from the CO2 absorber. It is recommended that flow, pressure, O2, and CO2 levels be monitored at the patient "Y," i.e., the proximal end of the endotracheal tube. Performance data from both in-vitro experiments and in-vivo PLV experiments in pigs are presented. The authors conclude that with the closed rebreathing system, the dose can be safely maintained with fewer redosing procedures, and an approximately 90% savings in dose is achieved.

Elevated plasma osmotic concentration stimulates water absorption response in a toad

The water-seeking behavior (WR) of toads (Bufo viridis) was investigated. Fully hydrated toads that are allowed free choice of wet or dry filter paper voluntarily and spontaneously select to sit on water-soaked paper at a regular frequency during trials. Dehydration of bladder-emptied toads by 14% elicits WR in all animals. Injection of aldosterone or angiotensin-I reduced the dehydration threshold to 7% weight loss. WR frequency increased when plasma osmolality was elevated by injection of NaCl or other solutes (both ionic and non-ionic). Only urea, to which cell membranes are highly permeable, was the exception that did not produce this response. The increase in WR frequency induced by elevated plasma osmolality was augmented by injection of aldosterone or angiotensin-I. In vivo water uptake, measured in a water bath, was increased by an NaCl or oxytocin injection, but not by aldosterone. It is concluded that elevated plasma osmolality induces an increase in WR frequency that is separate and prior to the water uptake process. Different hormones are involved in each step.