Factors influencing uptake of pharmacogenetic testing in a diverse patient population

BACKGROUND

The successful integration of pharmacogenetic (PGx) testing into clinical care will require attention to patient attitudes. In this study, we aimed to identify the major reasons why patients would or would not consider PGx testing and whether these factors differed by race, socioeconomic and insurance status, and medical history.

METHODS

We developed and conducted a survey within the adult patient population of the Duke Family Medicine Center.

RESULTS

Of 75 completed surveys (65% African-American), 77% indicated they were 'very likely' or 'somewhat likely' to take a PGx test. Respondents who had experienced a side effect were significantly more likely to indicate they would take a PGx test and expressed greater interest in learning more about testing than those who had not. Drug safety and effectiveness were the major reasons to have PGx testing. Privacy concerns and lack of insurance coverage for testing were the major reasons to decline testing.

CONCLUSIONS

We found no differences in interest in PGx tests by race or socioeconomic status, but found stronger interest from those with a history of side effects and private insurance. While the overall support of PGx testing is encouraging, greater reassurance of medical privacy and development of educational resources are needed.

[Clinical assessment of peritoneal drainages for necrotizing enterocolitis. A Bayesian approach]

AIM

To assess effectiveness of peritoneal drainages for necrotizing enterocolitis.

MATERIAL AND METHODS

Retrospective cohort study (years 2000 to 2006). Laparotomy or patient's death were considered as failure.

STUDY VARIABLES

sex, gestational age, weight at delivery, Apgar score at minutes 1 and 5, modified Bell score, radiology and ventilatory status.

RESULTS

25 patients were diagnosed with necrotizing enterocolitis and treated with peritoneal drainages. Sample's Bell score was: 13(52%) Ia, 6 (24%) IIa, 5 (20%) IIb, and 1 (4%) IIIa. Mean gestational age was 31.8 (+/- 4.2) weeks, and mean weight 1,564 (+/- 810) g. Patients classified as Bell I presented statistically significat differences compared with Bell II-III as for radiology (unspecific), delivery weight (lower) and ventilatory status (higher mechanical ventilation rates). For the 12 patients with Bell scores II-III, peritoneal drains were enough for 5 cases (41.7%) and failed in 7 (58.3%), who were operated on. Multivariate analysis (logistic regression) was not able to show any conection with collected variables. However, a bayesian analysis using data from similar studies showed that the probability for drainage success rate to be higher than 50% is 99%.

CONCLUSIONS

In our centre, 52% of peritoneal drainages were used in patinets with low clinical suspect for necrotizing enetrocolitis, maybe in relation with their lower body weight and need for ventilatory support. In patients affected with necrotizing enterocolitis, drainages were effective in 41.7%. Although limited for its retrospective nature, our study suggests that peritoneal drainages can be curative in, at least, 50% of patients with necrotizing enterocolitis without pneumoperitoneum and clinical signs of peritonitis.

[New oral anticoagulants: molecular characteristics, mechanisms of action, pharmacokinetics and pharmacodynamics]

The search for the ideal anticoagulant has been one of the most active research fields in medicine in the past few years. Anti-vitamin K replacement, particularly in the long term treatment of venous thromboembolism is a difficult objective to achieve due to the wide experience gathered in normal practice and low costs. But to improve the weak points of these drugs is an attractive challenge and would have a great health and social impact. It can be seen that the low molecular weight heparins, or even pentasaccharide, drugs that are already available on the market, although the have very predictable pharmacokinetics, their parenteral use, or their long half life, they are far from being ideal anticoagulants. Ximelagatran, a promising drug, a direct inhibitor of thrombin seemed to be a step forward, but the appearance of undesirable side effects led to its withdrawal. However, this line of investigation has remained open, as such that we now have data from clinical trials that back it up: the direct inhibition of thrombin and activated factor X. These two different mechanisms of action are showing promising results, in that the direct inhibitors of thrombin (dabigatran, hirudins...) are showing not to be inferior in efficacy and safety to enoxaparin in the primary prophylaxis of venous thromboembolism. Similarly, the activated factor X inhibitors (Rivaroxaban, Apixaban ) are also showing the same and in some cases, superior in its prevention. This review looks at the mechanisms of action of both pharmacological groups, their effects on haemostasis, and how they are reflected in coagulation times, their pharmacokinetics and pharmacodynamics. These new anticoagulants are nearer to the ideal anticoagulant and may, in the near future, change the panorama of anticoagulation, not only at health level, but also by achieving improved levels in the quality of life of the patients.

Neurofibromatosis type 1 revisited

Neurofibromatosis type 1 (NF1) is an autosomal dominant condition with a worldwide incidence of approximately 1 per 2500 to 3000 individuals. Caused by a germ-line-inactivating mutation in the NF1 gene on chromosome 17, the disease is associated with increased morbidity and mortality. In the past several years, significant progress has been made in standardizing management of the major clinical features of neurofibromatosis type 1. Moreover, improved understanding of how the neurofibromatosis type 1 protein, neurofibromin, regulates cell growth recently provided insight into the pathogenesis of the disease and has led to the development of new therapies. In this review, we describe the clinical manifestations, recent molecular and genetic findings, and current and developing therapies for managing clinical problems associated with neurofibromatosis type 1.

2q23.1 microdeletion identified by array comparative genomic hybridisation: an emerging phenotype with Angelman-like features?

BACKGROUND

Genome-wide screening of patients with mental retardation using array comparative genomic hybridisation (CGH) has identified several novel imbalances. With this genotype-first approach, the 2q22.3q23.3 deletion was recently described as a novel microdeletion syndrome. The authors report two unrelated patients with a de novo interstitial deletion mapping in this genomic region and presenting similar "pseudo-Angelman" phenotypes, including severe psychomotor retardation, speech impairment, epilepsy, microcephaly, ataxia, and behavioural disabilities.

METHODS

The microdeletions were identified by array CGH using oligonucleotide and bacterial artificial chromosome (BAC) arrays, and further confirmed by fluorescence in situ hybridisation (FISH) and semi-quantitative polymerase chain reaction (PCR).

RESULTS

The boundaries and sizes of the deletions in the two patients were different but an overlapping region of about 250 kb was defined, which mapped to 2q23.1 and included two genes: MBD5 and EPC2. The SIP1 gene associated with the Mowat-Wilson syndrome was not included in the deleted genomic region.

DISCUSSION

Haploinsufficiency of one of the deleted genes (MBD5 or EPC2) could be responsible for the common clinical features observed in the 2q23.1 microdeletion syndrome, and this hypothesis needs further investigation.

A multi-center, randomized, double blind placebo-controlled trial of estrogens to prevent Alzheimer's disease and loss of memory in women: design and baseline characteristics

BACKGROUND

Observational studies and small clinical trials suggested that hormone replacement therapy (HRT) decreases risk of cognitive loss and Alzheimer's disease (AD) in postmenopausal women and may have value in primary prevention.

PURPOSE

A clinical trial was designed to determine if HRT delays AD or memory loss. This report describes the rationale and original design of the trial and details extensive modifications that were required to respond to unanticipated findings that emerged from other studies during the course of the trial.

METHODS

The trial was designed as a multi-center, placebo-controlled primary prevention trial for women 65 years of age or older with a family history of dementia. Recruitment from local sites was supplemented by centralized efforts to use names of Medicare beneficiaries. Inclusion criteria included good general health and intact memory functioning. Participants were randomized to HRT or placebo in a 1:1 ratio. Assignment was stratified by hysterectomy status and site. The primary outcomes were incident AD and memory decline on neuropsychological testing.

RESULTS

Enrollment began in March 1998. In response to the Women's Health Initiative (WHI) May 2002 report of increased incidence of heart disease, stroke, pulmonary embolism, and breast cancer among women randomized to HRT, participants were re-consented with a revised consent form. Procedural modifications, including discontinuation of study medication and a modification of the planned primary outcome based on a final enrollment below the target enrollment (N = 477), were enacted in response to the subsequent WHI Memory Study report of increased risk of dementia and poorer cognitive function with HRT. The mean length of treatment exposure prior to discontinuation was 2.14 years. Participants' mean age at baseline was 72.8; mean education was 14.2 years. Minority participation was 19% and 34% had a hysterectomy. The study continues to follow these participants for a total of 5 years blind to the original medication assignment.

LIMITATIONS

Results reported from the WHI during the course of this study mandated extensive procedural modifications, including discontinuing recruitment before completion and halting study medication. Alternative strategies for study redesign that were considered are discussed.

Infrared single mode chalcogenide glass fiber for space

An important measuring technique under study for the DARWIN planet finding mission, is nulling interferometry, enabling the detection of the weak infrared emission lines of an orbiting planet. This technique requires a perfect wavefront of the light beams to be combined in the interferometer. By using a single mode waveguide before detection, wavefront errors are filtered and a virtually perfect plane wavefront is obtained. In this paper the results on the development and the optical characterisation of suitable infrared transmitting chalcogenide glasses and mid-IR guiding optical fibers are reported. Two different perform techniques for manufacturing core-cladding chalcogenide fibers are described. Two types of step index fibers, prepared with Te(2)As(3)Se(5) chalcogenide glasses, offer single mode guidance at 10.6 mum.

Association of low plasma Abeta42/Abeta40 ratios with increased imminent risk for mild cognitive impairment and Alzheimer disease

BACKGROUND

To develop preventive therapy for Alzheimer disease (AD), it is essential to develop AD-related biomarkers that identify at-risk individuals in the same way that cholesterol levels identify persons at risk for heart disease.

OBJECTIVE

To determine whether plasma levels of amyloid beta protein (Abeta40 and Abeta42) are useful for identifying cognitively normal elderly white subjects at increased risk for mild cognitive impairment (MCI) and AD.

DESIGN

Using well-established sandwich enzyme-linked immunosorbent assays, plasma Abeta40 and Abeta42 levels were analyzed at baseline in a prospective, elderly white cohort followed up for 2 to 12 (median, 3.7) years to detect incident cases of MCI or AD.

SETTING

Cognitively normal, community-based white volunteers recruited from primary care settings into the Mayo Rochester Alzheimer Disease Patient Registry. Patients We followed up 563 cognitively normal white volunteers (median age, 78 years; 62% female) who had at least 1 follow-up visit after measurement of baseline plasma Abeta levels.

MAIN OUTCOME MEASURES

The primary outcome was time to development of MCI or AD. The secondary outcome was the annualized rate of cognitive change in patients for whom we had 2 Mattis Dementia Rating Scale evaluations 3 to 7 years apart.

RESULTS

During follow-up, 53 subjects developed MCI or AD. Subjects with plasma Abeta42/Abeta40 ratios in the lower quartiles showed significantly greater risk of MCI or AD (P = .04, adjusted for age and apolipoprotein E genotype). Comparison of subjects with plasma Abeta42/Abeta40 ratios in the lowest vs the highest quartile gave a relative risk of 3.1 (95% confidence interval, 1.1-8.3). After adjusting for age and apolipoprotein E genotype, regression analysis using annualized changes in the Dementia Rating Scale scores as an outcome variable showed that participants with lower Abeta42/Abeta40 ratios had greater cognitive decline (P = .02).

CONCLUSION

The plasma Abeta42/Abeta40 ratio may be a useful premorbid biomarker for identifying cognitively normal elderly white subjects who are at increased risk for developing MCI or AD.

Cardiac arrest on the links: are we up to par? Availability of automated external defibrillators on golf courses in southeastern Pennsylvania

OBJECTIVES

A growing number of golfers are senior citizens, and it may be predicted that the number of golf-related medical emergencies, including the incidence of cardiac arrest, will increase. This study was designed to survey the level of preparedness of golf courses in southeastern Pennsylvania to respond to cardiac arrest among their members.

METHODS

A telephone survey of all of the 180 golf courses in the area was conducted to determine their type (public/private), volume in rounds per year, presence of automated external defibrillator (AED) devices, number of employees, and percentage of employees with cardiopulmonary resuscitation (CPR) training. Participants also were asked to estimate the time needed to reach the farthest point on their course in order to estimate a maximum time to the application of an AED device.

RESULTS

A total of 131 of 180 golf courses completed the survey (53 private, 78 public) for an overall response rate of 73%. Private courses reported a greater average number of employees with CPR training [private = 9.1, public = 3.6; p = 0.001] and in AED presence [public = 9%, private = 58.5%; p = 0.0001]. Public courses support a higher volume of play than do private courses [public = 32,000, private = 24,000; p = 0.001], yet have far fewer employees [public=25, private=44; p = 0.004]. The longest time necessary to reach the most remote point on the course was between four and five minutes in all courses. Analysis was performed using the Student's t-test and Pearson's Chi-square as appropriate.

CONCLUSION

Neither public nor private golf courses are well equipped to respond to cardiac arrest, but outcomes on public courses likely are to be far worse.

Safety Climate Survey: reliability of results from a multicenter ICU survey

BACKGROUND

It is important to understand the clinical properties of instruments used to measure patient safety before they are used in the setting of an intensive care unit (ICU).

METHODS

The Safety Climate Survey (SCSu), an instrument endorsed by the Institute for Healthcare Improvement, the Safety Culture Scale (SCSc), and the Safety Climate Mean (SCM), a subset of seven items from the SCSu, were administered in four Canadian university affiliated ICUs. All staff including nurses, allied healthcare professionals, non-clinical staff, intensivists, and managers were invited to participate in the cross sectional survey.

RESULTS

The response rate was 74% (313/426). The internal consistency of the SCSu and SCSc was 0.86 and 0.80, respectively, while the SCM performed poorly at 0.51. Because of poor internal consistency, no further analysis of the SCM was therefore performed. Test-retest reliability of the SCSu and SCSc was 0.92. Out of a maximum score of 5, the mean (SD) scores of the SCSu and SCSc were 3.4 (0.6) and 3.4 (0.7), respectively. No differences were noted between the three medical-surgical and one cardiovascular ICU. Managers perceived a significantly more positive safety climate than other staff, as measured by the SCSu and SCSc. These results need to be interpreted cautiously because of the small number of management participants.

CONCLUSIONS

Of the three instruments, the SCSu and SCSc appear to be measuring one construct and are sufficiently reliable. Future research should examine the properties of patient safety instruments in other ICUs, including responsiveness to change, to ensure that they are valid outcome measures for patient safety initiatives.

Agrobacterium tumefaciens-mediated transformation of Leptosphaeria spp. and Oculimacula spp. with the reef coral gene DsRed and the jellyfish gene gfp

Four filamentous ascomycetes, Leptosphaeria maculans, L. biglobosa, Oculimacula yallundae and O. acuformis, were transformed via Agrobacterium tumefaciens-mediated transformation with the genes encoding DsRed and GFP. Using vectors pCAMDsRed and pCAMBgfp, either germinated conidia of Leptosphaeria spp. and O. yallundae or physically fragmented cultures of Oculimacula spp. were transformed. In vitro, the expression of the two reporter proteins in mycelium of both Oculimacula and both Leptosphaeria species was sufficient to distinguish each species in co-inoculated cultures. In planta, transformants of L. maculans or L. biglobosa expressing DsRed or GFP could be observed together in leaves of Brassica napus. Either reporter protein could be used to view the colonization of leaf petioles by both Leptosphaeria spp. and growth in the xylem vessels could be clearly observed. With the generation of these transformants, further studies on interactions between pathogen species involved in disease complexes on various host species and between opposite mating types of the same species are now possible.

Cardiovascular phenotyping of fetal mice by noninvasive high-frequency ultrasound facilitates recovery of ENU-induced mutations causing congenital cardiac and extracardiac defects

As part of a large-scale noninvasive fetal ultrasound screen to recover ethylnitrosourea (ENU)-induced mutations causing congenital heart defects in mice, we established a high-throughput ultrasound scanning strategy for interrogating fetal mice in utero utilizing three orthogonal imaging planes defined by the fetus’ vertebral column and body axes, structures readily seen by ultrasound. This contrasts with the difficulty of acquiring clinical ultrasound imaging planes which are defined by the fetal heart. By use of the three orthogonal imaging planes for two-dimensional (2D) imaging together with color flow, spectral Doppler, and M-mode imaging, all of the major elements of the heart can be evaluated. In this manner, 10,091 ENU-mutagenized mouse fetuses were ultrasound scanned between embryonic days 12.5 and 19.5, with 324 fetuses found to die prenatally and 425 exhibiting cardiovascular defects. Further analysis by necropsy and histology showed heart defects that included conotruncal anomalies, obstructive lesions, and shunt lesions as well as other complex heart diseases. Ultrasound imaging also identified craniofacial/head defects and body wall closure defects, which necropsy revealed as encephalocele, holoprosencephaly, omphalocele, or gastroschisis. Genome scanning mapped one ENU-induced mutation associated with persistence truncus arteriosus and holoprosencephaly to mouse chromosome 2, while another mutation associated with cardiac defects and omphalocele was mapped to mouse chromosome 17. These studies show the efficacy of this novel ultrasound scanning strategy for noninvasive ultrasound phenotyping to facilitate the recovery of ENU-induced mutations causing congenital heart defects and other extracardiac anomalies.

Tocolyse par la nifédipine. Utilisation en pratique courante

OBJECTIVES

To assess tocolysis with nifedipine in preterm labour during actual clinical practice in terms of efficacy and safety.

PATIENTS AND METHODS

Retrospective observational study during two years including preterm labour between 26 and 33+6 weeks of amenorrhea. Preterm labour was defined by the presence of three or more uterine contractions in 10 minutes associated to cervical modifications diagnosed by vaginal sonography (length<or=25 mm). Patients were excluded if they had more than two fetuses or other gestational pathologies. Tocolysis resulted in oral taking of 30 mg of nifedipine (3x10 mg) with continuous follow-up of blood pressure. Tocolysis was modified when contractions did not disappear. Success was defined when delivery was delayed more than 48 hours. Failure was defined either by a delivery occurring in the first two days of tocolysis or when a modification of treatment was required.

RESULTS

Fifty-eight patients were included, 10 of whom having a twin pregnancy. Success was obtained in 84% of patients (49/58). All of these women did not deliver during the first seven days after introduction of tocolysis. Five patients delivered in the first two days after tocolysis and four others required a change in tocolysis. Mean gestational age at delivery was 37+5 weeks and 35 weeks for single and twin pregnancies, respectively. No maternal or fetal side effects were described.

DISCUSSION AND CONCLUSION

Nifedipine could be prescribed for tocolysis in actual clinical practice because it seems to have safety and excellent tolerance.

Haemorrhage from small bowel ulceration complicating meningococcal septicaemia

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