Validity of the brief inpatient screen for intimate partner violence among adult women

BACKGROUND

Identifying intimate partner violence in healthcare settings is becoming the standard of care. The Brief Inpatient Screen was designed to assess recent emotional, physical, and sexual abuse in a general inpatient medical-surgical setting and compared to the Composite Abuse Scale.

METHODS

Researchers matched "cases" (inpatients screening Brief Inpatient Screen-positive) to up to four "controls" (inpatients screening Brief Inpatient Screen-negative). Forty-six female hospital inpatients ages 18-64 years completed a self-administered survey. The sensitivity and specificity of the Brief Inpatient Screen and its subscales were compared to the Composite Abuse Scale. Researchers examined the performance of the Brief Inpatient Screen when used as a verbal screen versus an anonymous written screen.

RESULTS

Twelve of 46 participants (26%) had a positive screen. Compared to the Composite Abuse Scale, the overall sensitivity and specificity of the verbal Brief Inpatient Screen were 52.6% (95% CI 28.9-75.6) and 92.6% (95% CI 75.7-99.1), respectively. The written Brief Inpatient Screen showed improved sensitivity overall (68.4%, 95% CI 43.5-87.4) for the most severe intimate partner violence. Subscale analysis revealed greater sensitivity for emotional and severe combined intimate partner violence.

CONCLUSIONS

The verbal Brief Inpatient Screen, when compared to the Composite Abuse Scale, was limited in its ability to identify intimate partner violence. An anonymous written format improved sensitivity. Future research should optimize intimate partner violence screening among inpatients.

Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial

CONTEXT

No consensus exists for adjusting inhaled corticosteroid therapy in patients with asthma. Approaches include adjustment at outpatient visits guided by physician assessment of asthma control (symptoms, rescue therapy, pulmonary function), based on exhaled nitric oxide, or on a day-to-day basis guided by symptoms.

OBJECTIVE

To determine if adjustment of inhaled corticosteroid therapy based on exhaled nitric oxide or day-to-day symptoms is superior to guideline-informed, physician assessment-based adjustment in preventing treatment failure in adults with mild to moderate asthma.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, parallel, 3-group, placebo-controlled, multiply-blinded trial of 342 adults with mild to moderate asthma controlled by low-dose inhaled corticosteroid therapy (n = 114 assigned to physician assessment-based adjustment [101 completed], n = 115 to biomarker-based [exhaled nitric oxide] adjustment [92 completed], and n = 113 to symptom-based adjustment [97 completed]), the Best Adjustment Strategy for Asthma in the Long Term (BASALT) trial was conducted by the Asthma Clinical Research Network at 10 academic medical centers in the United States for 9 months between June 2007 and July 2010.

INTERVENTIONS

For physician assessment-based adjustment and biomarker-based (exhaled nitric oxide) adjustment, the dose of inhaled corticosteroids was adjusted every 6 weeks; for symptom-based adjustment, inhaled corticosteroids were taken with each albuterol rescue use.

MAIN OUTCOME MEASURE

The primary outcome was time to treatment failure.

RESULTS

There were no significant differences in time to treatment failure. The 9-month Kaplan-Meier failure rates were 22% (97.5% CI, 14%-33%; 24 events) for physician assessment-based adjustment, 20% (97.5% CI, 13%-30%; 21 events) for biomarker-based adjustment, and 15% (97.5% CI, 9%-25%; 16 events) for symptom-based adjustment. The hazard ratio for physician assessment-based adjustment vs biomarker-based adjustment was 1.2 (97.5% CI, 0.6-2.3). The hazard ratio for physician assessment-based adjustment vs symptom-based adjustment was 1.6 (97.5% CI, 0.8-3.3).

CONCLUSION

Among adults with mild to moderate persistent asthma controlled with low-dose inhaled corticosteroid therapy, the use of either biomarker-based or symptom-based adjustment of inhaled corticosteroids was not superior to physician assessment-based adjustment of inhaled corticosteroids in time to treatment failure.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00495157.

Key observations from the NHLBI Asthma Clinical Research Network

The National Heart, Lung and Blood Institute (NHLBI) Asthma Clinical Research Network (ACRN) recently completed its work after 20 years of collaboration as a multicentre clinical trial network. When formed, its stated mission was to perform multiple controlled clinical trials for treating patients with asthma by dispassionately examining new and existing therapies, and to rapidly communicate its findings to the medical community. The ACRN conducted 15 major clinical trials. In addition, clinical data, manual of operations, protocols and template informed consents from all ACRN trials are available via NHLBI BioLINCC (https://biolincc.nhlbi.nih.gov/studies/). This network contributed major insights into the use of inhaled corticosteroids, short-acting and long-acting ß-adrenergic agonists, leukotriene receptor antagonists, and novel agents (tiotropium, colchicine and macrolide antibiotics). They also pioneered studies of the variability in drug response, predictors of treatment response and pharmacogenetics. This review highlights the major research observations from the ACRN that have impacted the current management of asthma.

Perceptions of anatomy: critical components in the clinical setting

The evolution in undergraduate medical school curricula has significantly impacted anatomy education. This study investigated the perceived role of clinical anatomy and evaluated perceptions of medical students' ability to apply anatomical knowledge in the clinic. The aim of this study was to develop a framework to enhance anatomical educational initiatives. Unlike previous work, multiple stakeholders (clinicians, medical students, and academic anatomists) in anatomy education were evaluated. Participants completed an eleven-point Likert scale survey written by the investigators. Responses from both clinical educators and medical students at Penn State Milton S. Hershey Medical Center and College of Medicine suggest that medical students are perceived as ill-prepared to transfer anatomy to the clinic. Although some areas of patient management differ in relevancy to anatomical education, there are areas of clinical care which were uniformly ranked as relying heavily on anatomical knowledge (imaging and diagnostic studies, physical examination, and arrival at correct diagnosis) by a variety of clinical specialists. Our results suggest a need for advanced anatomy courses to be taught coincidental with medical students' clinical education. Development of these courses would optimally rely on input from both clinicians and academic anatomists, as both cohorts rated clinical anatomy similarly (P ≥ 0.05). Additionally, we hypothesize that preclinical students' application of anatomy would be enhanced if clinical context was derived from areas of clinical care which rely heavily on anatomy, whereas courses designed for advanced medical students will benefit from anatomical context focused on specialty specific aspects of clinical care identified in this study.

Why do medical students choose orthopaedics as a career?

BACKGROUND

The primary influence on medical students' career choice is their third-year clerkship. However, orthopaedics is not a required rotation in the curriculum of most medical schools. Our goals were to identify factors that motivate students to choose an orthopaedic career and to compare these with the factors that influence students to choose nonorthopaedic disciplines.

METHODS

Fourth-year medical students and orthopaedic residents at the postgraduate year (PGY)-1 level at eight orthopaedic training programs in the United States were surveyed to determine the reasons that they chose orthopaedics instead of other medical or surgical fields.

RESULTS

Of the 622 individuals who responded to our survey, 125 were entering orthopaedics and 497 were not. Although career choice in both groups was most heavily influenced by third and fourth-year clinical rotations and faculty contacts, orthopaedics-bound respondents were more likely than non-orthopaedics-bound respondents to be strongly influenced by experiences and people prior to medical school. Orthopaedics-bound respondents were less likely to report a faculty member as the most important person influencing career choice. Fifty-one percent (sixty-three) of 124 students who selected orthopaedics had already decided to pursue this field prior to their third-year rotation. Patient care was chosen by 71% (347) of 490 non-orthopaedics-bound respondents and 75% (ninety-four) of 125 orthopaedics-bound respondents as the most important factor for pursuing a particular field. Income was not selected as the deciding factor by respondents in either group.

CONCLUSIONS

Although faculty contacts and third-year clinical rotations played an important role in student selection of specialty training, they were less influential for those choosing an orthopaedic career than for those choosing other disciplines. Many students choosing orthopaedics made this decision prior to medical school. We believe that increased exposure to positive clinical role models and experiences during medical school would enhance medical students' options for choosing orthopaedic surgery as a career. Anticipated income did not play a deciding role in career selection.

Performance of a malaria microscopy image analysis slide reading device

Background

Viewing Plasmodium in Romanovsky-stained blood has long been considered the gold standard for diagnosis and a cornerstone in management of the disease. This method however, requires a subjective evaluation by trained, experienced diagnosticians and establishing proficiency of diagnosis is fraught with many challenges. Reported here is an evaluation of a diagnostic system (a “device” consisting of a microscope, a scanner, and a computer algorithm) that evaluates scanned images of standard Giemsa-stained slides and reports species and parasitaemia.

Methods

The device was challenged with two independent tests: a 55 slide, expert slide reading test the composition of which has been published by the World Health Organization (“WHO55” test), and a second test in which slides were made from a sample of consenting subjects participating in a malaria incidence survey conducted in Equatorial Guinea (EGMIS test). These subjects’ blood was tested by malaria RDT as well as having the blood smear diagnosis unequivocally determined by a worldwide panel of a minimum of six reference microscopists. Only slides with unequivocal microscopic diagnoses were used for the device challenge, n = 119.

Results

On the WHO55 test, the device scored a “Level 4” using the WHO published grading scheme. Broken down by more traditional analysis parameters this result was translated to 89% and 70% sensitivity and specificity, respectively. Species were correctly identified in 61% of the slides and the quantification of parasites fell within acceptable range of the validated parasitaemia in 10% of the cases. On the EGMIS test it scored 100% and 94% sensitivity/specificity, with 64% of the species correct and 45% of the parasitaemia within an acceptable range. A pooled analysis of the 174 slides used for both tests resulted in an overall 92% sensitivity and 90% specificity with 61% species and 19% quantifications correct.

Conclusions

In its current manifestation, the device performs at a level comparable to that of many human slide readers. Because its use requires minimal additional equipment and it uses standard stained slides as starting material, its widespread adoption may eliminate the current uncertainty about the quality of microscopic diagnoses worldwide.

Genome-wide association identifies the T gene as a novel asthma pharmacogenetic locus

RATIONALE

To date, most studies aimed at discovering genetic factors influencing treatment response in asthma have focused on biologic candidate genes. Genome-wide association studies (GWAS) can rapidly identify novel pharmacogenetic loci.

OBJECTIVES

To investigate if GWAS can identify novel pharmacogenetic loci in asthma.

METHODS

Using phenotypic and GWAS genotype data available through the NHLBI-funded Single-nucleotide polymorphism Health association-Asthma Resource Project, we analyzed differences in FEV(1) in response to inhaled corticosteroids in 418 white subjects with asthma. Of the 444,088 single nucleotide polymorphisms (SNPs) analyzed, the lowest 50 SNPs by P value were genotyped in an independent clinical trial population of 407 subjects with asthma.

MEASUREMENTS AND MAIN RESULTS

The lowest P value for the GWAS analysis was 2.09 × 10(-6). Of the 47 SNPs successfully genotyped in the replication population, three were associated under the same genetic model in the same direction, including two of the top four SNPs ranked by P value. Combined P values for these SNPs were 1.06 × 10(-5) for rs3127412 and 6.13 × 10(-6) for rs6456042. Although these two were not located within a gene, they were tightly correlated with three variants mapping to potentially functional regions within the T gene. After genotyping, each T gene variant was also associated with lung function response to inhaled corticosteroids in each of the trials associated with rs3127412 and rs6456042 in the initial GWAS analysis. On average, there was a twofold to threefold difference in FEV(1) response for those subjects homozygous for the wild-type versus mutant alleles for each T gene SNP.

CONCLUSIONS

Genome-wide association has identified the T gene as a novel pharmacogenetic locus for inhaled corticosteroid response in asthma.

Design of clinical trials in AKI: a report from an NIDDK workshop. Trials of patients with sepsis and in selected hospital settings

AKI remains an important clinical problem, with a high mortality rate, increasing incidence, and no Food and Drug Administration-approved therapeutics. Advances in addressing this clinical need require approaches for rapid diagnosis and stratification of injury, development of therapeutic agents based on precise understanding of key pathophysiological events, and implementation of well designed clinical trials. In the near future, AKI biomarkers may facilitate trial design. To address these issues, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a meeting, "Clinical Trials in Acute Kidney Injury: Current Opportunities and Barriers," in December of 2010 that brought together academic investigators, industry partners, and representatives from the National Institutes of Health and the Food and Drug Administration. Important issues in the design of clinical trials for interventions in AKI in patients with sepsis or AKI in the setting of critical illness after surgery or trauma were discussed. The sepsis working group discussed use of severity of illness scores and focus on patients with specific etiologies to enhance homogeneity of trial participants. The group also discussed endpoints congruent with those endpoints used in critical care studies. The second workgroup emphasized difficulties in obtaining consent before admission and collaboration among interdisciplinary healthcare groups. Despite the difficult trial design issues, these clinical situations represent a clinical opportunity because of the high event rates, severity of AKI, and poor outcomes. The groups considered trial design issues and discussed advantages and disadvantages of several short- and long-term primary endpoints in these patients.

Design of clinical trials in acute kidney injury: a report from an NIDDK workshop--prevention trials

AKI is an important clinical problem that has become increasingly more common. Mortality rates associated with AKI remain high despite advances in supportive care. Patients surviving AKI have increased long-term mortality and appear to be at increased risk of developing CKD and progressing to ESRD. No proven effective pharmacologic therapies are currently available for the prevention or treatment of AKI. Advances in addressing this unmet need will require the development of novel therapeutic agents based on precise understanding of key pathophysiological events and the implementation of well designed clinical trials. To address this need, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored the "Clinical Trials in Acute Kidney Injury: Current Opportunities and Barriers" workshop in December 2010. The event brought together representatives from academia, industry, the National Institutes of Health, and the US Food and Drug Administration. We report the discussions of workgroups that developed outlines of clinical trials for the prevention of AKI in two patient populations: patients undergoing elective surgery who are at risk for or who develop AKI, and patients who are at risk for contrast-induced AKI. In both of these populations, primary prevention or secondary therapy can be delivered at an optimal time relative to kidney injury. The workgroups detailed primary and secondary endpoints for studies in these groups, and explored the use of adaptive clinical trial designs for trials of novel preventive strategies to improve outcomes of patients with AKI.

Design of clinical trials in acute kidney injury: report from an NIDDK workshop on trial methodology

Acute kidney injury (AKI) remains a complex clinical problem associated with significant short-term morbidity and mortality and lacking effective pharmacologic interventions. Patients with AKI experience longer-term risks for progressive chronic ESRD, which diminish patients' health-related quality of life and create a larger burden on the healthcare system. Although experimental models have yielded numerous promising agents, translation into clinical practice has been unsuccessful, possibly because of issues in clinical trial design, such as delayed drug administration, masking of therapeutic benefit by adverse events, and inadequate sample size. To address issues of clinical trial design, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a workshop titled "Clinical Trials in Acute Kidney Injury: Current Opportunities and Barriers" in December 2010. Workshop participants included representatives from academia, industry, and government agencies whose areas of expertise spanned basic science, clinical nephrology, critical care medicine, biostatistics, pharmacology, and drug development. This document summarizes the discussions of collaborative workgroups that addressed issues related to patient selection, study endpoints, the role of novel biomarkers, sample size and power calculations, and adverse events and pilot/feasibility studies in prevention and treatment of AKI. Companion articles outline the discussions of workgroups for model trials related to prevention or treatment of established AKI in different clinical settings, such as in patients with sepsis.

A large subgroup of mild-to-moderate asthma is persistently noneosinophilic

RATIONALE

Airway eosinophilia is typical of asthma, and many controller treatments target eosinophilic disease. Asthma is clinically heterogeneous, however, and a subgroup of people with asthma do not have airway eosinophilia. The size of this subgroup is uncertain because prior studies have not examined repeated measures of sputum cytology to determine when people with asthma have intermittent versus persistent sputum eosinophila and when they are persistently noneosinophilic.

OBJECTIVES

To determine the prevalence and clinical characteristics of the noneosinophilic asthma phenotype.

METHODS

We analyzed sputum cytology data from 995 subjects with asthma enrolled in clinical trials in the Asthma Clinical Research Network where they had undergone sputum induction and measures of sputum cytology, often repeatedly, and assessment of responses to standardized asthma treatments.

MEASUREMENTS AND MAIN RESULTS

In cross-sectional analyses, sputum eosinophilia (≥2% eosinophils) was found in only 36% of subjects with asthma not taking an inhaled corticosteroid (ICS) and 17% of ICS-treated subjects with asthma; an absence of eosinophilia was noted frequently, even in subjects with asthma whose disease was suboptimally controlled. In repeated measures analyses of people with asthma not taking an ICS, 22% of subjects had sputum eosinophilia on every occasion (persistent eosinophilia); 31% had eosinophilia on at least one occasion (intermittent eosinophilia); and 47% had no eosinophilia on every occasion (persistently noneosinophilic). Two weeks of combined antiinflammatory therapy caused significant improvements in airflow obstruction in eosinophilic asthma, but not in persistently noneosinophilic asthma. In contrast, bronchodilator responses to albuterol were similar in eosinophilic and noneosinophilic asthma.

CONCLUSIONS

Approximately half of patients with mild-to-moderate asthma have persistently noneosinophilic disease, a disease phenotype that responds poorly to currently available antiinflammatory therapy.

Lead, calcium uptake, and related genetic variants in association with renal cell carcinoma risk in a cohort of male Finnish smokers

BACKGROUND

Lead is classified as a probable human carcinogen. However, its role in renal cell cancer (RCC) has not been established. Calcium and vitamin D may off-set toxicity in vivo.

METHODS

In this nested case-control study, whole blood lead, total serum calcium, and serum 25-hydroxyvitamin D levels were measured in blood drawn prior to diagnosis among male smokers participating in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. Single-nucleotide polymorphisms (SNP) in five genes (CALB1, TRPV5, TRPV6, VDR, and ALAD) related to lead toxicity or calcium transport were genotyped. Logistic and linear regressions were used to determine RCC risk and time to diagnosis (respectively), adjusting for other risk factors.

RESULTS

Among 154 newly diagnosed cases and 308 matched controls, RCC was associated with higher whole blood lead [OR = 2.0; 95% confidence interval (CI), 1.0-3.9; quartile 4 (Q4) vs. Q1, P(trend) = 0.022] and CALB1 rs1800645 (P(trend) = 0.025, minor 'T' allele frequency = 0.34). Higher total serum calcium (P(trend) ≤ 0.001) was associated with reduced RCC risk. Total serum calcium and 25-hydroxyvitamin D levels did not alter the association observed with lead. Time from enrollment to RCC diagnosis was positively associated with serum calcium (P(trend) = 0.002) and 25-hydroxyvitamin D (P(trend) = 0.054) among cases.

CONCLUSIONS

Higher blood lead concentrations, below the 10 μg/dL level of concern, were associated with RCC, independent from serum calcium and CALB1 promoter polymorphism.

IMPACT

Increased risk of RCC is associated with lower serum calcium and higher whole blood lead in smokers. The clinical prognostic value of serum calcium and vitamin D in RCC should be further investigated.

Impact of race on asthma treatment failures in the asthma clinical research network

RATIONALE

Recent studies suggest that people with asthma of different racial backgrounds may respond differently to various therapies.

OBJECTIVES

To use data from well-characterized participants in prior Asthma Clinical Research Network (ACRN) trials to determine whether racial differences affected asthma treatment failures.

METHODS

We analyzed baseline phenotypes and treatment failure rates (worsening asthma resulting in systemic corticosteroid use, hospitalization, emergency department visit, prolonged decrease in peak expiratory flow, increase in albuterol use, or safety concerns) in subjects participating in 10 ACRN trials (1993-2003). Self-declared race was reported in each trial and treatment failure rates were stratified by race.

MEASUREMENTS AND MAIN RESULTS

A total of 1,200 unique subjects (whites = 795 [66%]; African Americans = 233 [19%]; others = 172 [14%]; mean age = 32) were included in the analyses. At baseline, African Americans had fewer asthma symptoms (P < 0.001) and less average daily rescue inhaler use (P = 0.007) than whites. There were no differences in baseline FEV(1) (% predicted); asthma quality of life; bronchial hyperreactivity; or exhaled nitric oxide concentrations. A total of 147 treatment failures were observed; a significantly higher proportion of African Americans (19.7%; n = 46) experienced a treatment failure compared with whites (12.7%; n = 101) (odds ratio = 1.7; 95% confidence interval, 1.2-2.5; P = 0.007). When stratified by treatment, African Americans receiving long-acting β-agonists were twice as likely as whites to experience a treatment failure (odds ratio = 2.1; 95% confidence interval, 1.3-3.6; P = 0.004), even when used with other controller therapies.

CONCLUSIONS

Despite having fewer asthma symptoms and less rescue β-agonist use, African-Americans with asthma have more treatment failures compared with whites, especially when taking long-acting β-agonists.

Daily or intermittent budesonide in preschool children with recurrent wheezing

BACKGROUND

Daily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations, as indicated by a positive value on the modified asthma predictive index (API) and an exacerbation in the preceding year, but concern remains about daily adherence and effects on growth. We compared daily therapy with intermittent therapy.

METHODS

We studied 278 children between the ages of 12 and 53 months who had positive values on the modified API, recurrent wheezing episodes, and at least one exacerbation in the previous year but a low degree of impairment. Children were randomly assigned to receive a budesonide inhalation suspension for 1 year as either an intermittent high-dose regimen (1 mg twice daily for 7 days, starting early during a predefined respiratory tract illness) or a daily low-dose regimen (0.5 mg nightly) with corresponding placebos. The primary outcome was the frequency of exacerbations requiring oral glucocorticoid therapy.

RESULTS

The daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations, with a rate per patient-year for the daily regimen of 0.97 (95% confidence interval [CI], 0.76 to 1.22) versus a rate of 0.95 (95% CI, 0.75 to 1.20) for the intermittent regimen (relative rate in the intermittent-regimen group, 0.99; 95% CI, 0.71 to 1.35; P=0.60). There were also no significant between-group differences in several other measures of asthma severity, including the time to the first exacerbation, or adverse events. The mean exposure to budesonide was 104 mg less with the intermittent regimen than with the daily regimen.

CONCLUSIONS

A daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations. Daily administration led to greater exposure to the drug at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; MIST ClinicalTrials.gov number, NCT00675584.).

A conceptual framework for pharmacodynamic genome-wide association studies in pharmacogenomics

Genome-wide association studies (GWAS) have emerged as a powerful tool to identify loci that affect drug response or susceptibility to adverse drug reactions. However, current GWAS based on a simple analysis of associations between genotype and phenotype ignores the biochemical reactions of drug response, thus limiting the scope of inference about its genetic architecture. To facilitate the inference of GWAS in pharmacogenomics, we sought to undertake the mathematical integration of the pharmacodynamic (PD) process of drug reactions through computational models. By estimating and testing the genetic control of PD and pharmacokinetic (PK) parameters, this mechanistic approach does not only enhance the biological and clinical relevance of significant genetic associations, but also improve the statistical power and robustness of gene detection. This report discusses the general principle and development of PDs-based GWAS, highlights the practical use of this approach in addressing various pharmacogenomic problems, and suggests that this approach will be an important method to study the genetic architecture of drug responses or reactions.

Genetic Ancestry, Skin Reflectance and Pigmentation Genotypes in Association with Serum Vitamin D Metabolite Balance

BACKGROUND

Lower serum vitamin D (25(OH)D) among individuals with African ancestry is attributed primarily to skin pigmentation. However, the influence of genetic polymorphisms controlling for skin melanin content has not been investigated. Therefore, we investigated differences in non-summer serum vitamin D metabolites according to self-reported race, genetic ancestry, skin reflectance and key pigmentation genes (SLC45A2 and SLC24A5).

MATERIALS AND METHODS

Healthy individuals reporting at least half African American or half European American heritage were frequency matched to one another on age (+/- 2 years) and sex. 176 autosomal ancestry informative markers were used to estimate genetic ancestry. Melanin index was measured by reflectance spectrometry. Serum vitamin D metabolites (25(OH)D₃, 25(OH)D ₂ and 24,25(OH)₂D₃) were determined by high performance liquid chromatography (HPLC) tandem mass spectrometry. Percent 24,25(OH)₂D₃ was calculated as a percent of the parent metabolite (25(OH)D₃). Stepwise and backward selection regression models were used to identify leading covariates.

RESULTS

Fifty African Americans and 50 European Americans participated in the study. Compared with SLC24A5 111^Thr homozygotes, individuals with the SLC24A5 111^Thr/Ala and 111^Ala/Ala genotypes had respectively lower levels of 25(OH)D₃ (23.0 and 23.8 nmol/L lower, p-dominant=0.007), and percent 24,25(OH)₂D₃ (4.1 and 5.2 percent lower, p-dominant=0.003), controlling for tanning bed use, vitamin D/fish oil supplement intake, race/ethnicity, and genetic ancestry. Results were similar with melanin index adjustment, and were not confounded by glucocorticoid, oral contraceptive, or statin use.

CONCLUSIONS

The SLC24A5 111^Ala allele was associated with lower serum vitamin 25(OH)D₃ and lower percent 24,25(OH)₂D₃, independently from melanin index and West African genetic ancestry.

High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players

BACKGROUND

Prior retrospective studies have reported magnetic resonance imaging (MRI) findings of common adductor-abdominal rectus enthesopathy and acetabular labral tear in athletes treated for athletic pubalgia and hip pain. The true prevalence of these findings and association with symptoms in this population is unknown.

PURPOSE

This study was undertaken to determine the prevalence of pelvic and hip MRI findings and association with clinical symptoms in professional and collegiate hockey players.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The study included 21 professional and 18 collegiate hockey players. Self-reported symptoms were measured using a modified Oswestry Disability Questionnaire. Participants underwent 3-T MRI evaluation of the pelvis and hips. The MRI scans were interpreted independently by 3 musculoskeletal radiologists in 2 sessions separated by 3 months using a 5-point Likert scale to assess for features associated with common adductor-abdominal rectus dysfunction and hip pathology. To estimate prevalence, MRI findings rated 4 or higher on 4 of the 6 interpretations were considered positive. A variance component analysis was applied to determine intrareader and interreader reliability and the lower 95% confidence limits (CLs).

RESULTS

No participants reported symptoms related to pelvic or hip disorders. The MRI findings of common adductor-abdominal rectus dysfunction were observed in 14 of 39 participants (36%) and hip pathologic changes in 25 of 39 (64%). There was moderate agreement between readings, with intrareader and interreader reliabilities ranging from 0.37 to 1.00. The interreader reliability was less for evaluation of hip pathologic abnormalities than for groin pathologic abnormalities, with the lowest reliability observed in reporting of hip osteochondral lesions (0.37 with lower 95% CL of 0.22) and fluid in the primary cleft (0.45 with lower 95% CL of 0.29) and perfect reliability in the absence of effusion and abdominal rectus tendon tears. Overall, 30 of 39 (77%) asymptomatic hockey players demonstrated MRI findings of hip or groin pathologic abnormalities.

CONCLUSION

Given the high prevalence of MRI findings in asymptomatic hockey players, it is necessary to cautiously interpret the significance of these findings in association with clinical presentation. Future investigations will determine whether these asymptomatic findings predict future disabilities.

Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Daily inhaled corticosteroids are an effective treatment for mild persistent asthma, but some children have exacerbations even with good day-to-day control, and many discontinue treatment after becoming asymptomatic. We assessed the effectiveness of an inhaled corticosteroid (beclomethasone dipropionate) used as rescue treatment.

METHODS

In this 44-week, randomised, double-blind, placebo-controlled trial we enrolled children and adolescents with mild persistent asthma aged 5-18 years from five clinical centres in the USA. A computer-generated randomisation sequence, stratified by clinical centre and age group, was used to randomly assign participants to one of four treatment groups: twice daily beclomethasone with beclomethasone plus albuterol as rescue (combined group); twice daily beclomethasone with placebo plus albuterol as rescue (daily beclomethasone group); twice daily placebo with beclomethasone plus albuterol as rescue (rescue beclomethasone group); and twice daily placebo with placebo plus albuterol as rescue (placebo group). Twice daily beclomethasone treatment was one puff of beclomethasone (40 μg per puff) or placebo given in the morning and evening. Rescue beclomethasone treatment was two puffs of beclomethasone or placebo for each two puffs of albuterol (180 μg) needed for symptom relief. The primary outcome was time to first exacerbation that required oral corticosteroids. A secondary outcome measured linear growth. Analysis was by intention to treat. This study is registered with clinicaltrials.gov, number NCT00394329.

RESULTS

843 children and adolescents were enrolled into this trial, of whom 288 were assigned to one of four treatment groups; combined (n=71), daily beclomethasone (n=72), rescue beclomethasone (n=71), and placebo (n=74)-555 individuals were excluded during the run-in, according to predefined criteria. Compared with the placebo group (49%, 95% CI 37-61), the frequency of exacerbations was lower in the daily (28%, 18-40, p=0·03), combined (31%, 21-43, p=0·07), and rescue (35%, 24-47, p=0·07) groups. Frequency of treatment failure was 23% (95% CI 14-43) in the placebo group, compared with 5·6% (1·6-14) in the combined (p=0·012), 2·8% (0-10) in the daily (p=0·009), and 8·5% (2-15) in the rescue (p=0·024) groups. Compared with the placebo group, linear growth was 1·1 cm (SD 0·3) less in the combined and daily arms (p<0·0001), but not the rescue group (p=0·26). Only two individuals had severe adverse events; one in the daily beclomethasone group had viral meningitis and one in the combined group had bronchitis.

INTERPRETATION

Children with mild persistent asthma should not be treated with rescue albuterol alone and the most effective treatment to prevent exacerbations is daily inhaled corticosteroids. Inhaled corticosteroids as rescue medication with albuterol might be an effective step-down strategy for children with well controlled, mild asthma because it is more effective at reducing exacerbations than is use of rescue albuterol alone. Use of daily inhaled corticosteroid treatment and related side-effects such as growth impairment can therefore be avoided.

FUNDING

National Heart, Lung and Blood Institute.

Matrix-based concordance correlation coefficient for repeated measures

In many clinical studies, Lin's concordance correlation coefficient (CCC) is a common tool to assess the agreement of a continuous response measured by two raters or methods. However, the need for measures of agreement may arise for more complex situations, such as when the responses are measured on more than one occasion by each rater or method. In this work, we propose a new CCC in the presence of repeated measurements, called the matrix-based concordance correlation coefficient (MCCC) based on a matrix norm that possesses the properties needed to characterize the level of agreement between two p× 1 vectors of random variables. It can be shown that the MCCC reduces to Lin's CCC when p= 1. For inference, we propose an estimator for the MCCC based on U-statistics. Furthermore, we derive the asymptotic distribution of the estimator of the MCCC, which is proven to be normal. The simulation studies confirm that overall in terms of accuracy, precision, and coverage probability, the estimator of the MCCC works very well in general cases especially when n is greater than 40. Finally, we use real data from an Asthma Clinical Research Network (ACRN) study and the Penn State Young Women's Health Study for demonstration.

Comparison of the ATS versus EU Mini Wright peak flow meter in normal volunteers

OBJECTIVES

The American Thoracic Society (ATS) and European Union (EU) have precise and accurate Mini Wright peak flow meters. The purpose of this investigation was to compare both 1) for accuracy using a pneumotachometer, 2) in volunteers to determine whether they are interchangeable, and 3) to spirometrically predicted peak flows.

METHODS

Lab testing: A pneumotachometer was connected in series with each peak flow meter and varying flows pushed through both meters for comparison. Human subjects: Nonsmoking adult volunteers did three standing peak flows. The order of peak flow meter used was random. The best of three efforts was used for analysis. The t-test, concordance correlation coefficient (CCC), Deming regression, and Bland-Altman plot were the analytic strategies used to determine agreement. Peak flow results were compared to spirometrically predicted values.

RESULTS

Fifty-seven volunteers, average age 37 ± 12 years and mean BMI 24.9 ± 2.5 years, were included. The average peak flows were different at 541 ± 114 and 526 ± 112 L/min for the ATS and EU meters, respectively (p < .01). Both peak flow meter values were significantly different than spirometrically predicted values of 483 ± 86 L/min (p < .01). The CCC was 0.98 (0.97-0.99) and regression revealed a slope and y-intercept consistent with 1 and 0, respectively. The Bland-Altman plot revealed no increase in scatter of values over the range of peak flows versus the difference with a mean bias of 15 ± 15 L/min. Laboratory testing revealed that the ATS and EU peak flow meters read 3.0 ± 2.1% above and -2.0 ± 1.5% below the comparison pneumotachometer, respectively. The pneumotachometer comparison was significantly different for both meters at p < .01, paired t-test.

CONCLUSIONS

The ATS peak flow meter reads 2.8% higher than the EU peak flow meter across a range of flows. Both meters have similar accuracy with a different bias compared with a pneumotachometer. Finally, both peak flow meters read slightly and significantly higher than spirometrically derived peak flows. Therefore, the peak flow meters are not interchangeable and both may obtain slightly higher values than those determined using current spirometrically derived prediction equations.