Ticagrelor vs Clopidogrel in Acute Myocardial Infarction Patients With a History of Ischemic Stroke

OBJECTIVE

To investigate whether use of ticagrelor compared to clopidogrel is associated with different risks for thrombotic events or major bleeding among acute myocardial infarction (AMI) patients with a prior history of acute ischemic stroke.

PATIENTS AND METHODS

This retrospective cohort study used the Health and Welfare Database in Taiwan. Stroke patients prescribed ticagrelor plus aspirin or clopidogrel plus aspirin after a primary hospitalization for AMI between July 1, 2013, and December 31, 2018, were included. Inverse probability of treatment weighting was applied to balance covariates between treatment groups. The primary effectiveness outcome included a composite measure of AMI, acute ischemic stroke, or all-cause mortality. The primary safety outcome included a composite measure of intracranial hemorrhage (ICH) and major gastrointestinal bleeding. The secondary effectiveness and safety outcomes comprised each of the individual components that make up the primary effectiveness and safety outcomes, respectively.

RESULTS

A total of 1691 eligible patients were included in the study, of whom 734 (43.4%) received ticagrelor plus aspirin and 957 received clopidogrel plus aspirin. There were no significant differences observed in the primary and secondary effectiveness outcomes between the two study groups. However, the use of ticagrelor was associated with a higher risk of ICH (ticagrelor: 8.68 per 1000 person-year; clopidogrel: 2.17 per 1,000 person-year; HR, 3.34; 95% CI, 1.27 to 8.81, P = .01) compared with clopidogrel.

CONCLUSION

In AMI patients with a history of acute ischemic stroke, the risks of cardiovascular events were comparable between ticagrelor plus aspirin and clopidogrel plus aspirin. However, ticagrelor was associated with a higher risk of ICH. Ticagrelor should be used cautiously in AMI patients with a history of acute ischemic stroke.

Telehealth use and perceptions among prostate cancer survivors

BACKGROUND

Reasons underlying disparities in telehealth use among cancer survivors are unknown.

METHODS

We surveyed a sociodemographically diverse population-based cohort of 487 prostate cancer survivors regarding their use and perceptions of telehealth during the COVID-19 pandemic.

RESULTS

Overall, only 28.5% of survivors had used telehealth at the time of survey and just 10% felt care through telehealth is comparable to that of an in-person visit. Still, over 55% felt telehealth is a good option for initial consultations or basic care and 15% felt more likely to use telehealth since the pandemic. After adjusting for other socioeconomic factors, survivors with lower education (≤high school vs. any college) had marginally lower use of telehealth (risk ratio [RR], 0.65 [95% CI, 0.42-1.01]) and lower probability of feeling more likely to use telehealth since the pandemic (RR, 0.39 [95% CI, 0.20-0.77]).

CONCLUSIONS

Differences in survivor perceptions of telehealth by education level highlight new insights underlying disparities in telehealth use and potential targets for interventions.

Income level and treatment selection in prostate cancer: analysis of a North Carolina population-based cohort

BACKGROUND/PURPOSE

Disparities in treatment selection based on socioeconomic status (SES) for prostate cancer exist. However, the association between patient-level income with treatment selection priorities and treatment received has not been studied.

METHODS

A population-based cohort of 1382 individuals with newly diagnosed prostate cancer was enrolled throughout North Carolina prior to treatment. Patients self-reported household income and were asked about the importance of 12 factors contributing to their treatment decision-making process. Diagnosis details and primary treatment received were abstracted from medical records and cancer registry data.

RESULTS

Patients with lower income were diagnosed with more advanced disease (p < .01). "Cure" was deemed to be "very important" by > 90% of patients at all income levels. However, patients with lower vs higher household income were more likely to rate factors beyond cure as "very important" such as "cost" (p < .01), "effect on daily activities" (p = .01), "duration of treatment" (p < .01), "recovery time" (p < .01), and "burden on family and friends" (p < .01). On multivariable analysis, high vs low income was associated with increased utilization of radical prostatectomy (odds ratio [OR] 2.01, 95% CI 1.33-3.04, p<.01) and decreased use of radiotherapy (OR 0.48, 95% CI 031-0.75, p<.01).

CONCLUSIONS

New insights from this study on the association between income and treatment decision-making priorities provide potential avenues for future interventions to reduce disparities in cancer care.

Cardiovascular disease prevention and management of pre-existent cardiovascular disease in a cohort of prostate cancer survivors

PURPOSE

Cardiovascular disease (CVD) is a common cause of mortality among men with prostate cancer. However, receipt of preventive care and management of pre-existent CVD has not been well studied in prostate cancer survivors.

METHODS

This study examined a prospective cohort of men newly diagnosed with localized prostate cancer between 2011 and 2013 throughout North Carolina linked to Medicare and private insurance claims and clinical data from the Veterans Affairs (VA). In patients without pre-existent CVD, the primary outcome was a composite measure of annual preventive care (blood glucose screening, cholesterol level testing, and ≥ 1 primary care provider visit). In patients with pre-existent CVD, the primary outcome was annual cardiologist visit; blood glucose, cholesterol level testing, and primary care visits were also assessed.

RESULTS

Our sample comprised 492 patients successfully linked to insurance claims and/or VA data, among whom 103 (20.9%) had pre-existent CVD. Receipt of preventive care declined from 52.7% (95% confidence interval [CI], 47.7 to 57.6%) during the first year after prostate cancer diagnosis to 40.8% (95% CI: 33.7 to 48.4%) during the third year. Among patients with pre-existent CVD, only 23.4% (95% CI: 13.6 to 37.2%) visited a cardiologist in all 3 years. Black men were more likely than White men to visit a cardiologist the first year (risk ratio [RR] = 1.72, 95% CI: 1.10 to 2.71).

CONCLUSION

In a population-based cohort of prostate cancer survivors, receipt of CVD preventive care declined over time, and frequency of cardiologist-led management of pre-existent CVD was low.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need to improve clinical strategies for reducing cardiovascular risk and managing pre-existent CVD in prostate cancer survivors.

Antipsychotic Use in Early Pregnancy and the Risk of Maternal and Neonatal Complications

OBJECTIVE

To assess the association between antipsychotic use in early pregnancy and the risk of maternal and neonatal metabolic complications.

METHODS

We conducted a population-based retrospective cohort study (January 1, 2010, to December 31, 2016) using the Health and Welfare Database in Taiwan. Pregnant women (18 to 49 years of age) were grouped as antipsychotic users (ie, received oral antipsychotic monotherapy during the first 20 weeks of pregnancy) and nonusers. Antipsychotic users were further categorized into first-generation antipsychotic and second-generation antipsychotic users. Propensity score methods, including matching and inverse probability of treatment weighting, were used to balance covariates. Conditional logistic regression and Cox proportional hazards models were used to compare risks of maternal (gestational diabetes mellitus, preterm birth) and neonatal (low birth weight [LBW], macrosomia) outcomes.

RESULTS

Antipsychotic users had a notably higher risk of preterm birth compared with nonusers (adjusted HR, 1.29; 95% CI, 1.04 to 1.60), but the risk of gestational diabetes mellitus (HR, 1.21; 95% CI, 0.94 to 1.56), LBW (odds ratio [OR], 1.07; 95% CI, 0.84 to 1.37), and macrosomia (OR, 1.36; 95% CI, 0.63 to 2.92) did not differ between the two groups. Among women who received antipsychotics, the odds of LBW were significantly higher in second-generation antipsychotic users compared with first-generation antipsychotic users (adjusted OR, 1.32; 95% CI, 1.04 to 1.68).

CONCLUSION

This study found that using antipsychotics in early pregnancy did not result in a greater risk of metabolic complications both for mothers and newborns. For women requiring treatment with antipsychotics during pregnancy, they should be monitored for the risk of preterm birth and low infant birth weight.

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

OBJECTIVE

To evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older.

PATIENTS AND METHODS

This retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding).

RESULTS

A total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use.

CONCLUSION

In patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.

Prenatal antidepressant use and the implication of hypertensive disorders during pregnancy

BACKGROUND

Evidence for the association between prenatal antidepressant use and the development of hypertensive disorders of pregnancy is inconsistent. Previous studies have reported that antidepressant use during pregnancy increases the risk for gestational hypertension and preeclampsia, but the results of these studies are potentially confounded by important methodologic limitations. Furthermore, it remains unknown whether a higher cumulative dose of antidepressant increases the risk for hypertensive disorders of pregnancy.

OBJECTIVE

This study aimed to investigate the association between prenatal antidepressant use and the risk for hypertensive disorders of pregnancy and the potential effect of a higher cumulative antidepressant dose.

STUDY DESIGN

This retrospective cohort study used data from the Health and Welfare Database in Taiwan. Pregnant women with depression aged 18 to 49 years were enrolled as part of the study population. Prenatal antidepressant use was defined as at least 1 dispensing record of an antidepressant between the conception date and 20 weeks of gestation. Antidepressant users were further divided into groups according to the cumulative defined daily dose based on whether they took the defined daily dose for ≤10 weeks (low cumulative dose group ≤70 cumulative defined daily dose) or for >10 weeks (high cumulative dose group >70 cumulative defined daily dose). The primary outcome was hypertensive disorders of pregnancy defined as the diagnosis of either gestational hypertension or preeclampsia during the period from 20 weeks of gestation to delivery. Propensity score matching and stabilized inverse probability of treatment weighting were used to balance the confounders between the comparison groups. A robust Cox regression model was used to evaluate the association between exposure and outcome.

RESULTS

A total of 5664 pregnant women with depression were included in the study (2832 antidepressant users matched to 2832 antidepressant nonusers). Prenatal antidepressant use was not associated with an increased risk for hypertensive disorders of pregnancy (adjusted hazard ratio, 0.89; 95% confidence interval, 0.67-1.18). However, among antidepressant users, the risk for hypertensive disorders of pregnancy was higher among women with a higher cumulative defined daily dose than among women with a lower cumulative defined daily dose (adjusted hazard ratio, 2.46; 95% confidence interval, 1.05-5.74).

CONCLUSION

No association was found between antidepressant use and the development of hypertensive disorders of pregnancy. However, women taking higher cumulative doses of antidepressants were at greater risk. More frequent or regular monitoring of blood pressure may be warranted in women on high cumulative doses of antidepressants.

Four-year Prostate-specific Antigen Response Rate as a Predictive Measure in Intermediate-risk Prostate Cancer Treated With Ablative Therapies: The SPRAT Analysis

AIMS

There is a lack of early predictive measures of outcome for patients with intermediate-risk prostate cancer (PCa) treated with stereotactic body radiotherapy (SBRT). The aim of the present study was to explore 4-year prostate-specific antigen response rate (4yPSARR) as an early predictive measure.

MATERIALS AND METHODS

Individual patient data from six institutions for patients with intermediate-risk PCa treated with SBRT between 2006 and 2016 with a 4-year (42-54 months) PSA available were analysed. Cumulative incidences of biochemical failure and metastasis were calculated using Nelson-Aalen estimates and overall survival was calculated using the Kaplan-Meier method. Biochemical failure-free survival was analysed according to 4yPSARR, with groups dichotomised based on PSA <0.4 ng/ml or ≥0.4 ng/ml and compared using the Log-rank test. A multivariable competing risk analysis was carried out to predict for biochemical failure and the development of metastases.

RESULTS

Six hundred and thirty-seven patients were included, including 424 (67%) with favourable and 213 (33%) with unfavourable intermediate-risk disease. The median follow-up was 6.2 years (interquartile range 4.9-7.9). The cumulative incidence of biochemical failure and metastasis was 7 and 0.6%, respectively; overall survival at 6 years was 97%. The cumulative incidence of biochemical failure at 6 years if 4yPSARR <0.4 ng/ml was 1.7% compared with 27% if 4yPSARR ≥0.4 ng/ml (P < 0.0001). On multivariable competing risk analysis, 4yPSARR was a statistically significant predictor of biochemical failure-free survival (subdistribution hazard ratio 15.3, 95% confidence interval 7.5-31.3, P < 0.001) and metastasis-free survival (subdistribution hazard ratio 31.2, 95% confidence interval 3.1-311.6, P = 0.003).

CONCLUSION

4yPSARR is an encouraging early predictor of outcome in patients with intermediate-risk PCa treated with SBRT. Validation in prospective trials is warranted.

Association of Cancer Screening Deficit in the United States With the COVID-19 Pandemic

Importance

The COVID-19 pandemic led to sharp declines in cancer screening. However, the total deficit in screening in the US associated with the pandemic and the differential impact on individuals in different geographic regions and by socioeconomic status (SES) index have yet to be fully characterized.

Objectives

To quantify the screening rates for breast, colorectal, and prostate cancers associated with the COVID-19 pandemic in different geographic regions and for individuals in different SES index quartiles and estimate the overall cancer screening deficit in 2020 across the US population.

Design, Setting, and Participants

This retrospective cohort study uses the HealthCore Integrated Research Database, which comprises single-payer administrative claims data and enrollment information covering approximately 60 million people in Medicare Advantage and commercial health plans from across geographically diverse regions of the US. Participants were individuals in the database in January through July of 2018, 2019, and 2020 without diagnosis of the cancer of interest prior to the analytic index month.

Exposures

Analytic index month and year.

Main Outcomes and Measures

Receipt of breast, colorectal, or prostate cancer screening.

Results

Screening for all 3 cancers declined sharply in March through May of 2020 compared with 2019, with the sharpest decline in April (breast, -90.8%; colorectal, -79.3%; prostate, -63.4%) and near complete recovery of monthly screening rates by July for breast and prostate cancers. The absolute deficit across the US population in screening associated with the COVID-19 pandemic was estimated to be 3.9 million (breast), 3.8 million (colorectal), and 1.6 million (prostate). Geographic differences were observed: the Northeast experienced the sharpest declines in screening, while the West had a slower recovery compared with the Midwest and South. For example, percentage change in breast cancer screening rate (2020 vs 2019) for the month of April ranged from -87.3% (95% CI, -87.9% to -86.7%) in the West to -94.5% (95% CI, -94.9% to -94.1%) in the Northeast (decline). For the month of July, it ranged from -0.3% (95% CI, -2.1% to 1.5%) in the Midwest to -10.6% (-12.6% to -8.4%) in the West (recovery). By SES, the largest screening decline was observed in individuals in the highest SES index quartile, leading to a narrowing in the disparity in cancer screening by SES in 2020. For example, prostate cancer screening rates per 100 000 enrollees for individuals in the lowest and highest SES index quartiles, respectively, were 3525 (95% CI, 3444 to 3607) and 4329 (95% CI, 4271 to 4386) in April 2019 compared with 1535 (95% CI, 1480 to 1589) and 1338 (95% CI, 1306 to 1370) in April 2020. Multivariable analysis showed that telehealth use was associated with higher cancer screening.

Conclusions and Relevance

Public health efforts are needed to address the large cancer screening deficit associated with the COVID-19 pandemic, including increased use of screening modalities that do not require a procedure.

Receipt of Guideline-Recommended Surveillance in a Population-Based Cohort of Prostate Cancer Patients Undergoing Active Surveillance

PURPOSE

Prospective clinical trials have demonstrated the safety and efficacy of active surveillance for men with localized prostate cancer but also suggested that inadequate surveillance may risk missing an opportunity for cure.

METHODS AND MATERIALS

We used data from a population-based cohort of active-surveillance patients to examine the rigor of surveillance monitoring in the general population.

RESULTS

Among 1419 patients enrolled from 2011 to 2013 throughout the state of North Carolina in collaboration with the state cancer registry and followed prospectively, 346 pursued active surveillance. Only 13% received all guideline-recommended surveillance testing (including prostate-specific antigen, digital rectal examination, and prostate biopsy) within the first 2 years. Furthermore, adherence was <20% in all patient subgroups.

CONCLUSIONS

These findings suggest that "active surveillance" as implemented in the general population may not represent the rigorous monitoring regimens used in the studies that demonstrated the safety of this management approach. More real-world studies on active surveillance are needed.

Associations between patient knowledge of others' experiences and treatment choice in men with localized prostate cancer

6578

Background: Men with localized prostate cancer must select from multiple treatment options, without one clear best choice. Consequently, personal factors, such as knowing other prostate cancer patients who have undergone treatment, may influence patient decision-making. However, associations between knowledge about others’ experiences and treatment decision-making among localized prostate cancer patients has not been well characterized. We used data from a population-based cohort of localized prostate cancer patients to examine whether patient-reported knowledge of others’ experiences is associated with treatment choice. Methods: The North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS) is a population-based cohort of localized prostate cancer patients enrolled from 2011-2013 throughout the state of North Carolina in collaboration with the North Carolina Central Cancer Registry. All patients were enrolled prior to treatment and followed prospectively. Patient decision-making factors including knowledge of others’ experiences with prostate cancer treatment options were collected through patient report. Patient treatment choice was determined through medical record abstraction and cancer registry data. Results: Among 1,202 patients, 17% reported knowing someone who pursued active surveillance (AS) while 28%, 46%, and 59% reported knowing someone who received brachytherapy, external beam radiation (EBRT), or radical prostatectomy (RP), respectively; 26% underwent AS, 9% brachytherapy, 21% EBRT, and 39% RP as their initial treatment. In unadjusted analyses, patients with knowledge of others’ experiences with brachytherapy, EBRT or RP had more than twice the odds of receiving that treatment compared to patients who did not. Knowledge of others’ experience with AS was not associated with choice to undergo AS. Multivariable analysis adjusting for age, race, risk group, and patient-reported goals of care showed knowledge of others’ experiences with brachytherapy (OR 4.60, 95% confidence interval [CI] 2.76 to 7.68), EBRT (OR 2.38, 95% CI 1.69 to 3.34), or RP (OR 4.02, 95% CI 2.84 to 5.70) was significantly associated with odds of receiving that treatment. The odds of receiving a particular treatment option were further increased among patients who reported knowing someone who had a “good” experience with the treatment in question. Conclusions: This is the first population-based study to directly demonstrate the impact of a patient’s knowledge of others’ experiences on treatment choice in prostate cancer. These data provide a new consideration to clinicians in their counseling of patients with newly diagnosed prostate cancer, and also impacts research into the informed decision-making process for this disease.

Effect of income on patient decision-making in localized prostate cancer

6552

Background: Socioeconomic status affects goals of care and treatment choices. We investigated the impact of low household income on diagnosis, goals of care, and treatment choice in patients with localized prostate cancer. Methods: The North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS) is a population-based cohort of prostate cancer patients identified at the time of diagnosis, enrolled from 2011-2013, and followed prospectively. Sociodemographic information and decision making factors including goals of care were collected by patient report. Patients were asked to rate the importance of quality of life, cure, burden to friends and family, cost, and effect on daily activity as well as which of these goals was the most important in their treatment decision making. Annual household income was stratified in to 3 levels: < 40K (low), 40-90K (middle),>90K (high). Results: Of 1382 patients, 539 (39%), 553 (40%), and 290 (21%) reported low, medium, and high household income. Lower income patients were less college educated, more frequently unemployed, and had higher rates of either no insurance or government sponsored insurances. Low income patients had higher PSA and worse clinical stage at diagnosis. In goals of care, low income patients more frequently rated high importance on burden (78.8% vs 76.0% vs 65.2% p<0.01) and cost of cancer (61.2% vs 38.5% vs 14.5% p<0.01), and factors other than cure as the most important treatment decision factor. While overall treatment rate at 1 year was similar by income group, the type of treatment differed. On multivariate analyses, adjusting for age, race, clinical risk group, employment, insurance, and treatment goal, high income was associated with increased odds of having surgery (OR 1.81, CI 1.16 – 2.81), and reduced odds of having radiation (0.60, CI 0.36-0.99). Conclusions: Poor patients with low household income have worse prostate cancer at diagnosis. These patients have different goals of care which impact their choice of treatment. These findings provide novel insight into disparities in diagnosis and outcome in prostate cancer.[Table: see text]

Care received by rural and urban patients with newly diagnosed prostate cancer: Results from a population-based prospective cohort

203

Background: Rural residence is a source of disparity in cancer access and outcomes. It is not known to what extent rurality affects access to care in patients with prostate cancer. Methods: The North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS) is a population-based cohort of newly-diagnosed prostate cancer patients. Patients were enrolled from 2011-2013 through collaboration with the state cancer registry at diagnosis and followed prospectively. Urban/rural residence was defined by the rural urban continuum code (RUCC): 1-3 (urban) and 4-9 (rural). Medical records were collected and abstracted for prostate cancer care received. Individual-level sociodemographic information was collected by patient report. Results: Among 1,456 NC ProCESS participants with a median age of 65 years, 1089 were categorized as urban and 367 (25%) rural. This is a sociodemographically diverse cohort with 30.2% non-White (including 26.9% Black), 34.1% with high school education or less, and 37.3% with household income < = $40,000. The distance to travel for diagnostic scans was greater for rural patients (miles): CT (7.5 urban vs 17.1 rural, p = 0.07), MRI (8.1 vs 12.0, p = 0.04) and bone scan (6.8 vs 14.1, p = 0.009). However, there was no difference in the percent of patients who underwent CT (15.9% urban vs 12.8% rural, p = 0.15), MRI (7.8% vs 8.2%, p = 0.81) and bone scan (15.9% vs 19.4%, p = 0.13); or the percentage of patients with high risk or metastatic disease who had any staging scan (64.2% vs 66.6% p = 0.8). While all patients consulted with a urologist, rural patients were less likely to have had consultation with a radiation oncologist (42.4% vs 35.8%, p = 0.04). Rural patients were also more likely to report that treatment was more difficult due to travel, including robotic prostatectomy (6.8% vs 13.9% p = 0.001) and radiation therapy (8.01% vs 16.07%, p = 0.001). In patients with low risk cancer, rural patients were more likely to have reported treatment at 12 months (68.2% vs 58.7% p = 0.04) instead of surveillance or observation. For high risk patients, both rural and urban patients reported high rates of treatment by 3 months (96.3% vs 91.3%, p = 0.40). After adjustment for age, income, race, education and insurance, rural residence was associated with increased likelihood of receiving treatment at 1 year (OR 1.54, CI 0.99 – 2.39) in low risk patients, but not associated with receiving treatment at 3 months (OR 3.63, CI 0.24 -54.5) among high risk patients. Conclusions: In a population-based cohort, rural patients with prostate cancer have greater barriers such as travel distance, but similar proportions of rural and urban patients received staging scans and timely treatment for high-risk prostate cancer. Rural patients were less likely to receive multidisciplinary consultation prior to treatment, and were less likely to have surveillance for low risk disease.

The Impact of the Affordable Care Act on Disparities in Private and Medicaid Insurance Coverage Among Patients Under 65 With Newly Diagnosed Cancer

PURPOSE

To investigate the impact of the Affordable Care Act on racial and rural-urban disparities in insurance coverage for patients under age 65 with cancer.

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results data from 2011 to 2015, we calculated the proportions of uninsured, Medicaid, and non-Medicaid insured (including private insurance) patients before and after the Medicaid expansion. We calculated the absolute percent change and difference in differences (DiD) to evaluate whether the Medicaid expansion had an impact on the distribution of types of insurance. Adjusted DiD analyses accounted for age, race, sex, county-level median household income, and rural-urban residence.

RESULTS

There was a greater decrease in uninsured rate in expansion states (-3.0%) versus nonexpansion states (-0.9%, DiD -2.1%), particularly among Black (DiD -3.4%), Hispanic (-3.9%), and rural patients (-4.8%). In expansion states, an increase in the proportion of patients with Medicaid coincided with a decrease in the proportion with non-Medicaid insurance; the opposite was observed in nonexpansion states. The decrease in non-Medicaid insurance varied by patient race: Asian/Pacific Islanders (adjusted DiD -9.7%), Hispanic (-4.2%), non-Hispanic black (-4.0%), and non-Hispanic white (-2.8%).

CONCLUSIONS

Medicaid expansion versus nonexpansion states observed a slightly greater reduction in the uninsured rate, but Medicaid expansion states also observed a corresponding shift from non-Medicaid (including private) to Medicaid insurance, which may paradoxically exacerbate disparities in access to care and cancer outcomes. Long-term outcomes and continued study are required to fully understand the impact of the Affordable Care Act on disparities in cancer care.

Population-based cohort of prostate cancer patients on active surveillance (AS): guideline adherence, conversion to treatment and decisional regret

6512

Background: AS is recommended for early-stage prostate cancer, for which over-treatment has been widely described. In published studies from large academic institutions and/or controlled clinical trials, where patients are monitored rigorously, AS is safe and results in low rates of cancer-specific mortality. However, active surveillance in the community setting has not been previously examined. Methods: In collaboration with the North Carolina state cancer registry, 346 men with newly-diagnosed low- or intermediate-risk prostate cancer throughout the state from 2011–13 who pursued active surveillance were enrolled in an observational cohort; medical records and patient-reported outcomes (validated measures of prostate cancer anxiety [MAX-PC] and Clark’s prostate cancer decision regret) were collected prospectively. Guideline-adherent monitoring during active surveillance was assessed using contemporary NCCN guidelines: PSA testing every 3–6 months and prostate biopsy within 18 months of initial diagnosis. Results: 58% of patients received adequate PSA testing and 45% prostate biopsy; overall, 32% of patients received guideline-adherent monitoring. Urology follow-up in Year 1 was 97% but dropped to 67% in Year 2. Within the first 2 years, 16% of patients converted to treatment. Multivariable analysis showed MAX-PC scores (OR 1.8, p = 0.008) and younger age were significantly associated with conversion; no other sociodemographic (race, education, marital status, rural/urban) or diagnostic variable (risk group) was associated. At 2 years, 94% expressed no regret. Conclusions: In a non-controlled setting of patients pursuing AS in the community, adherence to guideline-recommended monitoring was only 32%. Few patients expressed decisional regret. Conversion to treatment was likely driven by patient anxiety but not disease-related factors. While there are continued efforts to increase AS uptake, these results highlight the importance of behavioral interventions during active surveillance to reduce anxiety and improve monitoring adherence. Whether AS in non-controlled settings is safe and effective requires further study.

Patient characteristics, treatment patterns, and mortality in elderly patients newly diagnosed with ALL

To describe patient characteristics and treatment patterns among elderly patients (≥66 years) newly diagnosed with acute lymphoblastic leukemia (ALL), we analyzed 100% Medicare ALL data from 2007 to 2015. Only 764 out of 1428 (53.5%) elderly patients received treatment within 90 d of diagnosis with ≥30-d follow-up; 32.4% received chemotherapy without tyrosine kinase inhibitors (TKIs), 8.8% received both chemotherapy and TKIs, 9.8% received steroids only and 2.6% received TKIs only. Among 717 patients receiving chemotherapy any time during follow-up, 65.8% received only one course of treatment. Patients treated with chemotherapy or TKIs compared to untreated patients were younger (<75 years: 51.5 vs. 21.7%) and had a lower comorbidity burden (Charlson Comorbidity index ≤ 2: 90.9 vs. 71.4%). Overall, 67.5% of patients died within 3 years of diagnosis. Our findings demonstrate that many elderly ALL patients are not treated in the real-world setting and highlight the need for tolerable therapies for these patients.

Assessment of case definitions for identifying acute liver injury in large observational databases

BACKGROUND

Determining the aetiology of acute liver injury (ALI) may be challenging to both clinicians and researchers. Observational research is particularly useful in studying rare medical outcomes such as ALI; however, case definitions for ALI in previous observational studies lack consistency and sensitivity. ALI is a clinically important condition with various aetiologies, including drug exposure.

OBJECTIVE

The aim of this study was to evaluate four distinct case definitions for ALI across a diverse set of large observational databases, providing a better understanding of ALI prevalence and natural history.

DATA SOURCES

Seven healthcare databases: GE Healthcare, MarketScan(®) Lab Database, Humana Inc., Partners HealthCare System, Regenstrief Institute, SDI Health (now IMS Health, Inc.), and the National Patient Care Database of the Veterans Health Administration.

METHODS

We evaluated prevalence of ALI through the application of four distinct case definitions across seven observational healthcare databases. We described how laboratory and clinical characteristics of identified case populations varied across definitions and examined the prevalence of other hepatobiliary disorders among identified ALI cases that may decrease suspicion of drug-induced liver injury (DILI) in particular.

RESULTS

This study demonstrated that increasing the restrictiveness of the case definition resulted in fewer cases, but greater prevalence of ALI clinical features. Considerable heterogeneity in the frequency of laboratory testing and results observed among cases meeting the most restrictive definition suggests that the clinical features, monitoring patterns and suspicion of ALI are highly variable among patients.

CONCLUSIONS

Creation of four distinct case definitions and application across a disparate set of observational databases resulted in significant variation in the prevalence of ALI. A greater understanding of the natural history of ALI through examination of electronic healthcare data can facilitate development of reliable and valid ALI case definitions that may enhance the ability to accurately identify associations between ALI and drug exposures. Considerable heterogeneity in laboratory values and frequency of laboratory testing among individuals meeting the criteria for ALI suggests that the evaluation of ALI is highly variable.

Retrospective analysis of estimated cost avoidance following pharmacist-provided medication therapy management services

OBJECTIVE

To compare the estimated cost avoidance (ECA) of pharmacist-provided medication therapy management (MTM) services among common disease states encountered in community pharmacy practice.

DESIGN

Retrospective analysis.

SETTING

Nine community pharmacies in North Carolina.

PATIENTS

Three hundred and sixty-four patients who are 65 years of age or older, a Medicare Part D beneficiary and a North Carolina resident.

INTERVENTIONS

An MTM pharmacist-provider conducted medication reviews to eligible patients between July 2009 and October 2009. For each encounter, patient interventions, pharmacist recommendations, and ECA were recorded.

MAIN OUTCOME MEASURE

ECA.

RESULTS

In 9 pharmacy locations, 634 MTM interventions were documented during the study period. The ECA in a 4-month period yielded approximately $494 000. Comprehensive medication reviews, new prescription counseling and appropriate medication administration, and technique counseling made up nearly two-thirds of interventions. Overall, the probability that an MTM intervention would result in an ECA greater than $0 was .35.

CONCLUSIONS

Pharmacist-provided MTM effectively reduced costs associated with patient medication use. Such interventions reduced costs in overall health care specifically in the areas of cardiovascular, gastroesophageal reflux disease, pulmonary, and diabetes groups.

Human adipose stem cells maintain proliferative, synthetic and multipotential properties when suspension cultured as self-assembling spheroids

Adipose-derived stromal/stem cells (ASCs) have been gaining recognition as an extremely versatile cell source for tissue engineering. The usefulness of ASCs in biofabrication is further enhanced by our demonstration of the unique properties of these cells when they are cultured as three-dimensional cellular aggregates or spheroids. As described herein, three-dimensional formulations, or self-assembling ASC spheroids develop their own extracellular matrix that serves to increase the robustness of the cells to mechanical stresses. The composition of the extracellular matrix can be altered based on the external environment of the spheroids and these constructs can be grown in a reproducible manner and to a consistent size. The spheroid formulation helps preserve the viability and developmental plasticity of ASCs even under defined, serum-free media conditions. For the first time, we show that multiple generations of adherent ASCs produced from these spheroids retain their ability to differentiate into multiple cell/tissue types. These demonstrated properties support the idea that culture-expanded ASCs are an excellent candidate cellular material for 'organ printing'-the approach of developing complex tissue structures from a standardized cell 'ink' or cell formulation.

Heterotopic gastric mucosa causing significant esophageal stricture in a 14-year-old child

Esophageal heterotopic gastric mucosa (HGM) is not uncommon and can be seen in up to 10% of the general population among numerous reports and epidemiologic studies which have been essentially performed in adult population. Pediatric data are still limited. Diagnosis requires clinician awareness of symptomatic cases who present with dysphagia or swallowing difficulties, and thorough endoscopic examination is crucial. Early detection of cases provides favorable clinical outcome and may prevent potential significant or serious long-term consequences such as esophageal stricture or web, Barrett's esophagus or malignant transformation in pediatric population. We reported a 14-year-old male who presented with 1-year history of gradually worsening dysphagia and was found to have two salmon-colored patches, which resemble gastric mucosa, in the proximal esophagus causing significant esophageal stricture. Gastric cardiac-type mucosa with acute and chronic inflammation was documented on biopsy. After several sessions of balloon dilation and endoscopic treatment, the HGM and esophageal stricture resolved and he became asymptomatic.

Genetic and cellular mechanisms in chromium and nickel carcinogenesis considering epidemiologic findings

Genetic and environmental interactions determine cancer risks but some cancer incidence is primarily a result of inherited genetic deficits alone. Most cancers have an occupational, viral, nutritional, behavioral or iatrogenic etiology. Cancer can sometimes be controlled through broad public health interventions including industrial hygiene and engineering controls. Chromium and nickel are two human carcinogens associated with industrial exposures where public health measures apparently work. Carcinogenic mechanisms of these metals are examined by electron-spin-resonance-spectroscopy and somatic-mutation-and-recombination in Drosophila melanogaster in this report. Both metals primarily affect initiation processes in cancer development suggesting important theoretical approaches to prevention and followup.

Mesenchymal stem cells from rat visceral fat exhibit multipotential differentiation in vitro

Human subcutaneous fat-derived stem cells were recently shown to have the potential to differentiate in vitro into a variety of cell types, including adipocytes, osteoblasts, chondrocytes, and myoblasts (Zuk et al., Tissue Eng. 2001;7:211-228). Subcutaneous adipose tissue may therefore prove to be an easily acquired and abundant source of stem cells. Presently it is unclear whether mammals such as rats (which possess small or nonexistent subcutaneous fat pads) contain mesenchymal stem cells within the visceral fat of the abdominal cavity, or whether the visceral fat of any species contains stem cells. In this study we isolated and expanded a pool of mesenchymal cells from visceral fat of adult Sprague-Dawley rats and induced their differentiation in vitro into adipocytes, osteoblasts, neural cells, and chondrocytes. The differentiated phenotypes were verified by morphology as well as detection and expression of tissue-specific protein and mRNA. We conclude that despite well-documented differences in the metabolic and biochemical properties among anatomically distinct depots of fat, the visceral fat of rats contains adult mesenchymal stem cells with developmental potential similar to those isolated from subcutaneous fat in humans. Therefore, animals such as rats provide both a source of fat-derived stem cells and an immunocompetent, autologous host animal in which to investigate the capacity of the fat-derived cells to differentiate and form tissues in vivo.

Combining Drosophila melanogaster somatic-mutation-recombination and electron-spin-resonance-spectroscopy data to interpret epidemiologic observations on chromium carcinogenicity

Lung cancers are significantly increased among workers exposed to chromate (Cr6+, Cr3+), chromium pigments (Cr6+) and chromium plating (Cr6+). Chromium lung burdens and cancer risk increase proportionately with duration of employment at long latencies. However, this epidemiologic information alone is insufficient in determining whether Cr6+ or Cr3+ are equally important in causing cancer. We have attempted to combine epidemiologic data with data from the Drosophila melanogaster somatic-mutation-recombination-test and from the in vitro electron-spin-resonance spectroscopy study to demonstrate that following somatic recombination plays a more important role than somatic mutation in chromium carcinogenesis. Cr4+ is more important than Cr5+ or Cr6+ in inducing somatic recombination while Cr6+ produces more and bigger clones than Cr4+ in somatic mutation. Cr3+ produces negative results in this fruit-fly wing-spot-assay. When the larvae and flies exposed to Cr6+ and Cr4+ are examined by ESR, only Cr5+ and Cr3+ are found. Thermodynamic parameters deltaE, deltaH, and deltaS are also estimated from these latter experiments to explain the relative importance of Cr6+, Cr4+, Cr3+ in chromium carcinogenesis among exposed industrial workers.

Multilineage cells from human adipose tissue: implications for cell-based therapies

Future cell-based therapies such as tissue engineering will benefit from a source of autologous pluripotent stem cells. For mesodermal tissue engineering, one such source of cells is the bone marrow stroma. The bone marrow compartment contains several cell populations, including mesenchymal stem cells (MSCs) that are capable of differentiating into adipogenic, osteogenic, chondrogenic, and myogenic cells. However, autologous bone marrow procurement has potential limitations. An alternate source of autologous adult stem cells that is obtainable in large quantities, under local anesthesia, with minimal discomfort would be advantageous. In this study, we determined if a population of stem cells could be isolated from human adipose tissue. Human adipose tissue, obtained by suction-assisted lipectomy (i.e., liposuction), was processed to obtain a fibroblast-like population of cells or a processed lipoaspirate (PLA). These PLA cells can be maintained in vitro for extended periods with stable population doubling and low levels of senescence. Immunofluorescence and flow cytometry show that the majority of PLA cells are of mesodermal or mesenchymal origin with low levels of contaminating pericytes, endothelial cells, and smooth muscle cells. Finally, PLA cells differentiate in vitro into adipogenic, chondrogenic, myogenic, and osteogenic cells in the presence of lineage-specific induction factors. In conclusion, the data support the hypothesis that a human lipoaspirate contains multipotent cells and may represent an alternative stem cell source to bone marrow-derived MSCs.

A novel device for the simple and efficient refinement of liposuctioned tissue

In short, our device allows a surgeon who is harvesting adipose tissue for autologous fat transplantation to immediately, easily, efficiently, and sterilely isolate adipose tissue from the unwanted waste components that are associated with primary liposuction effluent. It does so by "trapping" the fat tissue contained within raw liposuction effluent. Once the tissue fraction has been separated, the device design then allows for direct implantation or subsequent washing/rinsing of the tissue with saline/buffer of choice in preparation for tissue reimplantation.

Prospective analysis suggests susceptibility genes for deficiencies of IgA and several other immunoglobulins on the [HLA-B8, SC01, DR3] conserved extended haplotype

The extended major histocompatibility complex (MHC) haplotype [HLA-B8, SC01, DR3] is increased in frequency among patients with immunoglobulin (Ig)A deficiency and common variable immunodeficiency. Because the genomic region from HLA-B to HLA-DR/DQ is virtually the same on all instances of the haplotype in the general population, we reasoned that all independent instances of [HLA-B8, SC01, DR3] carry MHC susceptibility genes for these disorders. To define immunoglobulin deficiencies determined by genes on this haplotype and their mode of expression and penetrance, serum immunoglobulin class and IgG subclass concentrations were determined prospectively in homozygotes and heterozygotes of this haplotype and in Caucasian controls. Prevalence of individual immunoglobulin deficiencies in persons with [HLA-B8, SC01, DR3] ranged from 13% to 37%, significantly higher than rates in non-carriers or general controls. We found significantly increased frequencies of IgA and IgG4 deficiency only in homozygotes (13.3% and 30%, respectively) compared with heterozygotes (1.7% and 3.4%) or non-carriers (1.6% each), suggesting recessive expression. In contrast, IgD and IgG3 deficiencies were significantly more common in both homozygotes (36.7% and 30%) and heterozygotes (20.3% and 17.5%) compared with controls (4.9% and 3.4%), suggesting dominant inheritance. These results indicate multiple distinct susceptibility genes, some recessive and others dominant, for deficiency of IgA, IgD, IgG3 or IgG4 (but not for IgE, IgG1, IgG2 or IgM) on [HLA-B8, SC01, DR3]. These observations may also help to explain the observed associations of [HLA-B8, SC01, DR3] with both IgA deficiency and common variable immunodeficiency and the common occurrence of IgG subclass deficiencies in some patients with IgA deficiency.

Modulation by temperature of the genotoxic potency of cisplatin in Drosophila wing spot assay

Effects of temperature on genotoxic potency of cisplatin were studied in the Drosophila wing spot assay. A fixed concentration of 0.05 mM cisplatin was evaluated for genotoxicity at 4 temperatures (18, 20, 25, and 29 degrees C). The compound was found to be a positive inducer of all three endpoints at all temperatures when compared to the water controls. While no effect of temperature was found on the percentages of cisplatin-treated wings with small spots, there were significant effects for large spots and twin spots. The capacity of cisplatin to induce both large spots and twin spots tended to increase with rising temperature. A significant linear regression was obtained in regard to temperature and number of cisplatin-induced large spots per wing. The lack of any effect of temperature on induced small spots provides additional evidence that small spots may be qualitatively different from large spots and twin spots. The observed enhancement by higher temperature of cisplatin's genotoxic potency is likely due in part to increased cellular uptake of the mutagen. Wide temperature fluctuations should be avoided when conducting the wing assay. Although the customary temperature for performing the assay has been within the range 24-25 degrees C, the optimum temperature for maximizing genotoxic potency (and sensitivity of the assay) may be nearer 27 degrees C.

Emerging approaches to the tissue engineering of fat

The eventual development of tissue-engineered fat equivalents for reconstructive and augmentation purposes will be most welcome by nearly every surgical discipline and prove to be especially useful for plastic surgeons. The clinical applications for which tissue-engineered fat will be particularly useful are vast and varied and can be loosely categorized into reconstructive, cosmetic, corrective, and orthotic indications. In this article, the authors discuss the emerging tissue-engineering strategies for fat, including the procurement of autologous cells, cell growth and differentiation, implantation and engraftment, polymer scaffolds, and implant integration and histogenesis.

Inhibition of peripheral blood mononuclear cell proliferation by cardiac glycosides

INTRODUCTION

Prior studies have shown that ouabain, a cardiac glycoside that inhibits the sodium, potassium adenosine triphosphatase (Na+,K+ ATPase) enzyme, downregulates phytohemagglutinin (PHA)-induced peripheral blood mononuclear cell (PBMNC) proliferation.

OBJECTIVE

This study examined and compared the effects of both ouabain and digoxin, a cardiac glycoside used therapeutically in humans, on PBMNC proliferation.

METHODS

Peripheral blood mononuclear cells were isolated from healthy human subjects, incubated for 72 hours with and without PHA (2%) in the presence and absence of ouabain (10(-12) M to 10(-4) M) or digoxin (10(-9) M to 10(-6) M), and pulsed with 3H thymidine.

RESULTS

For PHA-stimulated PBMNCs in the ouabain-treated group (n = 10 subjects), the mean (+/-STD) % uptake (% 3H thymidine uptake in absence of ouabain) was 80.5 +/- 6.0 at 10(-12) M ouabain, 73.1 +/- 8.4 at 10(-10) M, 47.89 +/- 13.1 at 10(-8) M, 6.9 +/- 3.2 at 10(-6) M, and 3.4 +/- 1.6 at 10(-4) M. For PHA-stimulated cells in the digoxin-treated group (n = 9 subjects), the mean (+/-STD) % uptake (% 3H thymidine uptake in absence of digoxin) was 89.8 +/- 9.8 at 10(-9) M digoxin, 92.6 +/- 8.2 at 10(-8) M, 54.3 +/- 19.8 at 10(-7) M, and 1.0 +/- 2.4 at 10(-6) M. Repeated measures ANOVA demonstrated a significant effect of concentration of both glycosides on PBMNC proliferation (P < .01). The inhibitory effect was reversible, but was largely abbrogated if ouabain was added after 48 hours of incubation with PHA. Further, the inhibitory effect extended to PBMNCs stimulated with recall antigen (tetanus) and to fractionated PBMNCs (CD4+, CD8+ and CD19+) stimulated with mitogens. Additionally, dose-response inhibitory effects of glycosides on PBMNC Na+,K+ ATPase enzyme activity and interleukin-2 (IL-2) secretion by PHA-stimulated PBMNC were also noted. Neither glycoside had an effect on spontaneous PBMNC proliferation (no PHA) or trypan blue exclusion.

CONCLUSIONS

These studies demonstrate that both cardiac glycosides inhibited PHA-induced PBMNC proliferation, possibly via Na+,K+ ATPase inhibition, but not via cell toxicity. The concentration range over which inhibition was observed was similar for both glycosides. The results raise the possibility that therapeutic or toxic doses of digoxin could have an effect on cell-mediated immunity in vivo.

Comparison of bacteria growth in single and pooled platelet concentrates after deliberate inoculation and storage

BACKGROUND

The ability to store pools of platelet concentrates (PCs) for extended periods would provide logistical flexibility. However, reports of severe adverse reactions due to the transfusion of contaminated PCs led to an examination of whether the total bacteria levels after storage of pools containing a deliberately inoculated platelet unit would be significantly different than the levels in paired unpooled concentrates.

STUDY DESIGN AND METHODS

A single PC was deliberately inoculated on Day 0 with one of three bacterial species (0.1-8.0 colony-forming units/mL). On Day 1, the deliberately inoculated PC was divided into three equal parts and either 1) pooled with 5 half-volume, ABO- and Rh-identical PCs; 2) similarly pooled and white cell reduced; or 3) kept as a control. Sterile connections were used during pooling; modified storage containers were used to ensure the correct surface-to-volume ratio of the single unit.

RESULTS

Between Day 2 and Day 5 of storage, in 26 of 36 paired samples, nonfiltered pools containing Escherichia coli had greater total numbers of bacteria than did the paired single PCs. Day 2 pools had total bacteria levels approximately five times higher (colony-forming units/mL x container volume) than those in single units (p < 0.05). There was rapid growth of Staphylococcus aureus by Day 2 in pooled and unpooled PCs; by Day 3, total bacteria levels were approximately five times higher in pools than in single units (p < 0.05). Between Days 3 and 5 of storage, in 23 of 27 paired samples, nonfiltered pools containing S. aureus had greater total bacteria levels than the single PCs. By Day 5, 15 of 16 non-white-cell reduced pools had total levels of Staphylococcus epidermidis bacteria approximately five times those in the paired single PCs. Greater total bacteria levels in pooled units than in single units generally occurred when bacteria in pools reached the stationary phase of growth (when bacteria concentration became constant), and they were well correlated with the sixfold volume of pooled units. White cell reduction did not substantially affect the time required to attain stationary phase.

CONCLUSION

The potential during storage for greater total bacteria levels in pools than in single PCs is a consequence of the greater volume of the pool.

Major histocompatibility complex susceptibility genes for dermatitis herpetiformis compared with those for gluten-sensitive enteropathy

Dermatitis herpetiformis (DH) shares some clinical features and major histocompatibility complex (MHC) markers with gluten-sensitive enteropathy (GSE). We compared MHC haplotypes in 27 patients with DH, 35 patients with GSE, and normal controls. As in GSE, the frequencies of two extended haplotypes, [HLA-B8, SC01, DR3] and [HLA-B44, FC31, DR7], were increased in patients with DH. Distributions of fragments of extended haplotypes, consisting of some but not all of the elements of complete extended haplotypes, were analyzed to attempt to localize a susceptibility gene. Besides complete extended susceptibility haplotypes, (DR3, DQ2) and (DR7, DQ2) fragments were most common in GSE. In contrast, DH showed only a few such fragments but many instances of the fragment (SC01). The differences in distribution of these fragments in the two diseases were highly significant (P < 0.002). HLA-DQ2 and DR3 had the highest odds ratios for GSE, but the highest odds ratio for DH was for the complotype SC01. These findings suggest that the MHC susceptibility gene for DH is between class II and complotype regions, closest to the complotype, whereas that for GSE is in the class II region.

Effect of temperature on frequencies of spots in Drosophila wing-spot assay

The effect of temperature on spontaneous mutation frequencies was studied in the Drosophila somatic mutation and recombination test. Transdihybrid mwh +/+ flr3 larvae were grown at various temperatures (15, 18, 20, 22, 25, 27, and 29 degrees C) in the absence of any chemical mutagen. Wings of surviving adults were removed and scored for presence of small single spots, large single spots, and twin spots. No significant effect of temperature was found on mean frequency per wing of twin spots. Similarly, no significant effect of temperature was found for large singles within the temperature range of 18-29 degrees C; however, at 15 degrees C, the mean frequency per wing of large spots was significantly elevated. A significant quadratic relationship was found between mean frequency of small spots and temperature. Frequency of small spots per wing was minimized within the temperature range of 20-27 degrees C and increased at higher and lower temperatures. Maximum frequency of small spots per wing was observed at 15 degrees C. The qualitative nature of the small single spots induced at high and low temperatures is unclear; they may represent slow-growing segmentally aneuploid (deleted) cells or possibly even monosomic cells. Both heat and cold were found to be mutagenic in the Drosophila wing-spot assay. However, the mutagenic potency associated with temperature was much less than that of most chemical mutagens, and no significant effect of temperature was observed in the range of 20-27 degrees C.

Relationship of common laboratory parameters to the activity of Crohn's disease in children

The Pediatric Crohn's Disease Activity Index (PCDAI) has been proposed as a simple instrument to aid in the classification of patients by disease severity. The PCDAI includes subjective patient reporting of symptoms, physical examination, nutritional parameters, and several common laboratory tests (hematocrit, erythrocyte sedimentation rate, albumin). In this report we examine the relationship of each of the laboratory parameters to the PCDAI, as well as to a modified Harvey-Bradshaw Index score and physician global assessment of disease activity. Data were gathered from the clinical and laboratory observations from 133 children and adolescents at 12 pediatric gastroenterology centers in North America. A statistically significant relationship (p less than 0.05) was noted between each of the laboratory tests and the PCDAI for patients with either disease limited to the small bowel or in those with colonic involvement. For patients with disease limited to the small bowel, a statistically significant (p less than 0.05) relationship was also noted between the three laboratory parameters and the modified Harvey-Bradshaw Index and global assessment. For patients with large-bowel involvement, the erythrocyte sedimentation rate was statistically related to the modified Harvey-Bradshaw Index and global assessment (p less than 0.01), as was hematocrit to global assessment (p less than 0.01). Although the laboratory parameters used in the PCDAI appear to generally reflect disease activity in most patients, no single laboratory test is adequate to reflect disease activity in all patients. Future work will need to identify additional laboratory measures to reflect the inflammatory process and serve as important adjuncts in the assessment of disease activity.

Tetracycline-induced esophagitis in adolescent patients

Ulcerative esophagitis may be caused by corrosive agents and by commonly prescribed medications. We report severe esophagitis in five adolescents after ingestion of tetracycline preparations with minimal water immediately before going to bed.

Development and validation of a pediatric Crohn's disease activity index

Clinical and laboratory observations of 133 children and adolescents with Crohn's disease were used to validate an index of severity of illness previously developed by a group of senior pediatric gastroenterologists at a research forum in April 1990. This pediatric Crohn's disease activity index (PCDAI) included (a) subjective reporting of the degree of abdominal pain, stool pattern, and general well-being; (b) presence of extraintestinal manifestations, such as fever, arthritis, rash, and uveitis; (c) physical examination findings; (d) weight and height; and (e) hematocrit, erythrocyte sedimentation rate, and serum albumin. Independent evaluation of each patient by two physician-observers was performed at the time of a visit, and each physician completed a PCDAI index and a modified Harvey-Bradshaw index and made a "global assessment" of disease activity as none, mild, moderate, or severe. Excellent interobserver agreement was noted for the PCDAI, modified Harvey-Bradshaw index, and global assessment. There was a strong correlation between global assessment and both the PCDAI or modified Harvey-Bradshaw. Increasing PCDAI scores were noted with increasing disease severity, and significant differences in scores were noted between the severity groups. We propose that the PCDAI could be used in multicenter projects to facilitate patient stratification by disease severity and that longitudinal PCDAI scores might provide a numerical measure of response to therapeutic regimens.

Genetic prediction of nonresponse to hepatitis B vaccine

In previous studies of the antibody response to hepatitis B vaccine in 598 subjects who received a full course of vaccination, we observed a bimodal response, with about 14 percent producing less than approximately 1000 radioimmunoassay (RIA) units. An analysis of the major histocompatibility complex (MHC) HLA and complement types of 20 of the subjects with the lowest responses indicated a greater-than-expected number of homozygotes for the extended or fixed MHC haplotype [HLA-B8, SC01, DR3]. This finding suggested that the lack of a normal response was a recessive MHC-linked trait. In this study, we prospectively vaccinated five homozygotes and nine heterozygotes for this haplotype in the expectation that the homozygotes would produce much lower levels of antibody than the heterozygotes. When the antibody response was assessed two months after the third injection, four of the five homozygotes had produced very low levels (approximately 1000 units or less) of antibody (mean, 467 RIA units; range, less than 8 to 1266), whereas all nine heterozygotes produced more than 2500 RIA units (mean, 15,608; range, 2655 to 28,900) (P less than 0.01). We conclude that the usual response to hepatitis B surface antigen is due to the presence of a dominant immune-response gene in the MHC and that a low response is due to the absence of such a gene and the presence on both chromosomes of MHC haplotypes (such as [HLA-B8, SC01, DR3]) that indicate such a response.

Strategy for purification of coagulation factor concentrates

Advances in biotechnology are permitting significant changes in traditional plasma fractionation schemes. Increases in product purity, safety, and recovery are possible, and new products are being developed. Applications of technology to the purification of factor IX, factor X, protein C, antithrombin III, thrombin, and fibrin glue are described.

Thirty compounds tested in the Drosophila wing spot test

The Drosophila wing somatic mutation and recombination test (SMART) was evaluated for its suitability in genotoxicity screening by testing 30 chemicals. Of the 2 crosses used, the mwh-flr3 cross turned out to be more convenient than the previously used mwh-flr cross. Based on the experience gained with both acute exposures and chronic exposures of different duration, we suggest that the optimal strategy in genotoxicity screening is to start with chronic exposure of 3-day-old larvae for 48 h (that is, until pupation). Only for unstable compounds and very volatile compounds and gases are acute treatments, including inhalation, recommended. In general, a qualitative evaluation of the genotoxicity of a compound in the wing assay is possible with as few as 1-2 different exposure concentrations. A more quantitative evaluation of genotoxicity, based upon dose-response data, can often be achieved with as few as 3-4 concentrations. The results reported here were obtained in 2 different laboratories, demonstrating that the wing spot test is easily transferable to other laboratories. The experience gained indicates that the assay has now been developed to an extent that a coordinated international comparative validation study is desirable.

Inhalation of methyl bromide gas induces mitotic recombination in somatic cells of Drosophila melanogaster

The fumigant methyl bromide was evaluated for genotoxicity in the somatic wing-spot assay of Drosophila melanogaster. Third instar larvae trans-dihybrid for mwh and flr3 were exposed to varying concentrations (0-16 mg/l) of the gas for 1 h. Following this exposure via inhalation, the larvae were placed into vials containing Instant Medium. 7 days after the exposure, the adult flies in the vials were collected, and their wings were scored under 400X magnification for the presence of clones of cells possessing malformed wing-hairs. Such clones appeared as mwh-flr3 twin spots and single spots of either mwh or flr3 phenotype. Exposure to methyl bromide was found to result in the positive induction of both twin spots and large (greater than 2 cells) single spots. For each endpoint, a significant exponential association was obtained between concentration and frequency of spots per wing. Methyl bromide was found to be a negative inducer of small (1-2 cells) single spots at all concentrations except 16 mg/l where a positive effect was observed. Because twin spots arise exclusively from mitotic recombination, methyl bromide was identified as having recombinogenic activity in the somatic tissue of Drosophila larvae.

Extended major histocompatibility complex haplotypes in patients with gluten-sensitive enteropathy

We have studied major histocompatibility complex markers in randomly ascertained Caucasian patients with gluten-sensitive enteropathy and their families. The frequencies of extended haplotypes, defined as haplotypes of specific HLA-B, DR, BF, C2, C4A, and C4B allelic combinations, occurring more frequently than expected, were compared on patient chromosomes, on normal chromosomes from the study families, and on chromosomes from normal families. Over half of patient chromosomes consisted almost entirely of two extended haplotypes [HLA-B8, DR3, SC01] and [HLA-B44, DR7, FC31] which, with nonextended HLA-DR7, accounted for the previously observed HLA markers of this disease: HLA-B8, DR3, and DR7. There was no increase in HLA-DR3 on nonextended haplotypes or in other extended haplotypes with HLA-DR3 or DR7. The distribution of homozygotes and heterozygotes for HLA-DR3 and DR7 was consistent with recessive inheritance of the major histocompatibility complex-linked susceptibility gene for gluten-sensitive enteropathy. On the other hand, by odds ratio analysis and from the sum of DR3 and DR7 homozygotes compared with DR3/DR7 heterozygotes, there was an increase in heterozygotes and a decrease in homozygotes suggesting the presence of modifying phenomena.