Health System Practices and Perspectives of Social Risk Screening in Oncology

PURPOSE/OBJECTIVE(S)

Social risks (e.g., food insecurity) are adverse social/economic conditions associated with poor health outcomes. Among patients with cancer, presence of social risks is associated with increased late-stage diagnoses, care delays, and mortality. The purpose of this project was to assess the perspectives and practices regarding social risk screening within a large NCI-designated cancer center.

MATERIALS/METHODS

Email invitations to complete a secure, online survey were distributed to oncology healthcare staff (e.g., oncologists, nurses, pharmacists, medical assistants, social workers, and patient navigators) at Moores Cancer Center between June 1, 2022 and July 31, 2022. The 6-item survey collected information on clinical role, current practices and perceived barriers to screening for social risks as part of routine care. Respondents were categorized as MD-trained providers versus non-MD clinical staff. Descriptive statistics were used, including Fisher's exact test to compare responses by respondent type (MD vs non-MD). All analyses were conducted using data management and decision management software. This project was approved by the UCSD Institutional Review Board.

RESULTS

A total of 59 respondents completed the survey, including 20 MDs (34%) and 39 non-MD staff (66%). Overall, most respondents reported asking patients about their social risks (75%) and communicating information about patients' social risks with other healthcare staff when clinically relevant (84%). MDs were significantly more likely to agree that they ask patients about social risks when clinically relevant than non-MDs (95% vs 64%, p = 0.024). MDs were also more likely to communicate, review and use social risk information than their non-MD colleagues. The most reported barriers to integrating social risk information into clinical care, overall, included insufficient time (73%), uncertainty about who is responsible (70%), and lack of knowledge about existing tools (75%) for asking patients about social risks, as well as lack of resources to address social risks (76%). Non-MDs were more likely to cite concern that patients and families will feel uncomfortable answering questions about social risks (67% vs 20% of MDs, p = 0.003) as a barrier. Only 30% of MDs and 46% of non-MDs agreed that "asking about social risks is outside of the scope of my role" was a barrier.

CONCLUSION

Most oncology providers and staff agree that obtaining social risk information is important for patient care. Developing clinic-based solutions that integrate social risk screening and referral workflows within the oncology setting is imperative to reduce cancer health disparities. Future efforts that leverage the use of electronic health records to conduct social risk screening and streamline referrals to community-based resources in oncology may improve cancer health equity.

Increasing Use of Conservative Management of Low-Risk Prostate Cancer in the Veterans Affairs System from 2012 to 2021

PURPOSE/OBJECTIVE(S)

Conservative management (CM), including either active surveillance or watchful waiting, is the preferred management strategy for men with low-risk prostate cancer. We sought to describe contemporary trends in CM among men with localized prostate cancer across the equal-access Veterans Affairs (VA) system.

MATERIALS/METHODS

Using VA tumor registry data, we identified all men with a new diagnosis of biopsy-proven, clinically node-negative, non-metastatic prostatic adenocarcinoma from 2012 to 2021, excluding men with missing National Comprehensive Cancer Network risk group. We quantified the yearly proportion of patients with low and favorable intermediate-risk (FIR) prostate cancer undergoing conservative management and examined age-specific rates. Multivariable logistic regression was used to identify independent clinical predictors of CM among men with low-risk and FIR disease.

RESULTS

The cohort included 86,415 patients with localized prostate cancer, of whom 20,290 (23.5%) had low risk and 25,447 (29.5%) had FIR disease. The proportion of men diagnosed with low-risk disease decreased from 27.7% in 2012 to 20.1% in 2021. The proportion of men with localized prostate cancer who were 70 years or older at diagnosis increased from 19.5% in 2012 to 46.4% in 2021, with similar increases seen across risk groups. The proportion of men with low-risk disease undergoing CM increased from 63.1% in 2012 to 86.6% in 2021. CM rates in 2021 among low-risk patients were largely consistent across age groups (50-59: 85.1%; 60-69: 87.4%; 70+: 86.3%). For FIR patients, CM rates increased among the subset with Gleason 6 disease (49.5% in 2012 to 80.7% in 2021). In multivariable models, independent predictors of CM in low-risk patients included older age, more recent year, lower PSA at diagnosis, North Atlantic or Pacific region, and presence of another cancer at diagnosis; similar predictors were found in FIR patients. Self-reported race (Black, White, or Other) was not associated with CM. While there was wide geographic variation in CM rates among low-risk patients early in the study period (2012-2014: 56.1% in Southeast region vs 74.1% in Pacific), these disparities resolved in recent years (2019-2021: 83.2% in Southeast vs 83.8% in Pacific).

CONCLUSION

Rates of conservative management for localized prostate cancer increased dramatically over time in the VA, with over 85% of low-risk patients managed conservatively in 2021. Recent years showed no differences in CM rates by self-reported race, geographic region, or age group. Despite this progress, we observed a concomitant increase in the proportion of men 70 years or older diagnosed with localized prostate cancer, including low risk disease. This raises a need to consider strategies to reduce the diagnosis of low-risk disease in elderly Veterans.

Association of Transgender or Gender Non-Binary Identity on Disease Characteristics and Survival Outcomes in Prostate Cancer

PURPOSE/OBJECTIVE(S)

While it is becoming increasingly common for people to identify as transgender or gender-non-binary, our understanding of the influence of gender identity on disease severity of hormone-sensitive malignancies, including prostate cancer (PC) is limited. The goal of this study is to compare the aggressiveness of disease and survival outcomes between transgender or gender non-binary (TG) and cis-gender (CG) patients with PC.

MATERIALS/METHODS

The cohort included patients diagnosed with PC between 1999 and 2022 within the Veterans Health Administration (VHA) Database. TG patients were identified with an ICD 9 or 10 diagnosis code that occurred prior to PC diagnosis. Treatment information and baseline disease characteristics were ascertained through the VHA electronic health records. Multivariable logistic regressions were performed to estimate the association between TG status and presenting with Gleason > = 8, PSA > 20 ng/mL, and metastatic disease at diagnosis. Covariates in these models included age at diagnosis, race, ethnicity, marital status, and smoking status. Metastases were identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The association between TG identity status and metastatic disease was calculated with a Cox regression model. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test.

RESULTS

The final cohort was composed of 282,264 individuals, 219 (0.08%) of which were identified as TG. TG patients have similar odds of presenting with presenting with Gleason Score ≥8 (Odds Ratio (OR) 1.18, p = 0.31), PSA >20 ng/mL (OR 0.78, p = 0.59), and metastasis at diagnosis (OR 0.47, p = 0.29). There were 34,918 patients who develop metastatic disease at any time, 24 of which were TG. The 10-year cumulative incidence of metastases for TG and CG individuals was 11.5% (95% Confidence Interval (CI): 6.6-16.1%) and 13.9% (CI: 13.7-14.0%), respectively. There was no significant difference between TG status and risk of developing metastases (Hazard Ratio (HR) 0.93, p = 0.71). The 10-year overall survival for TG and CG was 73.4% (CI: 66.5-80.9%) and 65.0% (CI: 64.8-65.2%), respectively. There was no significant difference between TG status and overall survival (Hazard Ratio (HR) 0.83, p = 0.13).

CONCLUSION

TG individuals do not appear to have a difference in disease characteristics at diagnosis or survival compared to CG individuals. Future research should be done to determine the effect of gender affirming treatment on these outcomes. Furthermore, it is unclear if diagnosis codes are accurately identifying TG individuals.

Psychiatric or Drug Hospitalizations in Older Cancer Survivors on Long-Term Opioids

PURPOSE/OBJECTIVE(S)

Non-cancer patients prescribed chronic courses of opioids are at high risk of psychiatric or drug overdose particularly during the post-tapering period, but data are limited on this effect in cancer survivors. This study quantified emergency room visits or hospital admissions for psychiatric or drug/alcohol overdose/withdrawal (henceforth "events") in cancer survivors prescribed opioids related to their cancer diagnoses.

MATERIALS/METHODS

We identified 15,002 cancer survivors in SEER-Medicare diagnosed between 2010 and 2017 with bladder, breast, colon/rectal, kidney, lung, head/neck, or prostate cancer who were prescribed at least 6 months of stable opioids following their cancer diagnosis. The post-tapering interval was defined as a 3-month period following monthly oral morphine equivalent (OME) reduction of at least 15%. Outcomes were studied with logistic regression and time-dependent analysis was performed using a generalized estimating equation (GEE) using an auto-regressive correlation matrix; all reported p-values are two-sided.

RESULTS

The study had a median follow up of 24 months; in this time, 8,311 patients (55%) initiated a taper at some point. The mean daily OME in non-tapering patients was 33.4 mg compared to 47.4 mg in tapering patients (p < 0.001); both groups had a low rate of any prior events in the baseline period (7.5% versus 8%, respectively p = 0.686). Patients attempting a taper also tended to be younger (40.3% versus 35.2% age 66-70, p <0.001). There was no difference by race. Opioid tapering was not associated with a higher rate of events in the 3-month post-taper period (p = 0.81) when correcting for sex, primary care site, baseline event rate, comorbidity, and age.

CONCLUSION

Many older cancer survivors who are prescribed chronic opioids remain on high doses of opioids after completing therapy. These patients are at risk of acute psychiatric and drug-related emergencies. Unlike the general population, this risk does not appear to be exacerbated in the months following opioid tapering. Oncologists should be mindful of psychiatric and drug-related events in long-term cancer survivors prescribed chronic opioids, and these data should reassure physicians deciding whether or not to initiate an opioid taper. Future research should explore risk mitigation in these patients.

Prostate Cancer Screening Uptake in Transgender Females

PURPOSE/OBJECTIVE(S)

Transgender females (TF) can experience aggressive forms of prostate cancer, but their uptake of prostate-specific antigen (PSA) screening for prostate cancer is not well-known. Although national guidelines recommend PSA screening based on age, they do not specify recommendations based on gender identity. We evaluate and compare factors associated with recent PSA screening between cisgender men (CM) and TF using Behavioral Risk Factor Surveillance System (BRFSS) survey data.

MATERIALS/METHODS

BRFSS 2018-2020 data was queried to identify CM and TF older than 40 who provided responses to BRFSS questions asking time since last PSA test and whether a provider discussed PSA advantages and disadvantages. Rates of recent screening, defined as receiving a PSA test in the last 2 years with no current or past history of prostate cancer, were calculated for CM and TF. Ages were grouped as younger than 55, 55-69, and 70 years and older based on national PSA screening guidelines, and a 1:4 age-matched cohort between CM and TF was created. Weighted multivariable logistic regressions to measure effects of gender identity, sociodemographic variables, and healthcare access on the odds of recent screening and were calculated and presented as odds ratios (ORs) [95% confidence intervals].

RESULTS

The age-matched cohort had 1,252 CM and 313 TF; TF had a lower overall screening rate than CM (24% vs. 42.3%). TF and CM had similar rates of primary care visits within the last year (85% vs. 86%), but TF were less likely to report that a PSA screen was recommended to them by a provider (33% vs. 49%, p<0.001). Even among all patients with this PSA screening recommendation, fewer TF were recently screened than CM (63% vs. 78%, p = 0.002). In a multivariable regression model, TF had lower odds of recent screening (OR = 0.5 [0.32-0.76], p<0.001) when compared to CM. Discussion of PSA advantages with a provider had higher odds (OR = 15 [10.6-21.5], p<0.001) while discussion of PSA disadvantages was not significantly associated with screening (OR = 0.84 [0.6-1.2], p = 0.3). A college education had higher odds of recent screening (OR = 2.66 [1.2-6.3], p = 0.02) than no high school education. In a multivariable regression model of TF patients, TF aged 70 years and older had higher odds of recent screening (OR = 2.8 [1.1-7.1], p = 0.002) than TF aged 55-69, with screening rates of 14%, 21% and 60% for the under 55, 55-69, and 70+ age groups, respectively. Similarly, to the overall cohort, provider-led discussion of PSA advantages had the strongest association with recent screening (OR = 15.4 [6.15-43.1], p < 0.001), followed by being college educated (OR = 5.7 [1.5-24.9], p = 0.01).

CONCLUSION

TF patients were screened with PSA at a lower rate than CM. Discussing PSA screening benefits with a provider had the largest effect on recent screening among TF patients, highlighting the provider's role in screening uptake. Future studies should continue to evaluate the effects of provider perceptions and barriers to healthcare access on PSA screening in TF.

FORMULA-509: A Multicenter Randomized Trial of Post-Operative Salvage Radiotherapy (SRT) and 6 Months of GnRH Agonist with Either Bicalutamide or Abiraterone Acetate/Prednisone (AAP) and Apalutamide (Apa) Post-Radical Prostatectomy (RP)

PURPOSE/OBJECTIVE(S)

FORMULA-509 was designed to evaluate whether adding six months of AAP and Apa to a GnRH Agonist could improve outcomes compared to six months of bicalutamide plus GnRH Agonist for patients with unfavorable features receiving SRT for a detectable PSA post-RP.

MATERIALS/METHODS

FORMULA-509 is an investigator-initiated, multi-center, open-label, randomized trial. Patients had PSA ≥0.1 post-RP and one or more unfavorable features (Gleason 8-10, PSA >0.5, pT3/T4, pN1 or radiographic N1, PSA doubling time <10 months, negative margins, persistent PSA, gross local/regional disease, or Decipher High Risk). All patients received SRT plus 6 months of GnRH agonist and randomization was to concurrent bicalutamide 50 mg or AAP 1000 mg/5 mg + Apa 240 mg QD. Radiation to pelvic nodes was required for pN1 and optional for pN0. The primary endpoint was PSA progression-free survival (PFS) and secondary endpoint was metastasis-free survival (MFS) determined by conventional imaging. The study was powered to detect a HR of 0.50 for PFS and a HR of 0.30 for MFS, each with 80% power and one-sided type I error of 0.05. Stratification was by PSA at study entry (>0.5 vs.≤0.5) and pN0 vs pN1. Analyses within these subgroups were pre-planned and utilized two-sided p-values.

RESULTS

Three hundred forty-five participants (332 evaluable) from 9 sites were randomized from 11/24/2017 to 3/25/2020 (172 bicalutamide, 173 AAP/Apa). Median follow-up was 34 (6-53) months; 29% were pN1 and 31% had PSA >0.5 ng/mL. The HR for PFS was 0.71 (90% CI 0.49-1.03), stratified one-sided log-rank p = 0.06 (3-year PFS was 68.5% bicalutamide vs 74.9% AAP/Apa). The HR for MFS was 0.57 (90% CI 0.33-1.01), stratified one-sided log rank p = 0.05 (3-year MFS was 87.2% bicalutamide vs 90.6% AAP/Apa). In a pre-planned analysis by stratification factors, AAP/Apa was significantly superior for patients with PSA >0.5 for PFS [HR 0.50, (95% CI 0.27-0.95), p = 0.03 (2-sided); 3-year PFS 46.8% bicalutamide vs. 67.2% AAP/Apa] and for MFS [HR 0.32 (95% CI 0.13-0.84), p = 0.02 (2-sided); 3-year MFS 66.1% bicalutamide vs. 84.3% AAP/Apa.] No statistically significant benefit was detected in pre-planned analyses of stratification subgroups defined by PSA≤0.5, pN0, or pN1. Adverse events were consistent with the known safety profiles of the agents being studied, with more rash and hypertension in the AAP/Apa arm.

CONCLUSION

Although this primary analysis did not meet the pre-specified threshold for statistical significance, it does strongly suggest that the addition of AAP/Apa instead of bicalutamide to SRT+6 months of GnRH Agonist may improve PFS and MFS, particularly in the subgroup of patients with PSA>0.5 where a pre-planned subgroup analysis by stratification factors observed a statistically significant benefit for both PFS and MFS. (NCT03141671).

Association between National Area Deprivation Index Rank on Disease Characteristics in Prostate Cancer

PURPOSE/OBJECTIVE(S)

Social determinants of health (SDH) play a large role in an individual's health; in recent years, there has been a push to examine the impact of one's neighborhood or "place." Previous studies have showed that living in a disadvantage neighborhood is associated with worth health outcomes. We hypothesize that equal access care will diminish the effects of living in a disadvantaged neighborhood.

MATERIALS/METHODS

We identified non-Hispanic African American (AA) and White (NHW) men diagnosed with PC between 2012 and 2015 in the Veterans Health Administration (VHA). Patient SDH was measured using census tract level 2015 Area Deprivation Index (ADI) information. The ADI is a composite measure that includes factor such as housing quality, income, health care access etc. We measured both National and State ADI rank as a continuous variable from 1 to 10 with 10 being highest deprivation. Patient information was gathered at the census tract level while ADI is assigned at the census block group. In order to get all information on the same geographic level, we averaged the ADI to its corresponding census tract. Associations between ADI and disease characteristics at diagnosis were measured using multivariable logistic regression models including age, race, and marital status as covariates.

RESULTS

The final cohort was composed of 25,222 men (8,384 AA and 16,838 NHW.) At the national level, there was no significant association between ADI and Gleason Score ≥8 (Odds Rations (OR) 0.99 [95% Confidence Interval (CI):0.98 - 1.00]), PSA >20 ng/mL (OR 0.99 [95% CI: 0.98 - 1.01]), and metastasis at diagnosis (OR 1.01 [CI: 0.98-1.04]).

CONCLUSION

Our results are consistent with our hypothesis that equal access care diminishes the impacts of living within a disadvantaged neighborhood. Future research should investigate the interaction between health care access and social and demographic factors.

Metabolic responses to intracerebroventricular leptin and restricted feeding

Leptin is a hormone secreted by adipocytes, which plays an important role in the control of food intake and metabolic processes. In the current study, a dose-dependent relationship was shown between a bolus intracerebroventricular rat recombinant leptin administration and reductions in food intake and body weight in Sprague-Dawley rats. During the 24 h postinjection period, food intake was decreased by 24, 26, and 52% with 0.625, 2.5, and 10 microg of leptin, respectively. Body weight was reduced by 2, 3, and 5% at 24 h after leptin administration at the doses of 0.156, 2.5, and 10 microg, respectively. Furthermore, indirect calorimetry demonstrated that five daily i.c.v. injections of leptin resulted in an increase in heat production per unit of metabolic body size and fat oxidation by approximately 10 and 48%, respectively. In contrast, food-restricted rats that consumed the equivalent amount of food as leptin-treated rats for 5 days decreased their energy expenditure by 10%. Food restriction was found to decrease respiratory quotient in a similar pattern as the leptin administration. When ad lib feeding was resumed, food-restricted rats quickly recovered their normal food intakes, body weights, and metabolism. Conversely, leptin treatment has prolonged effects on body weight resulting from different metabolic responses than food restriction. Leptin not only suppresses food intake, but also enhances energy expenditure to reduce fat depots.

Whole body composition of rats determined by dual energy X-ray absorptiometry is correlated with chemical analysis

The use of dual energy X-ray absorptiometry (DXA) is increasing in animal research, but data comparing whole body composition by DXA and chemical analysis (CHEM) in rats are limited. Lean and obese Zucker female rats were used to compare DXA (QDR1000W, Hologic, Waltham, MA) values with CHEM data for percent fat (%FATDXA, %FATCHEM), lean body mass (%PROTDXA, %PROTCHEM) and bone mineral content (%BMCDXA, %ASHCHEM). Four groups of rats (n = 9) were tested for differences in body composition due to consumption of a 100 g guar gum supplement/kg to see if DXA was as sensitive as CHEM in detecting body composition differences induced by diet. The study was analyzed using a split-plot ANOVA where the main plot was a 2 x 2 factorial with phenotype (obese or lean) and treatment (guar gum or control) as the effects, and the subplot was method of detecting body composition (DXA and CHEM), which was treated as a repeated measure. Absolute values for percent fat differed significantly (P < 0.0001) between the two methods as %FATDXA was consistently higher than %FATCHEM. There was not a statistically significant difference due to method for %PROT (P = 0.13). Values for %BMCDXA were significantly (P < 0.0049) lower than %ASHCHEM values. The differences in body composition due to diet treatment were detected similarly by DXA and CHEM. Significant correlations were found between the methods (P < 0.0001) for %FAT (r = 0.99), %PROT (r = 0.96) and %BMC or ASH (r = 0.81). Bland-Altman plots showed good agreement between methods, and regression equations were developed to estimate CHEM values from DXA readings. DXA may provide an alternative method for assessing changes in whole body composition.

Phototherapy: all wrapped up?

Preliminary reports indicate that the fiberoptic blanket can be an alternative to conventional phototherapy. With its reported advantages, the fiberoptic blanket may become more common in the home care setting and reduce prolonged hospitalizations.

Pyelosinus extravasation and urinoma associated with malignancy. Computed tomography demonstration

We report 3 cases of abdominal malignancy with urinary tract obstruction and pyelosinus extravasation. Urinomas were present in 2 cases. The computed tomographic findings are emphasized, including the distribution of the extravasated urine reflecting the partitioning in the perirenal space. The cases presented within an eighteen-month period suggest pyelosinus extravasation and urinoma formation may not be uncommon in malignant disease affecting the retroperitoneum and pelvis.

Transluminal balloon angioplasty of infrahepatic caval anastomotic stenosis following liver transplantation: case report

Treatment of an infrahepatic caval anastomotic stenosis with percutaneous transluminal balloon angioplasty is described in a patient 5 weeks after liver transplantation. Pressure measurements confirmed the significance of the obstruction and the success of the dilatation procedure.

Percutaneous transfemoral placement of the Kimray-Greenfield vena cava filter

In 109 patients in whom inferior vena caval interruption was indicated to prevent pulmonary embolism, Kimray-Greenfield (K-G) filters were inserted from a percutaneous transfemoral approach, 94 from the right common femoral vein and 15 from the left common femoral vein. All attempts at transfemoral filter insertion were successful except in two patients in whom a left common femoral approach was used. No complications occurred during insertion. In four patients, clinical evidence of femoral vein thrombosis ensued within 48 hours of filter insertion. There were no complications related to filter migration, and in 97% of patients the alignment was satisfactory. The percutaneous transfemoral route is a rapid and effective method for inserting K-G filters. The most frequent postinsertion complication was femoral vein thrombosis (ten patients), but only two patients suffered permanent sequelae.

The role of computed tomography in the evaluation of pneumatosis intestinalis

Computed tomography (CT) is useful in evaluating patients with pneumatosis intestinalis while excluding other causes of abdominal pain and sepsis. We present a case along with additional illustrative CT sections to show its usefulness in such cases.

Anthropometric and computerized tomographic measurements of lower extremity lean body mass

The loss of lean muscle mass is one of the hallmarks of protein-calorie malnutrition. Anthropometry is a standardized technique used to assess the response of muscle mass to nutrition therapy by quantifying the muscle and fat compartments. That technique does not accurately reflect actual limb composition, whereas computerized tomography does. Twenty lower extremities on randomly chosen men and women patients were evaluated by anthropometry and computerized tomography. Total area, muscle plus bone area, total volume, and muscle plus bone volume were correlated, using Heymsfield's equation and computerized tomography-generated areas. Anthropometrics overestimated total and muscle plus bone cross-sectional areas at almost every level. Anthropometry overestimated total area and total volume by 5% to 10% but overestimated muscle plus bone area and muscle plus bone volume by as much as 40%. Anthropometry, while easily performed and useful in large population groups for epidemiological studies, offers a poor assessment of lower extremity composition. On the other hand, computerized tomography is also easily performed and, while impractical for large population groups, does offer an accurate assessment of the lower extremity tissue compartments and is an instrument that might be used in research on lean muscle mass.

Gas bubbles in polymethylmethacrylate cranioplasty simulating abscesses: CT appearance

Polymethylmethacrylate (PMMA) cranioplasty procedures were performed on 20 patients over a 2-year period. Nine of these patients had a total of 17 CT examinations, performed when clinically indicated. On 16 of the 17 CT scans, the appearance of the cranioplasty plate was characteristic of plates with gas bubbles. The appearance of these bubbles was stable over an extended period of time, ruling out clinical reasons for this appearance. The original interpretations of the CT scans were variable, inconclusive, or even erroneous. An understanding of the application of PMMA plates and their characteristics is necessary to accurately interpret the CT appearance of the PMMA cranioplasty plate.

Traumatic atlantooccipital dislocation: two cases with survival

These two cases with long-term survival after anterior and posterior AO dislocation point out the importance of making the diagnosis. Our simple technique of rapid CT confirmation of AO dislocation is a practical adjuvant procedure, particularly in patients with suspected intracranial injury.

Naproxen in the treatment of rheumatoid arthritis

Naproxen, a new nonsteroidal anti-inflammatory analgesic drug was found to be better than placebo and as effective as indomethacin in the treatment of rheumatoid arthritis. The drug was well tolerated, and appears to be a useful alternative to more established medication such as aspirin.

Familial reactive arthritis of Reiter's and ankylosing spondylitis types in the HLA-27 genotype

The close relationship between Reiter's disease and ankylosing spondylitis, which had previously been suspected on the grounds of family and population studies, has been re-emphasised following the recent demonstration of their common close association with the HLA-27 genotype. Nevertheless there are few case reports of both conditions occurring simultaneously in first degree relatives; and documentation of HLA genotype in such families was not generally considered before 1973. Both varieties of reactive arthritis are reported here as occurring in first degree relatives sharing HLA-27 genotype.

Gout in Maoris

Historical evidence suggests that the Maori people of New Zealand were virtually untroubled by gout or obesity at a time when these disorders, along with other elements of the gouty diathesis, were rife in the best fed and hardest drinking sections of the Northern European population. By the mid 20th century, however, the apparent decline of the gout in Europe and North America and the breakup of the gouty diathesis in those lands had been more than compensated by their large-scale reappearance in the Maori and in other indigenous inhabitants of the Pacific Basin who, at first sight, appeared to have become one large gouty family. Half the Polynesian population of New Zealand, Rarotonga, Puka Puka, and the Tokelau Islands proved to be hyperuricemic by accepted European and North American standards, the associated gout rate reaching 10.2% in Maori males aged 20 and over. The trends towards hyperuricemia and gout, on the one hand, and towards obesity, diabetes mellitus, hypertension, and associated degenerative vascular disorders, on the other hand, which manifest themselves separately in some Polynesian Pacific Islanders, run together in the Maori and Samoan people, presenting a combined problem of considerable importance to the public health. The appearance of these traits under conditions of plenty in the descendants of hardy and wide-ranging Polynesian voyagers, suggests the emergence of a formerly favorable ancestral polygenic variation through selection for survival under harder conditions. This may now have lost its primitive survival value with a paradoxic shift towards increased prevalence of obesity and the gouty diathesis in more affluent environmental conditions. This may now constitute a genetic load, with recent environmentally determined increase in morbidity and mortality rates from degenerative vascular disorders. There is no satisfactory evidence that overproduction of uric acid differs in mechanism from its European counterparts, although more work remains to be done to determine whether there is any difficulty in renal handling of an increased uric acid load. A high Maori morbidity rate from gout and morbidity and mortality rates from associated components of the gouty diathesis in the face of readily available skilled medical advice and care, indicate the need for greater future attention to help education and health care delivery, at least while conditions of plenty continue. Continuation of previous epidemiologic surveillance may then be required in order to provide a continuing index of the effectiveness of these measures, as well as an opportunity for further research into the interrelationships of these associated disorders.

Rheumatoid arthritis of the cervical spine. An analysis of 333 cases

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