A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of a bupivacaine hydrochloride implant in patients undergoing abdominoplasty

INTRODUCTION

Surgical site infiltration with bupivacaine hydrochloride (HCl) is a standard element of postoperative analgesia for soft tissue surgeries, but results in short-lived analgesia. A novel bupivacaine implant, XARACOLL (bupivacaine HCl), is Food and Drug Administration approved for treatment of acute postsurgical pain following adult inguinal herniorrhaphy. This study examined the efficacy and safety of the bupivacaine implant (300 mg) compared with placebo for postsurgical pain after abdominoplasty.

METHODS

In this double-blind, placebo-controlled study, patients undergoing abdominoplasty were randomized to three 100 mg bupivacaine implants or three placebo collagen implants, in a 1:1 ratio, implanted intraoperatively. No other analgesics were administered into the surgical site. Patients were allowed opioids and acetaminophen for postoperative pain. Patients were followed for up to 30 days after treatment.

PRIMARY OUTCOME

the analgesic effect of the bupivacaine implants through 24 hours postsurgery, measured by the sum of time-weighted pain intensity (SPI24). Prespecified key secondary outcomes included SPI48 and SPI72, percentage of opioid-free patients through 24, 48, and 72 hours, and adverse events, which were tested sequentially to control for multiplicity (ie, if the first variable failed to reach significance, no subsequent variables were declared statistically significant).

RESULTS

The bupivacaine implant patients (n=181) reported statistically significant lower SPI24 (mean (SD) SPI24=102 (43), 95% CI 95 to 109) compared with placebo patients (n=184; SPI24=117 (45), 95% CI 111 to 123, p=0.002). SPI48 was 190 (88, 95% CI 177 to 204) for INL-001 and 206 (96, 95% CI 192 to 219) for placebo, and not significantly different between groups. The subsequent secondary variables were therefore declared not statistically significant. SPI72 was 265 (131, 95% CI 244 to 285) for INL-001 and 281 (146, 95% CI 261 to 301) for placebo. The opioid-free percentage of patients at 24, 48, and 72 hours was 19%, 17%, and 17% for INL-001 and 6.5% for placebo patients (at all timepoints). The only adverse event occurring in ≥5% of patients and for which proportion INL-001 >placebo was back pain (7.7% vs 7.6%).

CONCLUSION

The study design was limited by not containing an active comparator. Compared with placebo, INL-001 provides postoperative analgesia that is temporally aligned with the period of maximal postsurgical pain in abdominoplasty and offers a favorable safety profile.

TRIAL REGISTRATION NUMBER

NCT04785625.

Efficacy and Safety of Sublingual Cyclobenzaprine for the Treatment of Fibromyalgia: Results From a Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To evaluate the efficacy and safety of TNX-102 SL, a once-nightly sublingual formulation of cyclobenzaprine, in reducing pain in patients with fibromyalgia (FM).

METHODS

RELIEF was a double-blind, randomized, placebo-controlled trial. Overall, 503 patients received TNX-102 SL 2.8 mg for 2 weeks, followed by 5.6 mg for 12 weeks (248 patients), or matching placebo (255 patients). The primary end point was change from baseline at week 14 in the weekly average of daily pain scores. Secondary end points included Patient Global Impression of Change (PGIC) scores, Fibromyalgia Impact Questionnaire Revised (FIQR) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance and Fatigue scores, and daily sleep quality. Safety was assessed by adverse event (AE) reporting.

RESULTS

Reduction in daily pain from baseline at week 14 was significantly greater with TNX-102 SL (least squares [LS] mean change -1.9 [95% confidence interval (95% CI) -2.1, -1.7]) versus placebo (LS mean change -1.5 [95% CI -1.7, -1.3]; P = 0.01). TNX-102 SL was not associated with significant improvement in PGIC at week 14 but was associated with improvements in FIQR scores, PROMIS scores, and daily sleep quality. Overall, 59.7% of patients receiving TNX-102 SL and 46.3% receiving placebo reported treatment-emergent AEs; the most common were oral hypoesthesia (17.3% with TNX-102 SL versus 0.4% with placebo), oral paresthesia (5.6% versus 0.4%, respectively), and product taste abnormal (4.4% versus 0.4%, respectively).

CONCLUSION

In this phase III, randomized, controlled trial of patients with FM, treatment with TNX-102 SL was associated with significant reductions in daily pain and was safe and well tolerated.

Randomization tests in clinical trials with multiple imputation for handling missing data

Randomization-based inference is a useful alternative to traditional population model-based methods. In trials with missing data, multiple imputation is often used. We describe how to construct a randomization test in clinical trials where multiple imputation is used for handling missing data. We illustrate the proposed methodology using Fisher's combining function applied to individual scores in two post-traumatic stress disorder trials.

Efficacy of pitolisant in patients with high burden of narcolepsy symptoms: pooled analysis of short-term, placebo-controlled studies

STUDY OBJECTIVE

To evaluate the efficacy of pitolisant, a histamine 3 (H₃)-receptor antagonist/inverse agonist, in adult patients with high burden of narcolepsy symptoms.

METHODS

Data were pooled from two randomized, placebo-controlled, 7- or 8-week studies of pitolisant (titrated to a potential maximum dose of 35.6 mg/day) in adults with narcolepsy. Analyses included three independent patient subgroups: Epworth Sleepiness Scale (ESS) baseline score ≥16, Maintenance of Wakefulness Test (MWT) sleep latency ≤8 min, and ≥15 cataplexy attacks per week.

RESULTS

The analysis populations included 118 patients for ESS (pitolisant, n = 60; placebo, n = 58), 105 for MWT (pitolisant, n = 59; placebo, n = 46), and 31 for cataplexy (pitolisant, n = 20; placebo, n = 11). On the ESS, least-squares mean change from baseline was significantly greater for pitolisant (-6.1) compared with placebo (-2.3; P < 0.001). Significantly more pitolisant-treated patients were classified as treatment responders: ESS score reduction ≥3, 69.0% in the pitolisant group versus 35.1% in the placebo group (P = 0.001); final ESS score ≤10, 36.2% versus 10.5%, respectively (P = 0.005). On the MWT, mean sleep latency increased from 3.5 min to 10.4 min with pitolisant and from 3.4 min to 6.8 min with placebo (P = 0.017). Least-squares mean change in the weekly rate of cataplexy was significantly greater for pitolisant (-14.5; baseline, 23.9; final, 9.4) compared with placebo (-0.1; baseline, 23.1; final, 23.0; P = 0.004). Headache was the most common adverse event with pitolisant.

CONCLUSIONS

Pitolisant, at once-daily doses up to 35.6 mg, was efficacious for reducing excessive daytime sleepiness and cataplexy in patients with severe narcolepsy symptom burden.

0768 Time Course Of Improvement In Excessive Daytime Sleepiness And Cataplexy During Treatment With Pitolisant In Patients With Narcolepsy

Introduction

This analysis evaluated the efficacy of pitolisant over time in three 7- to 8-week, randomized, placebo-controlled studies of adults with narcolepsy.

Methods

Patients in all 3 studies (HARMONY-1, HARMONY-1bis, HARMONY-CTP) experienced excessive daytime sleepiness (EDS) at study baseline; patients in HARMONY-CTP also experienced ≥3 cataplexy attacks/week. Pitolisant was titrated to a maximum dose of 35.6 mg/day (HARMONY-1, HARMONY-CTP) or 17.8 mg/day (HARMONY-1bis). Change from baseline in mean Epworth Sleepiness Scale (ESS) score (3 studies) and mean weekly rate of cataplexy (WRC; 1 study) was compared for pitolisant versus placebo.

Results

In the higher-dose HARMONY-1 (pitolisant, n=31; placebo, n=30) and HARMONY-CTP (pitolisant, n=54; placebo, n=51) studies, ESS score improvement was significantly greater with pitolisant versus placebo beginning at Week 2 (LS mean difference, -2.8; P=0.015) and Week 3 (LS mean difference, -2.0; P=0.005), respectively. In the lower-dose HARMONY-1bis study (pitolisant, n=66; placebo, n=32), significant separation from placebo was first observed at Week 7 (LS mean difference, -2.3; P=0.044). At end-of-treatment, LS mean difference in ESS score change from baseline was -3.1 (P=0.022) in HARMONY-1, -3.4 (P&lt;0.001) in HARMONY-CTP, and -2.2 (P=0.030) in HARMONY-1bis. In HARMONY-CTP, LS mean WRC with pitolisant was 11.7 at baseline, 4.6 at end-of-treatment, and 5.1 after a 1-week, placebo-washout period. Improvement in WRC was significantly greater with pitolisant versus placebo beginning at Week 2 (LS mean difference, -5.3; P=0.004) and continued through end-of-treatment (LS mean difference, -6.2; P&lt;0.001); there was no evidence of rebound cataplexy after placebo-washout (LS mean difference, -4.9; P=0.027).

Conclusion

During pitolisant treatment, improvement in EDS occurred sooner (within first few weeks) and was more robust in studies that permitted titration to the maximum recommended dose (35.6 mg/day). The rate of cataplexy attacks decreased early during treatment, with no evidence of rebound when pitolisant was withdrawn.

Support

Bioprojet Pharma and Harmony Biosciences, LLC.

0762 Efficacy Of Pitolisant In Patients With High Burden Of Narcolepsy Symptoms

Introduction

Recent literature suggests that histamine may play an important role in narcolepsy. This post hoc analysis evaluates the efficacy of pitolisant, a histamine 3 (H3)-receptor antagonist/inverse agonist, in patients with high burden of the main narcolepsy symptoms.

Methods

Data were pooled from 2 randomized, placebo-controlled, 7- and 8-week studies of pitolisant (individually titrated; maximum dose, 35.6 mg/day) in adults with narcolepsy. Analyses included 3 independent patient subgroups: baseline score of &gt;16 on the Epworth Sleepiness Scale (ESS), sleep latency of ≤8 minutes on the Maintenance of Wakefulness Test (MWT), and ≥15 cataplexy attacks per week.

Results

The analysis populations included 108 patients for the ESS (pitolisant, n=54; placebo, n=54), 105 for the MWT (pitolisant, n=59; placebo, n=46), and 31 for cataplexy (pitolisant, n=20; placebo, n=11). Mean change in ESS from baseline was significantly greater for pitolisant (-6.1) compared with placebo (-2.6; P=0.0002). A significantly greater percentage of pitolisant-treated patients were classified as treatment responders: for ESS score reduction ≥3, 68.5% in the pitolisant group versus 35.2% in the placebo group (P=0.0006); for final ESS score ≤10, 35.2% versus 9.3%, respectively (P=0.0026). Mean increase in sleep latency on the MWT was significantly greater for pitolisant (7.0 minutes) compared with placebo (3.4 minutes; P=0.0089). Decrease in mean weekly rate of cataplexy was significantly greater for pitolisant (baseline, 21.8; final, 3.9) compared with placebo (baseline, 20.9; final, 18.2); the rate ratio was 0.35 (95% CI, 0.26‒0.47; P&lt;0.001). The adverse event profile in the analysis populations was consistent with the known safety profile for pitolisant; headache was the most common adverse event in pitolisant-treated patients (10.0%-20.4%).

Conclusion

In patients with severe symptom burden, pitolisant produced significantly greater improvements in excessive daytime sleepiness and cataplexy compared with placebo, highlighting the important role of histamine in narcolepsy.

Support

Bioprojet Pharma and Harmony Biosciences, LLC.

Analgesic efficacy, safety, and tolerability of a long-acting abuse-deterrent formulation of oxycodone for moderate-to-severe chronic low back pain in subjects successfully switched from immediate-release oxycodone

OBJECTIVES

This post hoc analysis of data from a randomized, double-blind, placebo-controlled, enriched-enrollment randomized-withdrawal Phase III study evaluated the safety, tolerability, and analgesic efficacy of Oxycodone DETERx extended-release (ER), abuse-deterrent capsules (Xtampza® ER) in subjects with chronic low back pain who were successfully transitioned from immediate-release (IR) oxycodone.

METHODS

Continuous outcomes were analyzed using a mixed-model repeated-measures approach; binomial outcomes were analyzed using chi-squared; and time-to-event outcomes using Kaplan-Meier analyses.

RESULTS

A total of 110 subjects previously prescribed IR oxycodone entered the Open-label Titration Phase. Forty-four subjects were randomized to Oxycodone DETERx (n=22) or placebo (n=22) in the 12-week Double-blind Maintenance Phase. Efficacy results in this subgroup showed a statistically significant difference between Oxycodone DETERx and placebo in average pain intensity scores from Randomization Baseline to Week 12 (least squares mean [± standard error], -1.88 [0.70]; P=0.0078). Additional efficacy results indicated that Oxycodone DETERx vs placebo was associated with a statistically significant benefit in durability of effect from Week 2 through Week 12 (P<0.01), numbers of subjects with a ≥30% (n [%] 10 [45.5%] vs 0 [0%]; P=0.0004) and ≥50% (10 [45.5%] vs 0 [0%]; P=0.0004) improvement in pain intensity, longer time-to-exit (P=0.0014), a greater number of subjects who completed the study (14 [63.6%] vs 4 [18.2%]), and less rescue medication use (acetaminophen; mean [SD], 163.5 [337.8] mg) vs 216.2 [377.3] mg). Adverse event profiles were consistent with opioid class effects and results from the original study; Oxycodone DETERx was well tolerated in subjects previously treated with short-acting oxycodone.

CONCLUSIONS

Oxycodone DETERx resulted in clinically meaningful and statistically significant efficacy in subjects with chronic low back pain who were previously prescribed IR oxycodone and were successfully switched to ER Oxycodone DETERx.

Characterizing the inpatient care of young adults experiencing early psychosis

Introduction/objectives

The available literature suggests that treatments and health services for psychosis are considered to be poorly organized and highly variable. Little is known, however, about how inpatient care is provided to individuals experiencing early psychosis. To facilitate quality improvement activities, we characterized the care this patient group receives in an inner city hospital.

Methods

We performed chart reviews of individuals admitted to psychiatric inpatient units at St. Paul's Hospital, Vancouver, British Columbia between 01/04/2014 and 31/03/2016. Those who were 17–25 years of age and hospitalized for psychotic symptoms at the time of admission were included. Demographic and health service use were summarized using descriptive characteristics.

Results

We identified 73 inpatients (mean age = 22; males = 78%; Caucasian = 41%) that met study inclusion criteria, having a combined total of 102 care episodes and an average length of stay of 30.7 days (median = 18; min = 3; max = 268). Half of the care episodes were repeat admissions, with up to 30% of the patients readmitted within 28 days of discharge. Physical and mental status examinations (MSE) were performed in virtually all care episodes, although frequency is low (31.4% had daily physical examinations and 18.6% had MSE every nursing shift). In 49% and 50% of care episodes, patients were given oral antipsychotics and discharged on depot medications. Even when indicated, not all care episodes had follow-up appointments (60%) or referrals to income assistance (35%), community mental health teams (61%), and housing support (38%).

Conclusions

Specific programs are needed to address current gaps in inpatient care for patients with early psychosis.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Evaluation of the durability of pain relief throughout a 12 hour dosing interval of a novel, extended-release, abuse-deterrent formulation of oxycodone

BACKGROUND

Abuse deterrent formulations (ADF) are designed to prevent the misuse of opioids by tampering (e.g. physical and chemical manipulation) in order to ingest the opioid in a manner other than intended. Extended-release (ER) formulations are formulated with a larger drug load than immediate-release (IR) formulations, which makes ER opioids more desirable to drug abusers than I.R. formulations. ADFs, therefore, are particularly useful with ER opioid agents, which are designed to produce consistent analgesia over prolonged dosing intervals. However, the drug release properties of these formulations vary and sometimes may not provide adequate pain relief throughout the intended dosing interval, requiring patients to take additional medication for pain relief. Oxycodone DETERx* (Xtampza ER * ) is a novel, microsphere-in-capsule opioid formulation, which allows for twice daily dosing (i.e. every 12 hours) and mitigates the ability to tamper with the formulation.

OBJECTIVE

To evaluate the durability of pain relief of a novel formulation of oxycodone throughout the 12 hour dosing interval.

RESEARCH DESIGN AND METHODS

This study is a post-hoc analysis of 193 subjects in a Phase 3 randomized withdrawal, double-blind, placebo-controlled, enriched-enrollment, parallel-group, multicenter, 12-week clinical study.

MAIN OUTCOME MEASURES

The analysis evaluated the frequency and distribution of use of oxycodone ER and rescue medication during the Double-blind Maintenance Phase of the study.

RESULTS

Usage patterns captured by an electronic diary indicated limited overall and limited per-day use of rescue medication with no increase in rescue medication consumption 8 to 12 hours post-dose, suggesting that subjects did not experience end-of-dose failure during this time period.

LIMITATIONS

This study is limited in that it is a post-hoc analysis based on data gathered electronically from a large, prospective, double-blind, randomized, placebo-controlled, Phase 3 clinical study.

CONCLUSION

The evaluation of dosing patterns indicates that this ER oxycodone capsule formulation has durability of effect over the entire 12-hour dosing interval. These data support the use of abuse-deterrent oxycodone ER as a 12-hour dosing formulation.

Differential effects of outdoor versus indoor fungal spores on asthma morbidity in inner-city children

BACKGROUND

Although sensitization to fungal allergens is prevalent in inner-city children with asthma, the relationship between fungal exposure and morbidity is poorly understood.

OBJECTIVE

We examined relationships between fungal sensitization, exposure, and asthma morbidity in inner-city children.

METHODS

Participants were 5 to 11 years old and enrolled in the Inner-City Asthma Study. This report includes the subset of children with at least 1 positive skin test (PST) response to a fungal allergen extract; for these children, indoor and outdoor airborne culturable fungi levels were measured at baseline and throughout the 2-year study. Asthma morbidity measures were collected prospectively. The primary outcome was symptom days per 2 weeks.

RESULTS

At baseline, children with a PST response to a fungal allergen extract had significantly more symptom days compared with those without a PST response to any fungal allergen extract (6.3 vs 5.7 days per 2 weeks, P = .04). During the study, increases in total fungal exposure and indoor Penicillium species exposure were associated with increases in symptom days and asthma-related unscheduled visits. Indoor exposures to total fungi and to Penicillium species were associated with significant increases in unscheduled visits, even after controlling for outdoor fungal levels. Adverse effects associated with exposure to a specific fungus were stronger among children with PST responses to that fungal allergen extract compared with those seen in children with negative skin test responses.

CONCLUSION

Outdoor fungal exposure is primarily associated with increased asthma symptoms and increased risk of exacerbations in this population.

Asthma cases attributable to atopy: results from the Third National Health and Nutrition Examination Survey

BACKGROUND

The percentage of asthma cases attributable to atopy is the subject of debate.

OBJECTIVES

The objectives were to estimate the percentage of asthma cases in the US population attributable to atopy and to examine associations between allergen-specific skin tests and asthma.

METHODS

Data were obtained from the Third National Health and Nutrition Examination Survey, in which subjects age 6 to 59 years were skin tested with 10 allergens. Atopy was defined as at least 1 positive allergen-specific test. Doctor-diagnosed current asthma was assessed by questionnaire.

RESULTS

In the United States, 56.3% of the asthma cases were attributable to atopy, and that percentage was greater among males than females, among persons in the highest education category than in lower education categories, and among persons living in highly populated metropolitan areas than in all other areas. Each allergen-specific test was strongly associated with asthma before adjustment (odds ratios varied from 2.1 to 4.5); however, after adjustment by all the allergens, only tests to cat, Alternaria, white oak, and perennial rye were independently associated with asthma. Perennial rye was inversely associated with asthma. Of the 10 allergens, a positive response to cat accounted for the highest percentage of asthma cases (29.3%).

CONCLUSION

About half of the current asthma cases in the US population represented by the Third National Health and Nutrition Examination Survey were attributable to atopy. Some allergen-specific skin tests were not independently associated with asthma.

CLINICAL IMPLICATIONS

If atopy could be prevented or reversed, or its effect on asthma blocked, then a large percentage of asthma cases in the US population could be prevented.

Cockroach allergen reduction by cockroach control alone in low-income urban homes: a randomized control trial

BACKGROUND

We previously reported significant reductions in cockroach allergen concentrations in urban homes by reducing cockroach infestations.

OBJECTIVE

To determine the effectiveness of pest control performed by professional entomologists, compared with commercial companies, in reducing cockroach allergen.

METHODS

This 3-arm randomized controlled trial enrolled 60 cockroach-infested homes in North Carolina. Homes were randomly assigned to a control group or 1 of 2 treatment groups. Treatment 1 had insecticide baits placed by entomologists from North Carolina State University. Treatment 2 received pest control from a randomly assigned commercial company. Vacuumed dust sampling and cockroach trapping were conducted at 0, 6, and 12 months. Dust samples were analyzed by ELISA.

RESULTS

In treatment 1 homes, there were significant reductions in geometric mean trap counts compared with control and treatment 2 homes at 12 months. Relative to control, significant 12-month reductions in Bla g 1 were evident in treatment 1 homes at all sampled sites, except bedroom floor. From baseline to month 12, geometric mean Bla g 1 concentrations (U/g) decreased from 64.2 to 5.6 in kitchen, 10.6 to 1.1 in living room, 10.7 to 1.9 on bedroom floor, and 3.6 to 2.3 in bed. Treatment 2 homes showed no significant 12-month allergen reductions versus control.

CONCLUSION

Reductions in Bla g 1 in cockroach-infested homes can be achieved by reducing infestations; however, the magnitude of allergen reduction is dependent on the thoroughness and effectiveness of cockroach eradication efforts.

CLINICAL IMPLICATIONS

Elimination of cockroaches is an effective method for reducing exposure to cockroach allergen.

Oral pathogens and allergic disease: results from the Third National Health and Nutrition Examination Survey

BACKGROUND

The hygiene hypothesis contends that fewer opportunities for infection have led to increases in the prevalences of asthma and other allergic diseases.

OBJECTIVE

This study evaluated the association between asthma, wheeze, and hay fever and antibodies to 2 oral bacteria associated with periodontal disease.

METHODS

Data were obtained from the Third National Health and Nutrition Examination Survey. Serum levels of IgG antibodies to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis were quantified by enzyme-linked immunoassays in 9385 subjects age 12 years and older. The outcomes were current asthma, wheeze, and hay fever. Odds ratios (ORs) representing a 1-log-unit increase in IgG concentrations were estimated with logistic regression. ORs were adjusted for 8 confounders and weighted to represent the US population.

RESULTS

For each disease outcome, geometric mean antibody concentrations were higher in persons without the disease outcome than with the disease outcome. For a 1-log-unit increase in P gingivalis antibody concentration, adjusted ORs were 0.41 (95% CI, 0.20-0.87) for asthma, 0.43 (0.23-0.78) for wheeze, and 0.45 (0.23-0.93) for hay fever. For A actinomycetemcomitans, those ORs were 0.56 (0.19-1.72), 0.39 (0.17-0.86), and 0.48 (0.23-1.03), respectively.

CONCLUSION

Consistent with the hygiene hypothesis, higher concentrations of IgG antibodies to P gingivalis were significantly associated with lower prevalences of asthma, wheeze, and hay fever, and higher concentrations of IgG antibodies to A actinomycetemcomitans were significantly associated with a lower prevalence of wheeze.

CLINICAL IMPLICATIONS

Colonization of the oral cavity by bacteria and other microbes might play a protective role in the etiology of allergic disease.

Comparison of enzyme immunoassay-based assays for environmental Alternaria alternata

BACKGROUND

Alternaria alternata-derived allergenic materials are causes of human disease. Several immunoassays exist to quantify these materials.

OBJECTIVE

To compare methods for evaluating Alternaria content.

METHODS

Four methods, including 1 monoclonal antibody (MAb)-based assay specific for recombinant Alt a 1, 1 MAb-based assay for chromatographically purified Alt a 1, 1 polyclonal antibody (PAb)-based assay for chromatographically purified Alt a 1, and 1 PAb-based assay for whole Alternaria extract, were evaluated. Environmental samples collected as part of the National Survey of Lead and Allergens in Housing were examined. Alternaria spore counts were determined in dust by observation.

RESULTS

The MAb-based assay for recombinant Alt a 1 detected Alternaria in few samples (25%); the PAb-based assay for whole Alternaria proteins detected antigen in 97% of the samples. The PAb- and MAb-based assays for purified Alt a 1 detected antigen in 100% of the samples. There was a significant positive correlation between the 2 assays directed against purified Alt a 1. There was a positive correlation between the PAb-based assay for whole Alternaria and the PAb-based assay for Alt a 1. Nearly all the dust samples contained Alternaria spores, and there was a strong positive correlation between counts and all assays.

CONCLUSION

Because of the multifaceted nature of Alternaria, the disparities between methods for quantifying Alternaria, the cross-reactivity between fungal allergens, and the documented genetic promiscuity of this fungus, enzyme immunoassays using PAbs against a range of Alternaria proteins will probably produce the most reliable estimation of overall Alternaria exposure in house dust.

Feasibility of using subject-collected dust samples in epidemiologic and clinical studies of indoor allergens

Studies of indoor allergen exposures are often limited by the cost and logistics of sending technicians to homes to collect dust. In this study we evaluated the feasibility of having subjects collect their own dust samples. The objectives were to compare allergen concentrations between subject- and technician-collected samples and to examine the sample return rate. Using a dust collection device and written instructions provided to them by mail, 102 subjects collected a combined dust sample from a bed and bedroom floor. Later the same day, a technician collected a side-by-side sample. Dust samples were weighed and analyzed for the cat allergen Fel d 1 and the dust mite allergen Der p 1. Fifty additional subjects who were enrolled by telephone were mailed dust collection packages and asked to return a dust sample and questionnaire by mail. A technician did not visit their homes. Correlations between subject- and technician-collected samples were strong for concentrations of Fel d 1 (r = 0.88) and Der p 1 (r = 0.87). With allergen concentrations dichotomized at lower limits of detection and clinically relevant thresholds, agreements between methodologies ranged from 91 to 98%. Although dust weights were correlated (r = 0.48, p < 0.001), subjects collected lighter samples. Among the group of 50 subjects, 46 returned a dust sample and completed questionnaire. The median number of days to receive a sample was 15. With some limitations, subject-collected dust sampling appears to be a valid and practical option for epidemiologic and clinical studies that report allergen concentration as a measure of exposure.

Abatement of cockroach allergens (Bla g 1 and Bla g 2) in low-income, urban housing: month 12 continuation results

BACKGROUND

In the first 6 months of this previously published, randomized trial, the combined intervention of occupant education, insecticide bait application, and professional cleaning significantly reduced cockroach numbers and Bla g 1 allergen levels in inner-city homes.

OBJECTIVE

This continuation study investigated whether the cockroach allergen reductions achieved by month 6 could be maintained through month 12 with insecticide application alone.

METHODS

Because we had agreed to place insecticide bait in control homes at the conclusion of the first study, intervention and control homes were treated with insecticide bait at months 6 and 9. No other intervention was conducted in either arm. Vacuumed dust and swab samples were collected at month 12. Twenty-one of the 31 original homes completed the 12-month study.

RESULTS

Among the original intervention homes, Bla g 1 concentrations remained essentially unchanged from months 6 to 12. However, among the crossed-over control homes, the geometric mean Bla g 1 concentrations (Units per gram of dust) decreased from 287 to 14.4 for kitchen floors (95% reduction), from 28.8 to 5.6 for living room floors/sofas (81% reduction), from 26.7 to 4.7 for bedroom floors (82% reduction), and from 7.2 to 2.4 for beds (67% reduction). At month 12, Bla g 1 concentrations did not significantly differ between intervention and crossed-over control homes (P >.64 at each location). Similar results were seen for the allergen Bla g 2.

CONCLUSIONS

Reductions in cockroach allergen concentrations achieved through the combined intervention of occupant education, insecticide application, and professional cleaning can be maintained with continued cockroach control. Surprisingly, and in contrast to other studies, insecticide application alone significantly lowered allergen concentrations in the crossed-over control homes. This unexpected result is being tested further in another randomized trial.

Abatement of cockroach allergen (Bla g 1) in low-income, urban housing: A randomized controlled trial

BACKGROUND

Clinically relevant reductions in exposure to cockroach allergen, an important risk factor for asthma in inner-city households, have proven difficult to achieve in intervention trials.

OBJECTIVE

This study investigated a method for the abatement of cockroach allergen in low-income, urban homes. The goal was to reduce mean Bla g 1 concentrations below the previously proposed thresholds for allergic sensitization and asthma morbidity.

METHODS

A prerandomized, nonmasked trial with 16 intervention and 15 control homes was conducted. Study inclusion was based on 50 to 500 cockroaches trapped in a 3-day period. The interventions consisted of occupant education, placement of insecticide bait, and professional cleaning. Vacuumed dust and multiple swab samples were collected at 0, 1, 2, 4, and 6 months in intervention homes and at 0 and 6 months in control homes. Room maps containing cockroach and allergen data were used to guide and monitor the interventions.

RESULTS

From 0 to 6 months among intervention homes, geometric mean Bla g 1 concentrations (U/g dust) decreased from 633 to 24 on kitchen floors (96% reduction), from 25 to 4.3 on living room floors/sofas (83% reduction), from 46 to 7.3 on bedroom floors (84% reduction), and from 6.1 to 1.0 in bedroom beds (84% reduction). These reductions, with the exception of that on the bedroom floor (P =.06), were statistically significant relative to changes in control homes.

CONCLUSIONS

Substantial reductions in cockroach allergen levels can be achieved in inner-city homes. In this study, allergen levels were reduced below the sensitization threshold (2 U/g) in beds, arguably the most relevant site for exposure, and below the asthma morbidity threshold (8 U/g) on bedroom floors and living room floors/sofas. The level on kitchen floors, although reduced 96%, remained above the asthma morbidity threshold. Future studies will test the intervention's effectiveness in asthma prevention trials.

Prospective long-term study of vagus nerve stimulation for the treatment of refractory seizures

PURPOSE

To determine the long-term efficacy of vagus nerve stimulation (VNS) for refractory seizures. VNS is a new treatment for refractory epilepsy. Two short-term double-blind trials have demonstrated its safety and efficacy, and one long-term study in 114 patients has demonstrated a cumulative improvement in efficacy at 1 year. We report the largest prospective long-term study of VNS to date.

METHODS

Patients with six or more complex partial or generalized tonic-clonic seizures enrolled in the pivotal EO5 study were prospectively evaluated for 12 months. The primary outcome variable was the percentage reduction in total seizure frequency at 3 and 12 months after completion of the acute EO5 trial, compared with the preimplantation baseline. Subjects originally randomized to low stimulation (active-control group) were crossed over to therapeutic stimulation settings for the first time. Subjects initially randomized to high settings were maintained on high settings throughout the 12-month study.

RESULTS

The median reduction at 12 months after completion of the initial double-blind study was 45%. At 12 months, 35% of 195 subjects had a >50% reduction in seizures, and 20% of 195 had a >75% reduction in seizures.

CONCLUSIONS

The efficacy of VNS improves during 12 months, and many subjects sustain >75% reductions in seizures.

Role of arachidonyl triglycerides within lipid bodies in eicosanoid formation by human polymorphonuclear cells

Increasing evidence suggests that the subcellular and glycerolipid localization of esterified arachidonic acid (AA) is a key factor in regulating its availability to lipases. The goal of the current study was to determine the potential of AA stored in triglycerides (TG) to serve as a substrate for lipases and 5-lipoxygenase during neutrophil (polymorphonuclear leukocytes, PMN) activation. PMN containing high concentrations of AA in TG were generated by culturing PMN in vitro with high concentrations of exogenous AA (eAA) for 12 h. Cellular AA increased 2- and 4-fold in PMNs incubated with 5 and 20 microM AA, respectively, and this increase was almost exclusively observed in neutral lipids (NL). Further analysis revealed that 88% of the AA in the NL fraction was associated with TG. Subsequent experiments were designed to determine whether this AA in TG could be mobilized and metabolized to eicosanoids during cell activation. TG pools of AA were increased as previously described and then PMN were stimulated with ionophore, A23187. In contrast to the 43-fold increase in TG AA after eAA loading (20 microM), free AA increased by only 1.9-fold after cell stimulation. Similarly, leukotriene (LT)B(4) production increased only 2-fold after loading TG with large quantities of AA. The magnitude of increase in free AA released and in LTB(4) formation was similar to the magnitude of increase in AA mass in phospholipase (PL), suggesting that PL, and not TG, served as the source of released AA and subsequent product generation. To confirm that AA in TG did not serve as a source for eicosanoid production, cellular pools of AA were differentially labeled with [(14)C]AA and [(3)H]AA, and the [(3)H]AA-to-[(14)C]AA ratio of LTB(4) and 20-hydroxyl LTB(4) produced during cell stimulation was measured. The [(3)H]AA/[(14)C]AA ratios of LTs were markedly different from the ratios in TG, thus providing further evidence that AA pools in TG are not a major source of AA for LT generation.

A double-blind, randomized, placebo-controlled, crossover trial of pentoxifylline for the prevention of chemotherapy-induced oral mucositis

Oral mucositis is a frequent side effect of cancer therapy. No effective method of prophylaxis is currently available. We conducted a randomized, double-blind, placebo-controlled, crossover trial of pentoxifylline to evaluate its potential in preventing mucositis in cancer patients receiving chemotherapy. Ten cancer patients were randomized for treatment with a 15-day course of 400 mg of pentoxifylline given orally four times daily. Concurrent chemotherapy consisted of bolus cisplatin and infusional 5-fluorouracil. Mucositis was evaluated with the use of the Oral Assessment Guide developed at the University of Nebraska. Patients completing two cycles of chemotherapy--one with pentoxifylline and one with placebo--were evaluated for prophylaxis efficacy. Comparison of the oral assessment scores of the two cycles with a two-sided Student's t test failed to demonstrate a cytoprotective effect for pentoxifylline over placebo. We conclude that pentoxifylline as given in this study is ineffective for preventing mucositis in patients receiving cisplatin and 5-FU.

Psychoanalytic reconstructions and empirical data: reciprocal contributions

Freud (1905, 1917, 1937) throughout his lifetime sought empirical scientific confirmation of the validity of his discoveries. In pursuit of this goal, he persistently emphasized the importance of establishing agreement between analytic reconstructions and the results of naturalistic child observation. The same objective lead Lichtenberg (1983), Emde (1981, 1985), and Stern (1985) to produce detailed evaluations of the impact of infant research findings on analytic developmental propositions. The present paper examines the relation among clinical reconstructions from an analysis developed through transference interpretations, empirical observations originating in the analytic patient's daughter's psychotherapy, and the results of empirical infant research that was being concurrently conducted by two of the authors. The findings from the clinical analysis of the mother, the psychotherapy of the daughter, and empirical infant research all converged on the same larger causative factor for the daughter's psychopathology--a type of maternal deprivation. Such a confluence of different sources of evidence, each identified by a different method of investigation, provides one kind of validation for psychoanalytic reconstructions, making it possible to provide that "satisfactory degree of certainty" which Freud (1937) called for in the attempt to integrate the patient's "psychic truth" with "actual" or historical truth.

Culdocentesis and ectopic pregnancy

Seventy-seven patients with ectopic pregnancy underwent culdocentesis; the tap was positive in 70%, negative in 10% and inadequate in 20%. A positive tap was significantly associated with a low hematocrit but was often obtained in patients without hypotension, tachycardia, peritoneal irritation or tubal rupture. While patients with peritoneal irritation were significantly more likely to have a large hemoperitoneum, many with 500 ml or more of hemoperitoneum did not have peritoneal irritation, hypotension, tachycardia, low hematocrit or tubal rupture. Culdocentesis is valuable for evaluating the patient suspected of having an ectopic pregnancy, and the absence of tachycardia, hypotension, low hematocrit or peritoneal irritation should not dissuade one from performing the test. A positive tap does not indicate tubal rupture, and a large hemoperitoneum may accumulate in its absence.

The relationship of prenatal maternal anxiety to infant behavior and mother-infant interaction during the first six months of life

The IPAT Anxiety Scale was administered to a large sample of primiparous women from an economically disadvantaged population in their third trimester of pregnancy. At birth and at three and six months postpartum, the infants and mothers were assessed using a variety of behavioral and standardized procedures. Results indicate that anxiety was not a factor in the incidence of pregnancy and delivery complications or infant anomalies. Neonatal behavior and mother-infant interaction did differ among the high anxious and the low anxious groups. These differences, however, were only significant for female infants. Results are discussed in terms of practical implications and future research.

Measuring temperament in pediatric practice

The present study reports data concerning the discriminant validity of the Carey Infant Temperament Questionnaire. Subjects were 187 primiparous women who completed a battery of psychologic tests prior to the births of their infants. They also filled out the ITQ at three and six months after the baby was born. Nine of the 20 variables derived from the prenatal test battery discriminated mothers whose babies were diagnosed as temperamentally "difficult" from those whose infants were diagnosed as temperamentally "easy" based on three-month ITQ scores. Seven of the prenatal variables similarly discriminated these two groups on the six-month ITQ. The implications of these findings for uses of the ITQ are discussed.

Individual differences in infant-mother attachment at twelve and eighteen months: stability and change in families under stress

100 economically disadvantaged mothers and their infants were observed in the Ainsworth and Wittig "strange situation" at 12 and 18 months. Infants were classified as secure, anxiously attached/avoidant, or anxiously attached/resistant. In addition, mothers reported occurrence of stressful events related to the stability of the caretaking environment during the 12--18 month period by completing a 44-item checklist concerning work, finances, family, neighbors, health, etc. 62 infants were assigned to the same attachment classification at both 12 and 18 months (p less than .01). Despite this stability, significantly more infants changes classification than in a recent study of stable middle-class families. With the present sample, anxious attachment was associated with less stable caretaking environments than secure attachment; change from secure to anxious attachment was associated with higher stressful-event scores than stable secure attachment.

The temporal relationship between infant heart rate acceleration and crying in an aversive situation

The temporal relationship between heart rate (HR) acceleration and crying was examined in 16 8-16-month-old infants. Consistently, the HR acceleration began well before the onset of crying, suggesting that such acceleration is not merely a by-product of crying. The accelerations observed were above and beyond a return to baseline following orienting. The crying itself validates the association between these instances of HR acceleration and negative effect.