TB testing in HIV-positive patients prior to antiretroviral treatment

BACKGROUND: TB diagnosis in patients with HIV is challenging due to the lower sensitivities across tests. Molecular tests are preferred and the Xpert^® MTB/RIF assay has limitations in lower-income settings. We evaluated the performance of loop-mediated isothermal amplification (LAMP) and the lipoarabinomannan (LAM) test in HIV-positive, ART-naïve clinic patients.METHODS: A total of 783 eligible patients were enrolled; three spot sputum samples of 646 patients were tested using TB-LAMP, Xpert, smear microscopy and culture, while 649 patients had TB-LAM testing. Sensitivity, specificity, and negative and positive predictive values were estimated with 95% confidence intervals.RESULTS: Sensitivities for smear microscopy, TB-LAMP and Xpert were respectively 50%, 63% and 74% compared to culture, with specificities of respectively 99.2%, 98.5% and 97.5%. An additional eight were positive on TB-LAM alone. Seventy TB patients (9%) were detected using standard-of-care testing, an additional 27 (3%) were detected using study testing. Treatment was initiated in 57/70 (81%) clinic patients, but only in 56% (57/97) of all those with positive TB tests; 4/8 multidrug-resistant samples were detected using Xpert.CONCLUSION: TB diagnostics continue to miss cases in this high-burden setting. TB-LAMP was more sensitive than smear microscopy, and if followed by culture and drug susceptibility testing as required, can diagnose TB in HIV-positive patients. TB-LAM is a useful add-in test and both tests at the point-of-care would maximise yield.

De novo and recurrent metastatic breast cancer - A systematic review of population-level changes in survival since 1995

BACKGROUND

Advances in breast cancer (BC) care have reduced mortality, but their impact on survival once diagnosed with metastasis is less well described. This systematic review aimed to describe population-level survival since 1995 for de novo metastatic BC (dnMBC) and recurrent MBC (rMBC).

METHODS

We searched MEDLINE 01/01/1995-12/04/2021 to identify population-based cohort studies of MBC reporting overall (OS) or BC-specific survival (BCSS) over time. We appraised risk-of-bias and summarised survival descriptively for MBC diagnoses in 5-year periods from 1995 until 2014; and for age, hormone receptor and HER2 subgroups.

FINDINGS

We identified 20 eligible studies (14 dnMBC, 1 rMBC, 5 combined). Potential sources of bias in these studies were confounding and shorter follow-up for the latest diagnosis period.For dnMBC, 13 of 14 studies reported improved OS or BCSS since 1995. In 2005-2009, the median OS was 26 months (range 24-30), a median gain of 6 months since 1995-1999 (range 0-9, 4 studies). Median 5-year OS was 23% in 2005-2009, a median gain of 7% since 1995-1999 (range -2 to 14%, 4 studies). For women ≥70 years, the median and 5-year OS was unchanged (1 study) with no to modest difference in relative survival (range: -1·9% (p = 0.71) to +2·1% (p = 0.045), 3 studies). For rMBC, one study reported no change in survival between 1998 and 2006 and 2007-2013 (median OS 23 months). For combined MBC, 76-89% had rMBC. Three of four studies observed no change in median OS after 2000. Of these, one study reported median OS improved for women ≤60 years (1995-1999 19·1; 2000-2004 22·3 months) but not >60 years (12·7, 11·6 months).

INTERPRETATION

Population-level improvements in OS for dnMBC have not been consistently observed in rMBC cohorts nor older women. These findings have implications for counselling patients about prognosis, planning cancer services and trial stratification.

FUNDING

SL was funded in part by a National Health and Medical Research Council (NHMRC) Project Grant ID: 1125433. NH was funded by the NBCF Chair in Breast Cancer Prevention grant (EC-21-001) and a NHMRC Investigator (Leader) grant (194410). BD and SAP were funded in part by the NHMRC Centre of Research Excellence in Medicines Intelligence (1196900).

Ventriculoperitoneal shunt complications in an adult population: A comparison of various shunt designs to prevent overdrainage

Background:

Overdrainage after cerebrospinal fluid diversion remains a significant morbidity. The hydrostatic, gravitational force in the upright position can aggravate this. Siphon control (SC) mechanisms, as well as programmable and flow regulating devices, were developed to counteract this. However, limited studies have evaluated their safety and efficacy. In this study, direct comparisons of the complication rates between siphon control (SC) and non-SC (NSC), fixed versus programmable, and flow- versus pressure regulating valves are undertaken.

Methods:

A retrospective chart review was performed over all shunt implantations from January 2011 to December 2016 within the Houston Methodist Hospital system. Complication rates within 6 months of the operative date, including infection, subdural hematoma, malfunction, and any other shunt-related complication, were analyzed via Fisher’s exact test, with P < 0.05 regarded as significant. Subgroup analyses based on diagnoses – normal pressure hydrocephalus (HCP), pseudotumor cerebri, or other HCP – were also performed.

Results:

The overall shunt-related complication rate in this study was 19%. Overall rates of infection, shunt failure, and readmission within 180 days were 3%, 11%, and 34%, respectively. No difference was seen between SC and NSC groups in any complication rate overall or on subgroup analyses. When comparing fixed versus programmable and flow- versus pressure-regulating valves, the latter in each analysis had significantly lower malfunction and total complication rates.

Conclusions:

Programmable and pressure regulating devices may lead to lower shunt malfunction and total complication rates. Proper patient selection should guide valve choice. Future prospective studies may further elucidate the difference in complication rates between these various shunt designs.

Clinical Impact of Accelerate PhenoTM Rapid Blood Culture Detection System in Bacteremic Patients

BACKGROUND

Accelerate Pheno blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) results within 8h of blood culture growth. Limited data exists regarding its clinical impact. Other rapid platforms coupled with antimicrobial stewardship program (ASP) real-time notification (RTN) have shown improved length of stay (LOS) in bacteremia.

METHODS

A single-center, quasi-experimental study of adult bacteremic inpatients before/after AXDX implementation was conducted comparing clinical outcomes from 1 historical and 2 intervention cohorts (AXDX and AXDX+RTN). Primary outcome was LOS.

RESULTS

Of 830 bacteremic episodes, 188 (77%) of 245 historical and 308 (155 AXDX, 153 AXDX+RTN; 65%) of 585 intervention episodes were included. Median LOS was shorter with AXDX (6.3d) and AXDX+RTN (6.7d) compared to historical (8.1d; P=0.001). Achievement of optimal therapy (AOT) was more frequent (93.6% and 95.4%) and median time to optimal therapy (TTOT) was faster (1.3d and 1.4d) in AXDX and AXDX+RTN compared to historical (84.6%, P≤0.001 and 2.4d; P≤0.001) respectively. Median antimicrobial days of therapy (DOT) was shorter in both intervention arms compared to historical (6d each vs 7d; P=0.011). Median LOS benefit was most pronounced in patients with coagulase negative Staphylococcus bacteremia (5.5d and 4.5d vs 7.2d; P=0.003) in AXDX, AXDX+RTN, and historical cohorts respectively.

CONCLUSIONS

LOS, AOT, TTOT, and total DOT significantly improved after AXDX implementation. Addition of RTN did not show further improvement over AXDX and an already active ASP. These results suggest AXDX can be integrated into healthcare systems with an active ASP even without the resources to include RTN.

Who Needs What? Perceptions of Patients and Caregivers in Oncology Phase 1 Trials

Background:

The study design and nature of oncology phase 1 clinical trials create a uniquely vulnerable patient population yet little research has been conducted to identify the added burden these trials create for both cancer patients and their caregiver(s).

Objective:

Examining the perceptions and needs of patients and their caregivers participating in phase 1 oncology clinical trials, the investigators tested the hypothesis that the caregiver will exhibit a higher level of burden and/or distress than the patient.

Method:

A mixed-methods exploratory process utilizing patient and caregiver interviews and quality-of-life questionnaires was used to assess the psychosocial burdens associated with oncology clinical trial participation. A qualitative and quantitative analysis of the responses were 8 performed.

Result:

Both patients and caregivers reported similar themes identifying the burdens and benefits related to phase 1 clinical trial participation. However, the caregivers’ expressed burden exceeded that of the patients’ validating the study’s hypothesis.

Conclusion:

The need for ongoing additional support services for not only the patient but also the caregiver was identified.

Symptomatic, left-sided deep brain stimulation lead edema 6 h after bilateral subthalamic nucleus lead placement

Background:

Deep brain stimulation (DBS) lead edema can be a serious, although rare, complication in the postoperative period. Of the few cases that have been reported, the range of presentation has been 33 h–120 days after surgery.

Case Description:

We report a case of a 75-year-old male with a history of Parkinson’s disease who underwent bilateral placement of subthalamic nucleus DBS leads that resulted in symptomatic, left-sided lead edema 6 h after surgery, which is the earliest reported case.

Conclusions:

DBS lead edema is noted to be a self-limiting phenomenon. It is critical to recognize the possibility of lead edema as a cause of postoperative encephalopathy even in the acute phase after surgery. Although it is important to rule out other causes of postoperative changes in the patient examination, the recognition of lead edema can help to avoid extraneous diagnostic tests or DBS lead revision or removal.

Identifying incident cancer cases in dispensing claims: A validation study using Australia's Repatriation Pharmaceutical Benefits Scheme (PBS) data

Introduction

Dispensing claims are used commonly as proxy measures in pharmacoepidemiological studies; however, their validity is often untested.

Objectives

To assess the performance of a proxy for identifying cancer cases based on the dispensing of anticancer medicines and estimate the misclassification of cancer status and potential for bias researchers may encounter when using this proxy.

Methods

We conducted our validation study using Department of Veterans’ Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and Repatriation Pharmaceutical Benefits Scheme data. We included DVA clients aged ≥65 years residing in NSW between July 2004 and December 2012. We matched clients with a cancer diagnosis to clients without a diagnosis based on demographic characteristics and available observation time. We used dispensing claims for anticancer medicines dispensed between July 2004 and December 2013 as a proxy to identify clients with cancer and calculated sensitivity, specificity, positive predictive values and negative predictive values compared with cancer registrations (gold standard), overall and by cancer site. We illustrated misclassification by the proxy in a cohort of people initiating opioid therapy. Using the proxy, we excluded people with cancer from the cohort, in an attempt to delineate people potentially using opioids for cancer rather than chronic non-cancer pain.

Results

We identified 15,679 new cancer diagnoses in 14,112 DVA clients from the cancer registry and 62,663 clients without a diagnosis. Sensitivity of the proxy based on dispensing claims was 30% for all cancers and around 20% for specific cancers (range: 10-67%). Specificity was above 90% for all cancers. The dispensing proxy correctly identified 26% of people with a cancer diagnosis who initiated opioid therapy and failed to identify 74% those with a cancer diagnosis; the proxy was most robust for clients with breast cancer where 61% were correctly identified by proxy.

Conclusions

Using dispensing of anticancer medicines to identify people with a cancer diagnosis performed poorly. Excluding patients with evidence of anticancer medicine use from cohort studies may result removal of a disproportionate number of women with breast cancer. Researchers excluding or otherwise using anticancer medicine dispensing to identify people with cancer in pharmacoepidemiological studies should acknowledge the potential biases introduced to their findings.

Keywords

cancer, diagnosis, proxy, dispensing records, validation study

Abstract P2-12-01: Real-world use and outcomes of trastuzumab for HER2+ metastatic breast cancer in Australia: Analysis of the herceptin program, 2001-2015

Aims

Between December 2001 and July 2015 Australian women with HER2-positive metastatic breast cancer (MBC) accessed trastuzumab in combination with taxane chemotherapy or as monotherapy via the government funded Herceptin Program (HP); we characterise their treatment patterns and survival outcomes.

Methods

This retrospective, whole-of-population cohort study used linked dispensing, medical services, and death records. We stratified patients into three year-of-trastuzumab-initiation groups: 1. 2001-2002 (may include patients accessing trastuzumab in later lines); 2. 2003 - October 2006 (likely first-line treated but prior to trastuzumab availability for early breast cancer (EBC)); and 3: October 2006–June 30 2015 (most representative of contemporary practice). Patients were observed until death or censored at June 30 2016.

We estimated duration of trastuzumab therapy from the initial dispensing date for MBC until 30 days after the last dispensing. We considered a gap of ≥90 days between trastuzumab dispensings a separate course of treatment. We estimated overall survival (OS) as the time from first trastuzumab dispensing until death from any cause. We used Kaplan-Meier methods to estimate the total duration of trastuzumab therapy and OS. We used dispensing dates of cancer medicines to determine concomitant treatments and used claims for echocardiography and MUGA scans to determine the timing of cardiac monitoring.

Results

5,895 patients accessed trastuzumab for MBC. Median age at trastuzumab initiation was 57 years (IQR: 48 – 66). 800 patients (22%) from Group 3 also received trastuzumab for EBC. Treatment details and OS are tabulated:

 Overall (n = 5,895)Group 1 (n = 495)Group 2 (n = 1,709)Group 3 (n = 3,691)Median time on trastuzumab for MBC, first course, months (IQR)13.2 (5.7 – 26.6)9.2 (3.8 – 22.5)12.3 (5.4 – 23.3)14.0 (6.1 – 29.8)Median OS from first trastuzumab dispensing for MBC, months (IQR)30.3 (13.4 – 68.7)19.8 (8.9 – 38.8)27.5 (12.5 – 58.9)34.6 (15.1 – 82.8)Patients initiating trastuzumab, n (%):    monotherapy1,571 (27)226 (46)625 (37)720 (20)+ taxane3,150 (53)157 (32)800 (47)2,193 (59)+ hormonal therapy763 (13)47 (9)169 (10)561 (15)+ non-taxane chemotherapy376 (6)65 (13)115 (7)217 (6)Cardiac assessment:    at baseline (60 days prior to 30 days following trastuzumab initiation)3,721 (63%)189 (38%)831 (49%)2,701 (73%)during treatment3,324 (56%)150 (30%)778 (46%)2,396 (65%)

Conclusions

Our real-world estimates of OS for each patient group are both similar to and shorter than those from clinical trials published during similar time periods. Group 3 median OS is 6 months shorter than the control arm of the CLEOPATRA study (34.6 v 40.8 months) while median duration of first trastuzumab course was 4 months longer (14.0 v 10.4 months), suggesting patients continue trastuzumab beyond progression. In Group 3, 25% of patients died within 15 months of starting trastuzumab, 50% survived beyond 3 years and 25% survived beyond 7 years. These estimates will be useful for clinicians discussing expected survival time with patients in routine practice. Although the cardiotoxicity of trastuzumab is well recognised, baseline cardiac assessment was not universal, even in the most recent cohort.

Citation Format: Daniels B, Kiely BE, Lord SJ, Houssami N, Pearson S-A. Real-world use and outcomes of trastuzumab for HER2+ metastatic breast cancer in Australia: Analysis of the herceptin program, 2001-2015 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-01.

ROR1 and ROR2 play distinct and opposing roles in endometrial cancer

OBJECTIVE

In recent years, the Wnt signalling pathway and the ROR1 and ROR2 receptors have been implicated in a range of gynecological cancers. These receptors have been described as prospective therapeutic targets, and this study investigated such potential in an endometrial cancer context.

METHOD

Immunohistochemistry for ROR1 and ROR2 was performed in a patient cohort, and expression was correlated with clinicopathological parameters including type, stage, grade, myometrial invasion, lymphovascular involvement, patient age and survival. The functional role of these receptors in endometrial cancer was investigated via siRNA knockdown of ROR1 and ROR2 in three cell line models (KLE, RL95-2 and MFE-319). Effects on proliferation, adhesion, migration and invasion were measured.

RESULTS

High ROR1 expression in patient samples correlated with worse overall survival (p = 0.0169) while high ROR2 expression correlated with better overall survival (p = 0.06). ROR1 knockdown in KLE cells significantly decreased proliferation (p = 0.047) and reduced migration and invasion. ROR2 knockdown in RL95-2 cells increased cell migration and invasion (p = 0.011). Double ROR1 and ROR2 knockdown in MFE-319 cells decreased adhesion and significantly increased cell migration (P = 0.008) and invasion (p < 0.001).

CONCLUSION

ROR1 and ROR2 play distinct roles in endometrial cancer. ROR1 may promote tumor progression, similar to its role in ovarian cancer, while ROR2 may act as a tumor suppressor in endometrioid endometrial cancer, similar to its role in colorectal cancer. With several ROR-targeting therapies currently in development and phase I clinical trials for other tumor types, this study supports the potential of these receptors as therapeutic targets for women with endometrial cancer.

Virtual surgical planning and 3D printing in repeat calvarial vault reconstruction for craniosynostosis: technical note

Repeat surgery for restenosis after initial nonsyndromic craniosynostosis intervention is sometimes needed. Calvarial vault reconstruction through a healed surgical bed adds a level of intraoperative complexity and may benefit from preoperative and intraoperative definitions of biometric and aesthetic norms. Computer-assisted design and manufacturing using 3D imaging allows the precise formulation of operative plans in anticipation of surgical intervention. 3D printing turns virtual plans into anatomical replicas, templates, or customized implants by using a variety of materials. The authors present a technical note illustrating the use of this technology: a repeat calvarial vault reconstruction that was planned and executed using computer-assisted design and 3D printed intraoperative guides.

The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience

OBJECTIVE Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008-2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement. METHODS A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment. RESULTS A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor-dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4-8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change. CONCLUSIONS Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.

Massive sialadenitis resulting in critical airway after elective craniotomy: case report

The authors report an unusual case of acute, rapidly progressive, unilateral neck swelling following extubation after elective left anterior temporal lobectomy with amygdalohippocampectomy. Due to severe neck swelling, the patient developed critical airway compromise, brachial plexopathy, and Horner's syndrome. After critical airway management and appropriate rehabilitation, the patient recovered completely and remains seizure free at 1.5 years of follow-up. This case highlights the importance of early recognition of acute postoperative sialadenitis and the steps needed to prevent serious morbidity and possible mortality from this rare complication.

Acute spinal cord injury associated with multilevel pediatric idiopathic intervertebral disc calcification: case report

Pediatric idiopathic intervertebral disc calcification (PIIVDC) is a rare condition; most cases are reported to be selflimited with conservative management. In this study, we describe a case of PIIVDC presenting with acute incomplete spinal cord injury with Brown-Séquard-plus syndrome that was treated with surgery and demonstrate the subsequent rehabilitation time course.

Second cancers and late mortality in Australian children treated by allogeneic HSCT for haematological malignancy

We examined risk of second cancer and late mortality in a population-based Australian cohort of 717 pediatric allogeneic stem cell transplant (HSCT) recipients treated for a malignant disease during 1982-2007. Record linkage with population-based death and cancer registries identified 17 second cancers at a median of 7.9 years post HSCT; thyroid cancer being the most common malignancy (n=8). The cumulative incidence of second cancer was 8.7% at follow-up, and second cancers occurred 20 times more often than in the general population (standardised incidence ratio 20.3, 95% confidence interval (CI)=12.6-32.7). Transplantation using radiation-based conditioning regimens was associated with increased second cancer risk. A total of 367 patients survived for at least 2 years post HSCT and of these 44 (12%) died at a median of 3.1 years after HSCT. Relapse was the most common cause of late mortality (n=32). The cumulative incidence of late mortality was 14.7%. The observed rate of late mortality was 36 times greater than in the matched general population (standardised mortality ratio 35.9, 95% CI=26.7-48.3). Recipients who relapsed or who had radiation-based conditioning regimens were at higher risk of late mortality. Second cancers and late mortality continue to be a risk for pediatric patients undergoing HSCT, and these results highlight the need for effective screening and survivorship programs.

Attitude of German women towards hormone therapy: results of a lay survey

OBJECTIVE

Hormone therapy (HT) use has experienced a substantial change since publication of Women's Health Initiative (WHI) controlled trial. We aimed to investigate the attitude towards HT in German women aged 45-60 years.

STUDY DESIGN

A questionnaire was sent to 9785 randomly selected women in Germany aged between 45 and 60 years.

RESULTS

Response rate was 19.3% (n = 1,893). Of those, 81% experienced climacteric symptoms. Vasomotor symptoms were most frequently reported (71.2%; n = 1332). Of the respondents, 19.7% (n = 369) used HT. The most frequently mentioned benefits of HT were the improvement of climacteric complaints (71.2%; n = 1346), followed by the relief of osteoporosis (37.2%; n = 697) and the "anti-aging" effect (16.3%; n = 305). Breast cancer was stated as the main risk (64.9%; n = 1215), closely followed by weight gain (53.4%; n = 1000) and thromboembolism (48%; n = 898). About 44% of the women who has been advised by gynaecologists choose a HT, whereas this rate dropped down to 14.3% and 11.3% for women who have been advised by friends or media.

CONCLUSION

German women were generally aware of the main risks and benefits of HT. "More informed" women appear to be more likely to use HT compared to "less informed" women. The media produces negative impression of HT.

High frequency of vitamin D deficiency in ambulatory HIV-Positive patients

Several reports have suggested an increased prevalence of osteopenia and osteoporosis in HIV-infected individuals. Vitamin D deficiency may be a risk factor for osteoporosis and bone fractures. We aimed to determine the prevalence of vitamin D insufficiency in an outpatient HIV clinic in Boston. We collected serum levels of 25-OH vitamin D and evaluated calcium and vitamin D intake in adult HIV-positive outpatients during the winter and spring of 2005. Fifty-seven subjects were enrolled. The prevalence of moderate (< or = 20 and>10 ng/ml) and severe (< or =10 ng/ml) 25-OH vitamin D deficiency was 36.8% and 10.5%, respectively. Lower vitamin D intake was significantly associated with severe 25-OH vitamin D deficiency (p=0.01). Lactose intolerance tended to be associated with severe vitamin D deficiency (p=0.08). Antiretroviral use and low daily calcium intake were significantly associated with elevated parathyroid hormone levels (p=0.01 and 0.03, respectively). Vitamin D deficiency was frequent in ambulatory HIV-positive patients. HIV-infected individuals living in areas with low exposure to ultraviolet light during winter may benefit from vitamin D supplementation.

Systematic review: the methodological quality of trials affects estimates of treatment efficacy in functional (non-ulcer) dyspepsia

AIM

To evaluate treatment efficacy using objective quality criteria.

METHODS

A systematic review was performed of randomized controlled trials of endoscopically investigated dyspepsia (1979-2003) using the Jadad score and Rome II guidelines. The Jadad score differentiated studies as 'high quality' (score 4-5/5) vs. 'poor quality' (score 1-3/5). Three key Rome II guidelines on study design (cut-off of 0/3 or > 0/3) were also compared with the Jadad score.

RESULTS

Poor quality trials suggested a benefit of prokinetic therapy [relative risk (RR) of remaining dyspeptic, 0.47; 95% confidence interval (CI), 0.39-0.56), which was not confirmed in high quality trials (RR, 1.0; 95% CI, 0.84-1.19). There was a marked benefit of H2-receptor antagonist therapy in poor quality trials (RR, 0.68; 95% CI, 0.61-0.76), but a marginal benefit in good quality trials (RR, 0.87; 95% CI, 0.79-0.97). Trial quality did not affect the small statistically significant benefit seen with Helicobacter pylori eradication. Two high quality trials suggested a limited benefit with the use of proton pump inhibitors, with no poor quality trials to provide a comparison. Separation of the studies by the Rome II criteria had a similar impact on the calculated treatment estimates.

CONCLUSIONS

The magnitude of benefit of prokinetic and H2-receptor antagonist therapies reported in previous meta-analyses has been over-estimated. The quality of trials has an impact on the efficacy estimates of treatment. The Rome II criteria for study methodology may be appropriate for judging study quality.

Rofecoxib, a new cyclooxygenase 2 inhibitor, shows sustained efficacy, comparable with other nonsteroidal anti-inflammatory drugs: a 6-week and a 1-year trial in patients with osteoarthritis. Osteoarthritis Studies Group

INTRODUCTION

Rofecoxib, a cyclooxygenase 2 inhibitor (sometimes known as a specific cyclooxygenase 2 inhibitor or Coxib), is used in osteoarthritis (OA). Published information indicates rofecoxib's improved gastrointestinal safety profile over nonselective nonsteroidal anti-inflammatory agents (NSAIDs).

OBJECTIVE

To evaluate the efficacy and safety of rofecoxib in treating OA in 2 studies.

METHODS

Two randomized, double-blind, parallel-group studies in patients with OA of the knee or hip were conducted using identical entry criteria and end points. A 6-week placebo-controlled trial in 736 patients compared 12.5 and 25 mg of rofecoxib once daily with 800 mg of ibuprofen 3 times daily, and a 1-year study compared 12.5 and 25 mg of rofecoxib once daily with 50 mg of diclofenac 3 times daily in 693 patients.

RESULTS

Rofecoxib, at 12.5 and 25 mg, demonstrated efficacy clinically comparable with ibuprofen, assessed by 3 primary end points according to predefined comparability criteria. Both rofecoxib doses and ibuprofen provided significantly greater efficacy than placebo on all primary end points at 6 weeks. Both rofecoxib doses and diclofenac showed similar efficacy over 1 year. All treatments were well tolerated.

CONCLUSIONS

Rofecoxib is effective in treating OA with once-daily dosing for 6 weeks and 1 year. Rofecoxib was generally safe and well-tolerated in OA patients for 6 weeks and 1 year. Arch Fam Med. 2000;9:1124-1134

A randomized trial of the efficacy and tolerability of the COX-2 inhibitor rofecoxib vs ibuprofen in patients with osteoarthritis. Rofecoxib/Ibuprofen Comparator Study Group

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). It is not known whether a specific inhibitor of COX-2 will provide efficacy in osteoarthritis (OA) comparable with NSAIDs. Therefore, we compared the efficacy and safety of the rofecoxib, which specifically inhibits COX-2, with those of the NSAID ibuprofen in patients with OA.

OBJECTIVE

To compare the clinical efficacy and tolerability of rofecoxib (12.5 and 25 mg once daily) with ibuprofen (800 mg 3 times daily).

METHODS

A randomized, double-blind trial of 809 adults with OA was conducted. Patients with OA in whom the knee or hip was the primary source of pain were randomized to 1 of 4 treatment groups on demonstration of disease activity: placebo; rofecoxib, 12.5 or 25 mg once daily; or ibuprofen, 800 mg 3 times daily. Clinical efficacy and safety were monitored during a 6-week treatment period.

RESULTS

Both doses of rofecoxib demonstrated efficacy clinically comparable with ibuprofen as assessed by 3 primary end points (pain walking on a flat surface [Western Ontario and McMaster Universities Osteoarthritis Index], patient global assessment of response to therapy, and investigator global assessment of disease status) according to predefined comparability criteria. Both rofecoxib doses and the ibuprofen dose provided significantly (P<.001) greater efficacy than placebo on all primary end points. Results from secondary end points were consistent with those of the primary end points. All treatments were well tolerated; the overall incidence rates of clinical adverse experiences were not significantly different (P>.05) among the treatment groups.

CONCLUSION

Rofecoxib was well tolerated and provided clinical efficacy comparable with a high dose of the NSAID ibuprofen.

Rofecoxib, a specific inhibitor of cyclooxygenase 2, with clinical efficacy comparable with that of diclofenac sodium: results of a one-year, randomized, clinical trial in patients with osteoarthritis of the knee and hip. Rofecoxib Phase III Protocol 035 Study Group

OBJECTIVE

To compare the clinical efficacy of rofecoxib, a specific inhibitor of cyclooxygenase 2 (COX-2), with that of diclofenac in patients with osteoarthritis (OA) and to evaluate the safety and tolerability of rofecoxib.

METHODS

We performed a randomized, double-blind, active comparator-controlled trial in 784 adults with OA of the knee or hip. Patients were randomized to 1 of 3 treatment groups: 12.5 mg of rofecoxib once daily, 25 mg of rofecoxib once daily, and 50 mg of diclofenac 3 times daily. Clinical efficacy and safety were evaluated over a 1-year continuous treatment period.

RESULTS

Rofecoxib at dosages of 12.5 and 25 mg demonstrated efficacy that was clinically comparable to that of diclofenac, as assessed by all 3 primary end points according to predefined comparability criteria. Results from secondary end points were consistent with those of the primary end points. There were small statistical differences favoring diclofenac for 2 of the end points. All treatments were well tolerated.

CONCLUSION

Rofecoxib was well tolerated and provided efficacy that was clinically comparable, according to predefined statistical criteria, to that of 150 mg of diclofenac per day in this 1-year study. Specific inhibition of COX-2 provided therapeutic efficacy in OA.

Rofecoxib, a specific inhibitor of cyclooxygenase 2, with clinical efficacy comparable with that of diclofenac sodium: results of a one-year, randomized, clinical trial in patients with osteoarthritis of the knee and hip. Rofecoxib Phase III Protocol 035 Study Group

OBJECTIVE

To compare the clinical efficacy of rofecoxib, a specific inhibitor of cyclooxygenase 2 (COX-2), with that of diclofenac in patients with osteoarthritis (OA) and to evaluate the safety and tolerability of rofecoxib.

METHODS

We performed a randomized, double-blind, active comparator-controlled trial in 784 adults with OA of the knee or hip. Patients were randomized to 1 of 3 treatment groups: 12.5 mg of rofecoxib once daily, 25 mg of rofecoxib once daily, and 50 mg of diclofenac 3 times daily. Clinical efficacy and safety were evaluated over a 1-year continuous treatment period.

RESULTS

Rofecoxib at dosages of 12.5 and 25 mg demonstrated efficacy that was clinically comparable to that of diclofenac, as assessed by all 3 primary end points according to predefined comparability criteria. Results from secondary end points were consistent with those of the primary end points. There were small statistical differences favoring diclofenac for 2 of the end points. All treatments were well tolerated.

CONCLUSION

Rofecoxib was well tolerated and provided efficacy that was clinically comparable, according to predefined statistical criteria, to that of 150 mg of diclofenac per day in this 1-year study. Specific inhibition of COX-2 provided therapeutic efficacy in OA.

The differential effect of personality on computer-based treatment of agoraphobia

The differential effects of the revised NEO Personality Inventory (NEO PI-R) personality factors and intelligence on response to a computerized vicarious exposure treatment for agoraphobia were investigated. The Fear Questionnaire (FQ), the Agoraphobia Cognitions Questionnaire (ACQ), and the Body Sensations Questionnaire (BSQ) were used to assess agoraphobic symptomatology. Fourteen females and four males with agoraphobia diagnoses completed three 45-minute weekly treatment sessions. There was a significant decrease in scores on all three measures following treatment. Compared with published population norms, the agoraphobic subjects showed very high neuroticism, low extroversion, and high openness. Lower agreeableness factor scores predicted good treatment outcome. The NEO PI-R openness factor was negatively correlated with proficiency on the computer program; however, proficiency on the computer program did not correlate with symptom improvement. Overall, these results suggest that personality interacts with treatment at different stages of the therapeutic process.

Regulation of phospholipase D2: selective inhibition of mammalian phospholipase D isoenzymes by alpha- and beta-synucleins

Two widely expressed mammalian phosphatidylcholine (PC)-specific phospholipases D (PLD), PLD1 and PLD2, have been identified. Recombinantly expressed PLD2 has high basal activity and is insensitive to GTP-binding protein activators of PLD1 [Colley, W. C., et al. (1997) Curr. Biol. 7, 191-201]. To investigate the regulation of PLD2 we isolated PLD2, from mouse brain by immunoaffinity chromatography. The native and recombinant proteins have indistinguishable properties: PLD2 is potently activated by phosphoinositides with a vicinal 4,5-phosphate pair but is not stimulated by guanosine 5'-O-(3-thio triphosphate)-activated ADP-ribosylation factor-1, Rho family GTP-binding proteins, or protein kinases C-alpha, or -beta1. We used recombinant PLD2 in a reconstitution assay to search for regulators in cell and tissue extracts. Bovine brain contains a heat-stable protein factor that inhibits PLD2 activity in vitro. This factor was purified to homogeneity and identified as a mixture of alpha- and beta-synucleins by microsequencing and Western blotting. Recombinantly expressed alpha- and beta-synucleins inhibit PLD2 activity in vitro (K0.5 10 nM). Inhibition is not overcome by the protein or lipid activators of PLD1. Synucleins have been implicated in Parkinson's and Alzheimer's diseases. Our findings suggest that inhibition of PLD2 may be a function of synucleins. Modulation of PLD2 activity by synucleins may play a role in some aspects of the pathophysiologies that characterize these neurodegenerative diseases.

A survey of social outcome in schizophrenia in Tasmania

OBJECTIVE

To survey the social outcome of patients with schizophrenia attending State mental health facilities in southern Tasmania.

METHOD

Using the Statewide Mental Health Register, patients using inpatient and outpatient facilities who received a diagnosis of schizophrenia between 1981 and 1988 were identified (n = 771), and demographic and illness measures, and admissions and length of inpatient stay were compiled. The Life Skills Profile (LSP) was completed by mental health personnel for the 247 who were regular attenders or inpatients in 1991.

RESULTS

Social morbidity as indexed by the LSP was highest in psychiatric hospital inpatients and patients in long-term rehabilitation programs, and lower in patients attending community centres. The majority of patients in suburban settings and attending community centres lived with their families, whereas patients in the inner city or in the rehabilitation service were mainly in hostel accommodation or living alone. Patients with schizophrenia attending State services were of a similar age range but had a longer duration of illness and more admissions, and had spent more days in hospital than patients who were not in regular contact with the service.

CONCLUSIONS

The distribution of social morbidity in schizophrenia confirms that the public health system is supporting a group with high social morbidity. Patients with the highest morbidity are receiving the highest levels of care and intervention.

The ldh phylogeny for environmental isolates of Lactococcus lactis is consistent with rRNA genotypes but not with phenotypes

Lactate dehydrogenase (ldh) gene sequences, levels of 16S rRNA group-specific probe binding, and phenotypic characteristics were compared for 45 environmental isolates and four commercial starter strains of Lactococcus lactis to identify evolutionary groups best suited to cheddar cheese manufacture, ldh sequences from the environmental isolates showed high similarity to those from two groups of L. lactis used for industrial fermentations, L. lactis subsp. cremoris and subsp. lactis. Within each phylogenetically defined subspecies, ldh sequence similarities were greater than 99.1%. Strains with phenotypic traits formerly diagnostic for both subspecies were found in each ldh similarity group, but only strains belonging to L. lactis subsp. cremoris by both the newer, genetic and the older, superseded phenotypic criteria were judged potentially suitable for the commercial production of cheddar cheese. Identical evolutionary relationships were inferred from ldh sequences and from binding of subspecies-specific, 16S rRNA-directed oligonucleotide probes. However, groups defined according to these chromosomal traits bore no relationship to patterns of arginine deamination, carbon substrate utilization, or bacteriophage sensitivity, which may be encoded by cryptic genes or sexually transmissible genetic elements. Fourteen new L. lactis subsp. cremoris isolates were identified as suitable candidates for cheddar cheese manufacture, and 10 of these were completely resistant to three different batteries of commercial bacteriophages known to reduce starter activity.

Ethnicity and renal disease: lessons from the Multiple Risk Factor Intervention Trial and the Treatment of Mild Hypertension Study

Hypertension, particularly severe hypertension, has proven to be a risk factor for renal disease. Whether the relationship of blood pressure (BP) and high renal disease exists across a wide range of BP levels has been less clear. Compared with whites, blacks have a higher rate of end-stage renal disease from a multiplicity of causes, including hypertension, most prominently in younger age groups. To examine ethnic patterns of renal disease across BPs spanning the range of "normal" to "elevated," data were summarized from three large studies: (1) 12-year mortality for the 347,978 men (22,471 black and 325,507 white) without prior myocardia infarction (MI) screened for the Multiple Risk Factor Intervention Trial (MRFIT) who have been followed an average of 12 years for cause-specific mortality, (2) the baseline and 6-year change in renal function in 5,524 hypertensive men (463 black and 5,061 white) randomized in the MRFIT, and (3) the baseline and 1-year change in creatinine level are compared in 902 black and white men and women (177 black and 725 white) with mild hypertension in the Treatment of Mild Hypertension Study (TOMHS). In the MRFIT screenees, there was a monotonic increase in the risk of renal mortality at higher BP levels, even within the "normal range," both in black and white men. Blacks had higher baseline creatinine levels in both the MRFIT and TOMHS. In the MRFIT hypertensive patients, 6-year change in creatinine predicts coronary heart disease and all-cause mortality while the baseline creatinine level did not. Comparisons of randomized groups in the MRFIT or TOMHS did not demonstrate improved renal function with more aggressive BP lowering, but in MRFIT average on-treatment DBP < 95 mm Hg was associated with more favorable slopes of reciprocal creatinine. At 1 year, no gender-specific ethnic differences in creatinine change were observed in TOMHS. In the MRFIT hypertensive men, 6-year creatinine change was slightly more favorable in white men than in black men (-0.088 mumol/l v +3.09 mumol/L, P = 0.004). These data demonstrate (1) a graded and continuous relationship between BP and renal disease in blacks and whites across a wide BP range, (2) that creatinine change predicts subsequent mortality, at least in hypertensive men treated with diuretic-based pharmacologic regimen, and (3) possibly different pattern of creatinine change in response to antihypertensive drug therapy in blacks and whites.

Retroviral vector-mediated gamma-interferon gene transfer into tumor cells generates potent and long lasting antitumor immunity

Retroviral vectors were used to introduce the gamma-interferon (IFN-gamma) gene into CMS-5 cells, a weakly immunogenic tumor of BALB/c origin. After selection in G418-containing medium, colonies were isolated, cloned, and expanded to cell lines. IFN-gamma secretion was assessed using a bioassay and enzyme-linked immunosorbent assay, and high (25 units/ml) and low (5 units/ml) IFN-gamma producers were isolated. Tumor growth was followed after intradermal injection, and spleen cells were isolated at different time points. IFN-gamma secretion by tumor cells abrogated their tumorigenicity and induced a persistent and specific antitumor immunity. In contrast to the normally observed cellular immunosuppression in unmodified CMS-5 tumor-bearing mice, IFN-gamma-producing tumors induced a long lasting state of T-cell immunity, as judged by rejection of a CMS-5 tumor challenge and persistence of specific cytotoxic activity in the spleen cell population. High levels of tumor-specific cytotoxic activity could also be detected if IFN-gamma-secreting tumor cells, but not unmodified CMS-5 cells, were used as targets at a time point when immunosuppression was usually seen. These studies highlight the potential advantages of localized IFN-gamma secretion to induce potent antitumor immune responses.

Interleukin 2 gene transfer into tumor cells abrogates tumorigenicity and induces protective immunity

To study the effects of localized secretion of cytokines on tumor progression, the gene for human interleukin 2 (IL-2) was introduced via retroviral vectors into CMS-5 cells, a weakly immunogenic mouse fibrosarcoma cell line of BALB/c origin. Secretion of low levels of IL-2 from the tumor cells abrogated their tumorigenicity and induced a long-lasting protective immune response against a challenge with a tumorigenic dose of parental CMS-5 cells. Co-injection of IL-2-producing CMS-5 cells with unmodified tumor cells inhibited tumor formation even when highly tumorigenic doses of CMS-5 cells were used. Cytolytic activity in mice injected with parental CMS-5 cells was transient and was greatly diminished 3 wk after injection, as commonly observed in tumor-bearing animals. However, in mice injected with IL-2-producing cells, tumor-specific cytolytic activity persisted at high levels for the duration of the observation period (at least 75 d). High levels of tumor-specific cytolytic activity could also be detected in parental CMS-5 tumor-bearing animals 18 d after inoculation with tumor cells, if IL-2-producing CMS-5 cells but not unmodified parental tumor cells were used as targets. These studies highlight the potential advantages of localized secretion of cytokines mediated via gene transfer to induce potent anti-tumor immune responses.

Anxiety and classroom examination performance

Studied classroom examination performance over the course of an entire semester as a function of (a) students' anxiety level (high, medium, low); (b) difficulty level of exam question (more vs. less difficult); (c) type of exam question (rote memory vs. generalization); (d) sex of S; and (e) intelligence level of S. As expected, there was a strong main effect of anxiety and a significant interaction between anxiety and item difficulty. The latter was consistent with the Hull-Spence formulation of learning and performance--as the habit strength of incorrect responses increases (i.e., as the items become more difficult), the superiority of low over high anxious Ss also should increase. When item difficulty was held constant, anxiety did not interact with type of exam question.