Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams

Background: Early advance care planning (ACP) conversations are essential to deliver patient-centered care. While primary care is an ideal setting to initiate ACP, such as Serious Illness Conversations (SICs), many barriers exist to implement such conversations in routine practice. An interprofessional team approach holds promises to address barriers. Objective: To develop and evaluate SIC training for interprofessional primary care teams (IP-SIC). Design: An existing SIC training was adapted for IP-SIC and then implemented and evaluated for acceptability and effectiveness. Setting/Context: Interprofessional teams in 15 primary care clinics in five US states. Measures: Acceptability of the IP-SIC training and participants' self-reported likelihood to engage in ACP after the training. Results: The 156 participants were a mix of physicians and advanced practice providers (APPs) (44%), nurses and social workers (31%), and others (25%). More than 90% of all participants rated the IP-SIC training positively. While nurse/social worker and other groups were less likely than physician and APP group to engage in ACP before training (4.4, 3.7, and 6.4 on a 1-10 scale, respectively), all groups showed significant increase in likelihood to engage in ACP after the IP-SIC training (8.5, 7.7, and 9.2, respectively). Both physician/APP and nurse/social worker groups showed significant increase in likelihood to use the SIC Guide after the IP-SIC training, whereas an increase in likelihood to use SIC Guide among other groups was not statistically significant. Conclusion: The new IP-SIC training was well accepted by interprofessional team members and effective to improve their likelihood to engage in ACP. Further research exploring how to facilitate collaboration among interprofessional team members to maximize opportunities for more and better ACP is warranted. ClinicalTrials.gov ID: NCT03577002.

Technology to Improve Autonomy and Inform Housing Decisions for Older Adults With Memory Problems Who Live at Home in Canada, Sweden, and the Netherlands: Protocol for a Multipronged Mixed Methods Study

BACKGROUND

Understanding the mobility patterns and experiences of older adults with memory problems living at home has the potential to improve autonomy and inform shared decision making (SDM) about their housing options.

OBJECTIVE

We aim to (1) assess the mobility patterns and experiences of older adults with memory problems, (2) co-design an electronic decision support intervention (e-DSI) that integrates users' mobility patterns and experiences, (3) explore their intention to use an e-DSI to support autonomy at home, and (4) inform future SDM processes about housing options.

METHODS

Informed by the Good Reporting of A Mixed Methods Study (GRAMMS) reporting guidelines, we will conduct a 3-year, multipronged mixed methods study in Canada, Sweden, and the Netherlands. For Phase 1, we will recruit a convenience sample of 20 older adults living at home with memory problems from clinical and community settings in each country, for a total of 60 participants. We will ask participants to record their mobility patterns outside their home for 14 days using a GPS tracker and a travel diary; in addition, we will conduct a walking interview and a final debrief interview after 14 days. For Phase 2, referring to results from the first phase, we will conduct one user-centered co-design process per country with older adults with memory issues, caregivers, health care professionals, and information technology representatives informed by the Double Diamond method. We will ask participants how personalized information about mobility patterns and experiences could be added to an existing e-DSI and how this information could inform SDM about housing options. For Phase 3, using online web-based surveys, we will invite 210 older adults with memory problems and/or their caregivers, split equally across the three countries, to use the e-DSI and provide feedback on its strengths and limitations. Finally, in Phase 4, we will triangulate and compare data from all phases and countries to inform a stakeholder meeting where an action plan will be developed.

RESULTS

The study opened for recruitment in the Netherlands in November 2018 and in Canada and Sweden in December 2019. Data collection will be completed by April 2021.

CONCLUSIONS

This project will explore how e-DSIs can integrate the mobility patterns and mobility experiences of older adults with memory problems in three countries, improve older adults' autonomy, and, ultimately, inform SDM about housing options.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04267484; https://clinicaltrials.gov/ct2/show/NCT04267484.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19244.

Professional training on shared decision making with older adults living with neurocognitive disorders: a mixed-methods implementation study

BACKGROUND

Shared decision making with older adults living with neurocognitive disorders is challenging for primary healthcare professionals. We studied the implementation of a professional training program featuring an e-learning activity on shared decision making and five Decision Boxes on the care of people with neurocognitive disorders, and measured the program's effects.

METHODS

In this mixed-methods study, we recruited healthcare professionals in family medicine clinics and homecare settings in the Quebec City area (Canada). The professionals signed up for training as a continuing professional development activity and answered an online survey before and after training to assess their knowledge, and intention to adopt shared decision making. We recorded healthcare professionals' access to each training component, and conducted telephone interviews with a purposeful sample of extreme cases: half had completed training and the other half had not. We performed bivariate analyses with the survey data and a thematic qualitative analysis of the interviews, as per the theory of planned behaviour.

RESULTS

Of the 47 participating healthcare professionals, 31 (66%) completed at least one training component. Several factors restricted participation, including lack of time, training fragmentation into several components, poor adaptation of training to specific professions, and technical/logistical barriers. Ease of access, ease of use, the usefulness of training content and the availability of training credits fostered participation. Training allowed Healthcare professionals to improve their knowledge about risk communication (p = 0.02), and their awareness of the options (P = 0.011). Professionals' intention to adopt shared decision making was high before training (mean ± SD = 5.88 ± 0.99, scale from 1 to 7, with 7 high) and remained high thereafter (5.94 ± 0.9).

CONCLUSIONS

The results of this study will allow modifying the training program to improve participation rates and, ultimately, uptake of meaningful shared decision making with patients living with neurocognitive disorders.

Determination of Domoic Acid Toxins in Shellfish by Biosense ASP ELISAA Direct Competitive Enzyme-Linked Immunosorbent Assay: Collaborative Study

A collaborative study was conducted on the Biosense amnesic shellfish poisoning (ASP) enzyme-linked immunosorbent assay (ELISA) for the determination of domoic acid (DA) toxins in shellfish in order to obtain interlaboratory validation data for the method. In addition, a method comparison study was performed to evaluate the ASP ELISA as an alternative to the current liquid chromatography (LC) reference method for DA determination. The study material comprised 16 shellfish samples, including blue mussels, Pacific oysters, and king scallops, spiked with contaminated mussel homogenates to contain 0.120 mg DA/kg shellfish flesh. The shellfish samples were extracted with 50% aqueous methanol, and the supernatants were directly analyzed. Sixteen participating laboratories in 10 countries reported data from the ASP ELISA, and 4 of these laboratories also reported data from instrumental LC analysis. The participating laboratories achieved interlaboratory precision estimates for the 8 Youden paired shellfish samples in the range of 1020% for RSDr (mean 14.8 4%), and 1329% for RSDR (mean 22.7 6%). The precision estimates for the ELISA data did not show a strong dependence on the DA concentration in the study samples, and the overall precision achieved was within the acceptable range of the Horwitz guideline with HorRat values ranging from 1.1 to 2.4 (mean HorRat 1.7 0.5). The analysis of shellfish samples spiked with certified reference material (CRM)-ASP-MUS-b gave recoveries in the range of 88122%, with an average recovery of 104 10%. The estimate on method accuracy was supported by a correlation slope of 1.015 (R2 = 0.992) for the determined versus the expected DA values. Furthermore, the correlation of the ASP ELISA results with those for the instrumental LC analyses of the same sample extracts gave a correlation slope of 1.29 (R2 = 0.984). This indicates some overestimation of DA levels in shellfish by the ELISA, but it is also a result of apparent low recoveries for the LC methods. This interlaboratory study demonstrates that the ASP ELISA is suitable for the routine determination and monitoring of DA toxins in shellfish, and that it offers a rapid and cost-effective methodology with high sample throughput.

Tailoring and evaluating an intervention to improve shared decision-making among seniors with dementia, their caregivers, and healthcare providers: study protocol for a randomized controlled trial

Background

The increasing prevalence of Alzheimer’s disease and other forms of dementia raises new challenges to ensure that healthcare decisions are informed by research evidence and reflect what is important for seniors and their caregivers. Therefore, we aim to evaluate a tailored intervention to help healthcare providers empower seniors and their caregivers in making health-related decisions.

Methods

In two phases, we will: (1) design and tailor the intervention; and (2) implement and evaluate it. We will use theory and user-centered design to tailor an intervention comprising a distance professional training program on shared decision-making and five shared decision-making tools dealing with difficult decisions often faced by seniors with dementia and their caregivers. Each tool will be designed in two versions, one for clinicians and one for patients. We will recruit 49 clinicians and 27 senior/caregiver to participate in three cycles of design-evaluation-feedback of each intervention components. Besides think-aloud and interview approaches, users will also complete questionnaires based on the Theory of Planned Behavior to identify the factors most likely to influence their adoption of shared decision-making after exposure to the intervention. We will then modify the intervention by adding/enhancing behavior-change techniques targeting these factors. We will evaluate the effectiveness of this tailored intervention before/after implementation, in a two-armed, clustered randomized trial. We will enroll a convenience sample of six primary care clinics (unit of randomization) in the province of Quebec and recruit the clinicians who practice there (mostly family physicians, nurses, and social workers). These clinics will then be randomized to immediate exposure to the intervention or delayed exposure. Overall, we will recruit 180 seniors with dementia, their caregivers, and their healthcare providers. We will evaluate the impact of the intervention on patient involvement in the decision-making process, decisional comfort, patient and caregiver personal empowerment in relation to their own healthcare, patient quality of life, caregiver burden, and decisional regret.

Discussion

The intervention will empower patients and their caregivers in their healthcare, by fostering their participation as partners during the decision-making process and by ensuring they make informed decisions congruent with their values and priorities.

Trial registration

ClinicalTrials.org, NCT02956694. Registered on 31 October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2697-1) contains supplementary material, which is available to authorized users.

Mitotic phosphotyrosine network analysis reveals that tyrosine phosphorylation regulates Polo-like kinase 1 (PLK1)

Tyrosine phosphorylation is closely associated with cell proliferation. During the cell cycle, serine and threonine phosphorylation plays the leading role, and such phosphorylation events are most dynamic during the mitotic phase of the cell cycle. However, mitotic phosphotyrosine is not well characterized. Although a few functionally-relevant mitotic phosphotyrosine sites have been characterized, evidence suggests that this modification may be more prevalent than previously appreciated. Here, we examined tyrosine phosphorylation in mitotic human cells including those on spindle-associated proteins.? Database mining confirmed ~2000 mitotic phosphotyrosine sites, and network analysis revealed a number of subnetworks that were enriched in tyrosine-phosphorylated proteins, including components of the kinetochore or spindle and SRC family kinases. We identified Polo-like kinase 1 (PLK1), a major signaling hub in the spindle subnetwork, as phosphorylated at the conserved Tyr217 in the kinase domain. Substitution of Tyr217 with a phosphomimetic residue eliminated PLK1 activity in vitro and in cells. Further analysis showed that Tyr217 phosphorylation reduced the phosphorylation of Thr210 in the activation loop, a phosphorylation event necessary for PLK1 activity. Our data indicate that mitotic tyrosine phosphorylation regulated a key serine/threonine kinase hub in mitotic cells and suggested that spatially separating tyrosine phosphorylation events can reveal previously unrecognized regulatory events and complexes associated with specific structures of the cell cycle.

Annexin A2 is SUMOylated on its N-terminal domain: regulation by insulin

Insulin receptor (IR) endocytosis requires a remodelling of the actin cytoskeleton. We show here that ANXA2 is SUMOylated at the K10 located in a non-consensus SUMOylation motif in the N-terminal domain. The Y24F mutation decreased the SUMOylation signal, whereas insulin stimulation increased ANXA2 SUMOylation. A survey of protein SUMOylation in hepatic Golgi/endosome (G/E) fractions after insulin injections revealed the presence of a SUMOylation pattern and confirmed the SUMOylation of ANXA2. The construction of an IR/ANXA2/SUMO network (IRASGEN) in the G/E context reveals the presence of interacting nodes whereby SUMO1 connects ANXA2 to actin and microtubule-mediated changes in membrane topology. Heritable variants associated with type 2 diabetes represent 41% of the IRASGEN thus pointing out the physio-pathological importance of this subnetwork.

Large-scale analysis of lysine SUMOylation by SUMO remnant immunoaffinity profiling

Small ubiquitin-related modifiers (SUMO) are evolutionarily conserved ubiquitin-like proteins that regulate several cellular processes including cell cycle progression, intracellular trafficking, protein degradation and apoptosis. Despite the importance of protein SUMOylation in different biological pathways, the global identification of acceptor sites in complex cell extracts remains a challenge. Here we generate a monoclonal antibody that enriches for peptides containing SUMO remnant chains following tryptic digestion. We identify 954 SUMO3-modified lysine residues on 538 proteins and profile by quantitative proteomics the dynamic changes of protein SUMOylation following proteasome inhibition. More than 86% of these SUMOylation sites have not been reported previously, including 5 sites on the tumour suppressor parafibromin (CDC73). The modification of CDC73 at K136 affects its nuclear retention within PML nuclear bodies on proteasome inhibition. In contrast, a CDC73 K136R mutant translocates to the cytoplasm under the same conditions, further demonstrating the effectiveness of our method to characterize the dynamics of lysine SUMOylation.

Annexin A1 is regulated by domains cross-talk through post-translational phosphorylation and SUMOYlation

Mouse prostate membrane-associated proteins of the annexin family showed changes in SUMOylation during androgen treatment. Among these the calcium-binding annexin A1 protein (ANXA1) was chosen for further characterization given its role in protein secretion and cancer. SUMOylation of ANXA1 was confirmed by overexpressing SUMO-1 in LNCaP cells. Site-directed mutagenesis indicated that K257 located in a SUMOylation consensus motif in the C-terminal calcium-binding DA3 repeat domain is SUMOylated. Mutation of the N-terminal Y21 decreased markedly the SUMOylation signal while EGF stimulation increased ANXA1 SUMOylation. A structural analysis of ANXA1 revealed that K257 is located in a hot spot where Ca(2+) and SUMO-1 bind and where a nuclear export signal and a polyubiquitination site are also present. Also, Y21 is buried inside an α-helix structure in the Ca(2+)-free conformation implying that Ca(2+) binding, and the subsequent expelling of the N-terminal α-helix in a disordered conformation, is permissive for its phosphorylation. These results show for the first time that SUMOylation can be regulated by an external signal (EGF) and indicate the presence of a cross-talk between the N-terminal and C-terminal domains of ANXA1 through post-translational modifications.

Deceased Organ Donation in Brazil: How Can We Improve?

METHODS

We retrospectively analyzed the registry data from one organ procurement organization obtained between January 1 and December 31, 2005.

RESULTS

Among the 378 potential deceased donors, 182 (48.2%) were lost, mainly due to clinical conditions (27%) or cardiac arrest (19.3%). Of the remaining 196 (51.8%) potential donors, family consent was obtained in 94 cases (48%). Family refusal was higher for potential donors aged between 18 and 59 years (70%). Of the 94 donors, 72 (77%) had their organs harvested. Cardiac arrest before harvesting (56.5%) and positive viral serology (26%) were the main reasons for further losses. The mean donor age was 40 years and 51% were men. Causes of death were cerebral vascular accidents (55.5%), cranium encephalic traumas (29%), and gun shot wounds (8%). The rate of organ donation was 100% for kidneys and livers, 96% for hearts, 86% for pancreatas, 76% for lungs, and 74% for corneas. After assessment of organ viability, 94% of corneas, 91% of kidneys, and 88% of livers were transplanted, but only 52% of pancreata and 42% of hearts. The most frequent causes of discarded organs were age and concomitant donor infection.

CONCLUSION

Areas for potential improvements are: (1) earlier identification and adequate maintenance of potential donors; (2) campaigns for organ donation; and (3) careful evaluation of donated organs and selection of a suitable population to increase utilization of expanded criteria organs.

RCAS1 is associated with ductal breast cancer progression

RCAS1/EBAG9 (receptor-binding cancer antigen expressed on SiSo cells/ estrogen receptor-binding fragment-associated gene 9), an estrogen-transcribed protein, has been shown to be expressed in a wide variety of cancers, including uterine, ovarian, and lung cancer cells. Soluble and membranous RCAS1 proteins may play a role in the immune escape of tumor cells by promoting T lymphocyte inhibition of growth and apoptosis. In the present report, the presence of RCAS1 was revealed in human ductal breast cancer biopsies by immunohistochemistry. Its cytoplasmic expression was exhibited in cancer cells obtained from tumor biopsies and in breast cancer cell lines. RCAS1 significantly correlated with tumor grade. In addition, RCAS1 was identified in MCF7 culture supernatants. Those observations suggest that RCAS1 is a new marker for breast cancer progression and a possible mechanism for breast cancer immune escape.

Preoperative mobilization of circulating dendritic cells by Flt3 ligand administration to patients with metastatic colon cancer

PURPOSE

To evaluate preoperative dendritic cell (DC) mobilization and tumor infiltration after administration of Flt3 ligand (Flt3L) to patients with metastatic colon cancer.

PATIENTS AND METHODS

Twelve patients with colon cancer metastatic to the liver or lung received Flt3L (20 microg/kg/d subcutaneously for 14 days for one to three cycles at monthly intervals) before attempted metastasectomy. The number and phenotype of DCs mobilized into peripheral-blood mononuclear cells (PBMCs) were evaluated by flow cytometry. After surgical resection, metastatic tumor tissue was evaluated for DC infiltration. In vivo immune responses to recall antigens were measured.

RESULTS

After Flt3L administration, on average, the total number of leukocytes in the peripheral blood increased from 5.9 +/- 1.0 x 10(3)/mm(3) to 11.2 +/- 3.8 x 10(3)/mm(3) (mean +/- SD, P: =. 0001). The percentage of CD11c(+)CD14(-) DCs in PBMCs increased from 2.4% +/- 1.8% to 8.8% +/- 4.7% (P: =.004). Delayed-type hypersensitivity (DTH) responses to recall antigens (CANDIDA:, mumps, and tetanus) showed marginally significant increases in reactivity after Flt3L administration (P: =.06, P: =.03, and P: =.08, respectively). An increase in the number of DCs was observed at the periphery of the tumors of patients who received Flt3L compared with those of patients who had not.

CONCLUSION

Flt3L is capable of mobilizing DCs into the peripheral blood of patients with metastatic colon cancer and may be associated with increases in DC infiltration in the peritumoral regions. Flt3L mobilization is associated with a trend toward increased DTH responses to recall antigens in vivo. The use of Flt3L to increase circulating DCs for cancer immunotherapy should be considered.

In vivo generation of human dendritic cell subsets by Flt3 ligand

Dendritic cells (DCs) represent a family of ontogenically distinct leukocytes involved in immune response regulation. The ability of DCs to stimulate T-cell immunity has led to their use as vectors for immunotherapy vaccines. However, it is unclear whether and to what degree in vitro-generated DCs are representative of DCs that develop in vivo. Treatment of mice with human Flt3 ligand (FL) dramatically increases the number of DCs. We report here that administration of FL to healthy human volunteers increased the number of circulating CD11c(+ )IL-3Ralpha(low) DC (mean 44-fold) and CD11c(-) IL-3Ralpha(high) DC precursors (mean 12-fold). Moreover, the CD11c(+ )DCs were efficient stimulators of T cells in vitro. Thus, FL can expand the number of circulating, functionally competent human DCs in vivo.

Flt3-ligand and granulocyte colony-stimulating factor mobilize distinct human dendritic cell subsets in vivo

Dendritic cells (DCs) have a unique ability to stimulate naive T cells. Recent evidence suggests that distinct DC subsets direct different classes of immune responses in vitro and in vivo. In humans, the monocyte-derived CD11c+ DCs induce T cells to produce Th1 cytokines in vitro, whereas the CD11c- plasmacytoid T cell-derived DCs elicit the production of Th2 cytokines. In this paper we report that administration of either Flt3-ligand (FL) or G-CSF to healthy human volunteers dramatically increases distinct DC subsets, or DC precursors, in the blood. FL increases both the CD11c+ DC subset (48-fold) and the CD11c- IL-3R+ DC precursors (13-fold). In contrast, G-CSF only increases the CD11c- precursors (>7-fold). Freshly sorted CD11c+ but not CD11c- cells stimulate CD4+ T cells in an allogeneic MLR, whereas only the CD11c- cells can be induced to secrete high levels of IFN-alpha, in response to influenza virus. CD11c+ and CD11c- cells can mature in vitro with GM-CSF + TNF-alpha or with IL-3 + CD40 ligand, respectively. These two subsets up-regulate MHC class II costimulatory molecules as well as the DC maturation marker DC-lysosome-associated membrane protein, and they stimulate naive, allogeneic CD4+ T cells efficiently. These two DC subsets elicit distinct cytokine profiles in CD4+ T cells, with the CD11c- subset inducing higher levels of the Th2 cytokine IL-10. The differential mobilization of distinct DC subsets or DC precursors by in vivo administration of FL and G-CSF offers a novel strategy to manipulate immune responses in humans.

Biologic activity of interleukin 1 (IL-1) alpha in patients with refractory malignancies

Interleukin 1 alpha (IL-1 alpha) is a cytokine with pleiotropic effects, including cytotoxic-cytostatic activity against some tumor cell lines. We have conducted a phase I study of recombinant human IL-1 alpha (rhIL-1 alpha) in 17 patients with refractory malignancies to examine its toxicity and biologic activity. rhIL-1 alpha was given as a 2-h IV infusion daily for 5 days at five dose levels (0.08, 0.2, 0.8, 2.0, and 5.0 micrograms/m2). Seventeen patients with malignancies were treated, with no objective tumor responses noted. Common toxicities included: fever (100%), rigors and/or chills (96%), myalgia (54%), and headache (48%). Three patients developed grade III hypotension. The maximum tolerated dose was 2.0 micrograms/m2. rhIL-1 alpha induced a significant increase in absolute neutrophil count over baseline (p < 0.05), a delayed but significant increase in platelet count over baseline (p < 0.05), and there was a marked increase in the number of progenitors [colony-forming units (CFU)-G, CFU-M, CFU-GM, CFU-GEMM and burst-forming units (BFU-E)] observed in the peripheral blood. Nine of 12 evaluable patients showed an increase in bone marrow cellularity or myeloid:erthyroid ratio. Immunophenotyping did not demonstrate an increase in peripheral blood or bone marrow CD34+ cells. Interferon-gamma-mediated monocyte cytotoxicity (MCCTX) was significantly enhanced from baseline (p < 0.001), although an increase in direct MCCTX did not reach statistical significance. In summary, rhIL-1 alpha administration is well tolerated at a dose of 2.0 micrograms/m2 with fever, rigors, myalgia, and headache being the most frequent toxicities. Although there were no objective tumor responses, we have demonstrated significant biologic activity with increased neutrophil and platelet counts, increased peripheral blood progenitor cells, and enhanced interferon-gamma-mediated MCCTX.

A foodborne outbreak of Cyclospora cayetanensis at a wedding: clinical features and risk factors for illness

BACKGROUND

Cyclospora cayetanensis, a coccidian parasite, has increasingly been recognized as a cause of gastrointestinal tract illness. We describe an outbreak of Cyclospora infection following a wedding reception.

OBJECTIVES

To investigate and characterize risk factors associated with the outbreak of Cyclospora and to describe the observed clinical course and spectrum of illness.

METHODS

Retrospective cohort study involving 94 of the 101 guests who attended a wedding reception at a restaurant in Boston, Mass.

RESULTS

Fifty-seven respondents met the case definition of infection; 12 of these had laboratory-confirmed Cyclospora. The epidemic curve was consistent with a point source outbreak with a median incubation period of 7 days. Commonly reported symptoms included diarrhea (100%), weight loss (93%), fatigue (91%), and anorexia (90%). The illness had a characteristic waxing and waning course, with 51 persons (89%) reporting recurring symptoms and 35 (61%) reporting illness lasting more than 3 weeks. By univariate analysis, infection was significantly associated (P<.05) with consumption of wine and a dessert containing raspberries, strawberries, blackberries, and blueberries. Only the dessert remained significant by stratified analysis with an adjusted relative risk of 2.1 (95% confidence interval, 1.4-3.2).

CONCLUSIONS

Findings from this study support a point source outbreak of the newly identified pathogen C cayetanensis, with berries as the vehicle of transmission. It suggests that Cyclospora may cause severe diarrhea associated with profound anorexia and weight loss, and should be considered in the evaluation of prolonged gastrointestinal tract illness.

Performance of the new plasma-compatible Advantage blood glucose test strips

OBJECTIVE

To establish a plasma calibration curve for the Advantage Blood Glucose System that would permit direct comparison with results provided by clinical laboratories.

DESIGN AND METHODS

The initial study involved the comparison between the Advantage whole blood referenced results and the laboratory plasma results. The second study validated the plasma-compatibility of the first new lot of Advantage test strips with this new calibration curve.

RESULTS

Plasma and whole blood glucose data, obtained at Hôpital Maisonneuve-Rosemont in Montréal, demonstrated the typical differences between these two sample types. Mathematical correction of the Advantage results eliminated this difference. This new equation was then encoded into the code keys of a new lot of Advantage test strips and a second study was conducted to verify the comparability to laboratory plasma glucose.

CONCLUSION

The results for the Advantage Blood Glucose System may now be compared directly with the laboratory plasma or serum glucose results.

Split-face comparison of adapalene 0.1% gel and tretinoin 0.025% gel in acne patients

BACKGROUND

Adapalene is a new naphthoic acid derivative developed for the topical treatment of acne vulgaris.

OBJECTIVE

We compared the skin tolerance of adapalene 0.1% gel with tretinoin 0.025% gel in subjects with acne.

METHODS

Fifteen acne patient volunteers were enrolled in this investigator-masked, left-right comparison, randomized, controlled, intraindividual study. Adapalene 0.1% gel and tretinoin 0.025% gel were applied once a day to one half-face by the volunteers for 14 consecutive days. Clinical signs (erythema, desquamation, papules, vesicles, edema) and subjective symptoms (tightness, pruritus, burning) were evaluated and scored daily except on weekends.

RESULTS

Adapalene 0.1% gel was better tolerated than tretinoin 0.025% gel. The overall mean score calculated from all features combined was significantly higher with tretinoin gel than with adapalene gel (p = 0.002).

CONCLUSION

Adapalene 0.1% gel was significantly less irritating than tretinoin 0.025% gel when tested in acne patients.

Skin tolerance of adapalene 0.1% gel in combination with other topical antiacne treatments

BACKGROUND

Adapalene (Differin gel) is a new naphthoic acid derivative developed for the topical treatment of acne vulgaris.

OBJECTIVE

We assessed, in healthy volunteers, the skin irritancy potential of three combinations, each including adapalene 0.1% gel and one topical marketed antiacne product.

METHODS

Twenty-five healthy volunteers were enrolled in a 21-day cumulative irritancy study performed in a double-blind, randomized, controlled, intraindividual design. Five days a week, the three materials (benzoyl peroxide, clindamycin phosphate, and erythromycin) were applied in a nonocclusive manner either alone or in combination with adapalene gel on seven cutaneous sites on the upper back. Adapalene was applied in the evening whereas the three other materials were applied in the morning. Irritation was evaluated and scored daily except on weekends.

RESULTS

All materials were well-tolerated when tested alone. The combinations of adapalene 0.1% gel and either benzoyl peroxide, clindamycin phosphate, or erythromycin were also well-tolerated. The mean cumulative irritancy indices indicated that all three combinations were nonirritating.

CONCLUSION

Under the conditions of the study, all tested treatments alone or in combination appeared nonirritating.

The use of scintigraphy to provide "proof of concept" for novel polysaccharide preparations designed for colonic drug delivery

PURPOSE

The aim of the present study was to provide "proof of concept" data in man for novel polysaccharide preparations designed for colonic drug delivery using gamma scintigraphy.

METHODS

Two placebo calcium pectinate matrix tablet formulations were studied: one contained calcium pectinate and pectin (CaP/P) and was designed to rapidly disintegrate in the ascending colon, the other contained calcium pectinate and guar gum (CaP/GG) and was designed to disintegrate more slowly, releasing its contents throughout the ascending and transverse colon. Both formulations were enteric coated in order to protect them from the stomach. Ten healthy volunteers received either a CaP/P or CaP/GG tablet, in a randomised cross-over study. Transit and disintegration of the radiolabelled formulations was followed by gamma scintigraphy. Rat studies were conducted in order to verify that the expected colonic degradation of the polysaccharide formulations was as a consequence of bacterial enzyme attack.

RESULTS

The in vivo clinical study confirmed the results obtained in the rat and bench in vitro fermentation models; complete tablet disintegration for Formulation CaP/GG appeared to be slower than that of Formulation CaP/P and the time and the location of complete tablet disintegration was more reproducible with Formulation CaP/P compared to Formulation CaP/GG.

CONCLUSIONS

These results provide "proof of concept" data for the use of calcium pectinate preparations for drug delivery to the colon and highlight the value of scintigraphy in focusing the development strategy for colonic targeting preparations.

Effects of PIXY321, a granulocyte-macrophage colony-stimulating factor/interleukin 3 fusion protein, on human tumor colony-forming units taken directly from patients

PIXY321, a granulocyte-macrophage colony-stimulating factor/interleukin 3 (GM-CSF/IL-3) genetically engineered hybrid, has shown greater biological activity in stimulating committed myeloid progenitors than either GM-CSF or IL-3 in vitro, in vivo, and in patients treated with high-dose chemotherapy. However, one concern is that PIXY321 may stimulate the proliferation of malignant cells which have functional GM-CSF or IL-3 receptors. Therefore, using a human tumor cloning assay, we have tested the effects of several concentrations of PIXY321 ranging from 0.1 to 100 ng/ml on tumor cells taken directly from 98 patients with solid tumors and Hodgkin's or non-Hodgkin's lymphomas. Of the 34 evaluable specimens, including 15 breast cancers, 5 ovarian cancers, 5 lung cancers, and 9 lymphomas, none showed stimulation of tumor growth. Interestingly, a significant inhibition of the tumor proliferation was seen in one breast cancer and in one large cell immunoblastic non-Hodgkin's lymphoma after continuous exposure of PIXY321. In conclusion, the use of PIXY321 to reduce myelosuppression after high-dose chemotherapy appears unlikely to result in stimulation of the growth of malignant cells in patients with lymphoma or cancers of the breast, lung, and ovary.

Monocyte activation following systemic administration of granulocyte-macrophage colony-stimulating factor

Twenty-four patients with solid malignancies were treated with granulocyte-macrophage colony-stimulating factor (GM-CSF) on a Phase 1b trial. The objective of the study was to evaluate the effects of GM-CSF on peripheral blood monocyte activation. GM-CSF was administered by subcutaneous injection daily for 14 days. Immune parameters measured were monocyte cytotoxicity against the human colon carcinoma (HT29) cell line, serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, and in vitro TNF-alpha and IL-1 beta induction. All patients were evaluable for toxicity. Fifteen patients were evaluable for immunologic response. Treatment with GM-CSF led to a statistically significant enhancement in direct monocyte cytotoxicity against HT29 cells. There was no increase in serum TNF-alpha or IL-1 beta and no consistent in vitro induction of TNF-alpha or IL-1 beta from monocytes posttreatment. Treatment was well tolerated overall. We conclude that treatment with GM-CSF can lead to enhanced monocyte cytotoxicity. Further studies are in progress to evaluate the effect of GM-CSF on other parameters of monocyte functions.

Repeated topical administration of all-trans-retinoic acid and plasma levels of retinoic acids in humans

BACKGROUND

Vitamin A ingestion raises plasma levels of several potentially teratogenic retinoic acids (RAs) with all-trans and 13-cis configuration, but definitive data concerning the consequences of topical administration of all-trans-RA are lacking.

OBJECTIVE

The study objective was to investigate the potential for inducing systemic activity after topical administration of 0.025% all-trans-RA by measuring plasma retinoid levels.

METHODS

Plasma levels of all-trans-RA, 13-cis-RA, and 4-oxo-13-cis-RA were measured in four healthy subjects before, during, and after 14 daily topical applications of all-trans-RA.

RESULTS

Topical administration of all-trans-RA did not significantly increase plasma levels of all-trans-RA, 13-cis-RA, and 4-oxo-13-cis-RA. Significant decreases in levels of these RAs observed during the night may reflect diurnal variations of retinoid metabolism or lowered absorption of dietary vitamin A.

CONCLUSION

Diurnal and nutritional factors influence plasma levels of endogenous retinoids to a greater extent than topical administration of all-trans-RA at doses used for acne therapy, which on the basis of these results appears unlikely to induce systemic effects.

Pharmacokinetic analysis of two new sustained-release products of diltiazem designed for twice- and once-daily treatment

The pharmacokinetics of two new sustained-release (SR) products of diltiazem, Dilapress 120 mg tablets and Dilapress 240 mg tablets, was analysed and characterized in three different studies, in comparison to the following diltiazem SR formulations: Cardizem Retard, Cardizem SR, and Cardizem CD. Dilapress 120, designated for twice-daily dosing, was found to be bioequivalent to Cardizem SR and to Cardizem Retard with mean (+/- SD) relative bioavailability values of 99 +/- 27% and 113 +/- 38%, respectively. Dilapress 240, designed for once-a-day treatment, was found to have a slower absorption rate than Cardizem SR and its extent of absorption was 56 +/- 19% relative to that of Cardizem SR. However, the bioavailability of Dilapress 240 relative to that of Cardizem CD was 118 +/- 46%, indicating that the bioavailability of Cardizem CD relative to that of Cardizem SR was only 54 +/- 29%. Diltiazem is partially available due to a saturable liver first-pass effect. A high dose of Cardizem SR may partially escape this first-pass effect and, thus, achieve a higher extent of absorption than a slower SR product. Consequently, SR products of diltiazem designed for once-daily treatment may not reach the saturation stage in the liver first-pass effect process that diltiazem is susceptible to. Consequently, a twice-daily SR product of diltiazem cannot serve as a reference for extent of absorption assessments of a once-daily SR product.

Barrier function of human skin and human reconstructed epidermis

The present study compares the stratum corneum of human skin and human reconstructed epidermis by histological examination as well as by estimation of water permeability. Measurement of the percutaneous absorption of benzoic acid, testosterone, and hydrocortisone revealed that under the same experimental conditions the reconstructed epidermis on de-epidermized dermis exhibits a barrier function with qualitative properties similar to that of normal skin: water and benzoic acid penetrate more rapidly than testosterone and hydrocortisone. Quantitatively, however, reconstructed epidermis is more permeable than normal human skin. This points to an impaired barrier function of the epidermis reconstructed in vitro.

A reliability study of SLEDAI: a disease activity index for systemic lupus erythematosus

SLEDAI, a disease activity index for systemic lupus erythematosus (SLE) has been validated against other such indices and its reliability has been shown by specialists in SLE. To assess its reliability among less experienced clinicians, we conducted a reliability study with 3 rheumatology trainees and 9 patients with SLE according to a Latin square design. SLEDAI easily distinguished between patients (p = 0.0009), and physician variability was not statistically significant (p = 0.27). Inter and intraobserver agreement were 78.7 and 98.0%, respectively. SLEDAI was thus shown to be a reliable instrument among less experienced observers for the assessment of disease activity in SLE.

Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE

OBJECTIVE

To standardize outcome measures in systemic lupus erythematosus (SLE). Three indices were identified which could adequately describe outcome (disease activity, damage from disease, and health status); we describe here the development of the Disease Activity Index.

METHODS

Twenty-four variables were identified as important factors in a disease activity index. These were used to generate 574 patient profiles, which were rated on a disease activity scale of 0-10 by 14 rheumatologists. A second rating of 10 of the profiles yielded scores that were not significantly different from the first, indicating that experienced clinicians can reliably make global estimates of disease activity. Multiple regression models were used to estimate the relative importance of the 24 clinical variables in the physicians' global rating of disease activity. These were estimated on a "training set" of 75% of physicians' ratings, and then validated on a "testing set," consisting of the remaining 25% of physicians' ratings.

RESULTS

The explanatory power of the models in the training set was high (R2 = 0.93). The models' regression coefficients for the organ systems were simplified for easier use in clinical practice. This generated a "weighted" index of 9 organ systems for disease activity in SLE, the SLEDAI, as follows: 8 for central nervous system and vascular, 4 for renal and musculoskeletal, 2 for serosal, dermal, immunologic, and 1 for constitutional and hematologic. The maximum theoretical score is 105, but in practice, few patients have scores greater than 45. The SLEDAI predicted well the physicians' ratings in the testing set (Pearson's correlation coefficients = 0.64-0.79).

CONCLUSION

The SLEDAI is a validated model of experienced clinicians' global assessments of disease activity in lupus. It represents the consensus of a group of experts in the field of lupus research.

Lithostar extracorporeal shock wave lithotripsy: the first 1,000 patients. Toronto Lithotripsy Associates

To our knowledge this study of our first consecutive 1,000 patients treated with the Siemens Lithostar device is the largest prospective series reported to date. Treatment results were determined at 3, 12 and 24 months after completion of therapy. The results at 3 months are presented. Complete followup data were available on 801 patients: 674 with renal and 127 with ureteral calculi. Results were analyzed according to stone size, location and number. The average number of shocks per treatment was 3,804 and the retreatment rate was 18.6%. At 3 months the stone-free rate was determined by a plain film of the kidneys, ureters and bladder and plain tomograms for renal calculi, and by an excretory urogram for ureteral calculi. The stone-free rate was 52% for renal and 76% for ureteral calculi. The overall stone-free rate for all calculi was 55.7%. Success rate, defined as stone-free or asymptomatic residual fragments measuring 4 mm. or less, was 72% for renal and 83% for ureteral calculi. The overall success rate for all calculi was 73.9%.

Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy

The potential for variability among observers interpreting diagnostic tests is well known but has not been well established for radiological imaging of urolithiasis. We measured the inter-observer and intra-observer variability in the reporting of plain abdominal films and tomograms from patients who had undergone extracorporeal shock wave lithotripsy (ESWL). Unlabeled copies of the plain abdominal films and tomograms for 58 patients were individually submitted to 3 different radiologists. Selected films from 25 patients were resubmitted to the same radiologists. We found differences among radiologists reporting plain abdominal films alone 52% of the time and even by the same radiologist rereading the films 24% of the time. Tomograms alone decreased the uncertainty but differences still occurred among radiologists 24% of the time and with themselves 16% of the time. When plain abdominal films and tomograms were read together there were differences among radiologists 28% of the time and with themselves 7% of the time but these were usually minor. We concluded from this study that the plain abdominal film alone was frequently difficult to interpret, resulting in uncertainty about the presence or absence of residual stone fragments. Tomograms alone or a plain abdominal film plus tomograms is superior to a plain abdominal film alone. Finally, radiological assessment with all modalities probably overestimates stone-free rates after ESWL even without consideration of the potential for reporting variability among observers.

Reconstructed human epidermis: a model to study in vitro the barrier function of the skin

In previous studies, we have shown that architecture and differentiation of human epidermis reconstructed by culturing dissociated keratinocytes on deepidermized dermis at the air-liquid interface resembles very much those of epidermis in vivo. The various types of epidermal layers are present with the appropriate differentiation markers, such as the bullous pemphigoid antigen, suprabasal keratins, involucrin, membrane-bound transglutaminase and filaggrin, positioned almost like in normal epidermis. At the ultrastructural level, heterogeneous keratohyalin granules and intra- and extracellular membrane-coating granules are observed. After 7 days of culture, a compact stratum corneum covers the reconstructed epidermis. In the present work, the barrier function of the reconstructed epidermis was evaluated by measuring fluxes of 3H-water. Our results show that under the various culture conditions tested, the presence of the reconstructed epidermis reduces dramatically the permeability of the deepidermized dermis although the skin equivalent exhibits a higher permeability than normal skin. Conditions that favor terminal differentiation of the keratinocytes such as maintaining the cultures in delipidized serum improve the barrier function. Reduction of the relative humidity has a similar effect, whereas the age of the culture is of no influence. Experiments are in progress to reconstruct human epidermis with a barrier function as efficient as in normal skin.

Correlation between the drug penetration and the blanching effect of topically applied hydrocortisone creams in human beings

Two topical formulations of 2.5% hydrocortisone were tested to investigate the possible correlation between the blanching response of topically applied hydrocortisone and its release from the formulation after its penetration into the stratum corneum. After application of the cream, the stratum corneum was removed at different intervals and the hydrocortisone content was measured by radioimmunoassay. The blanching responses (expressed as mean score vs time) showed a 1.5-fold difference (significant at p = 0.0026) between the two creams at the maximum effect, which was reached for both creams after 16 hours. The amounts of hydrocortisone present in the stratum corneum after every application period showed a twofold difference (p = 0.0001) between the two creams. However, in contrast to the blanching, these quantities remained constant from 4 to 24 hours. This steady state characteristic may be partially due to the use of occlusion and to the excess formulation remaining at the surface. Although there is no parallelism with time between the results of the two methods, both give clear evidence of a difference in stratum corneum penetration and pharmacologic activity of the two formulations. Drug penetrations and pharmacodynamic activities of the two creams can be correlated with in vitro release characteristics.

Adult celiac sprue: changes in the pattern of clinical recognition

We report the clinical, laboratory, and pathological findings in a series of 52 consecutive patients with adult celiac sprue observed over a 20-year period. The frequency of that diagnosis increased from an average of 0.7 case/year during the period 1966-1975 to 5.8 cases/year during the period 1981-1985. Apart from two patients with dermatitis herpetiformis, nonclassical clinical presentations were observed in 16 of 50 (32%) patients overall and in 13 of 28 (46%) patients diagnosed since 1981. Diarrhea was the most common complaint leading to the diagnosis; since 1981, hematologic abnormalities warranted investigation in 38% of the patients. Decreased iron stores (88%), decreased red cell folate (82%), or both (74%), and abnormal radiographic studies of the small bowel (83%) were the most sensitive tests in the diagnostic investigation. We conclude that atypical or nonclassical presentations of adult celiac sprue, mostly with hematologic abnormalities, are not uncommon.

Monoclonal antibodies to alpha 2u-globulin and immunocytofluorometric analysis of alpha 2u-globulin-synthesizing hepatocytes during androgenic induction and aging

Stable hybridomas generated by fusion of spleen cells from hyperimmunized mice and mouse myeloma cells were cloned to prepare monoclonal antibodies to alpha 2u-globulin, an androgen-dependent urinary protein of hepatic origin. One of these monoclonal antibodies was used as a probe for immunocytofluorometric analysis of alpha 2u-globulin producing hepatocytes during androgenic induction and aging through fluorescence-activated cell sorting (FACS). FACS patterns of hepatocytes from mature male rats that produce high levels of alpha 2u-globulin showed tow distinct peaks, arbitrarily designated as peak I (weakly fluorescent) and peak II (brightly fluorescent). In the mature male rat, peak II represented about 40% of the total hepatocytes, and the fluorescence intensity of this subpopulation decreased in direct correspondence with the gradual decline of alpha 2u-globulin synthesis during aging. Similarly the androgenic induction of this protein in ovariectomized female rats was associated with an increase in the fluorescence intensity of the hepatocyte subpopulation under peak II rather than an increase in the relative number of these cells. From these results we conclude that the androgen-dependent synthesis of alpha 2u-globulin and its alteration during aging are confined to a specific subpopulation of hepatocytes within the liver.

Open-loop intravenous insulin waveforms for postprandial exercise in type I diabetes

To obtain optimal metabolic control in diabetic individuals receiving open-loop insulin infusion, waveforms appropriate for exercise must be developed. The present study describes the responses of four nonobese type I diabetic individuals to a specific insulin waveform derived for postprandial exercise during intravenous open-loop insulin infusions. The open-loop system consisted of a silastic rubber reservoir, a programmable flow-rate controller, and a peristaltic pump connected by a silicone rubber catheter inserted into abranch of the external jugular vein. The basal insulin infusion rate (15 ± 0.5 mU/min) was adjusted to achieve fasting euglycemia (87 ± 7 mg/dl), and a three-step insulin infusion waveform to normalize the glycemic response to breakfast (peak glucose 127 ± 12 mg/dl at 45 min) was established. The three-step (each defined as S1, S2, S3) insulin waveform consisted of: S1, 30 ± 4 mU/min for 15 ± 3.5 min; S2, 58.7 ± 6.6 mU/min for 60 ± 4 min; S3, 33.7 ± 2.5 mU/min for 65 ± 12 min. When 45 min of moderate exercise (65 ± 6 W) wasperformed 30 min after the start of breakfast, symptomatic hypoglycemia occurred in all subjects (lowest mean glucose 49 ± 4 mg/dl) at varying times (65, 115, 180, and 180 min). The meal insulin waveform was then modified so that the infusion rate returnedto the premeal basal rate with the onset and for the duration of exercise, while at the conclusion of exercise, the remaining meal waveform was reinitiated. Under these circumstances, hypoglycemia was prevented and the meal glycemic excursion was entirely normalized.”Free“ immunoreactive insulin levels were significantly lower (P &lt; 0.05) during exercise, consistent with the reduction in the infusion rate to basal with the modified meal insulin waveform. This insulin infusion waveform appears appropriate to normalize the glycemic response to postprandial exercise with open-loop intravenous insulin replacement.

The effect of postprandial exercise on meal-related glucose intolerance in insulin-dependent diabetic individuals

Although exercise is a central therapeutic modality in insulin-dependent diabetic patients, its prescription and expected effects have remained far less precise than the concurrent modalities of insulin and diet. To quantify the potential benefit of exercise on meal glycemic excursions, eight insulin-dependent diabetic subjects were studied on two separate days during breakfast and lunch, with and without 45 min of moderate exercise, starting 30 min after breakfast. All other variables were kept constant, including their usual insulin doses, which were given subcutaneously in the abdomen. Fasting glycemias were brought to comparable levels by overnight insulin infusion (rest day: 110 ± 9 mg/dl; exercise day: 105 ± 9 mg/dl). Postprandial exercise reduced peak glycemia for breakfast (270 ± 22 versus 203 ± 22 mg/dl) and lunch (270 ± 16 versus 170 ± 20 mg/dl, P &lt; 0.05) for the group as a whole on rest day and exercise day, respectively. Three types of individual responses were seen. Five subjects showed an improved glycemic excursion with exercise during both breakfast and lunch. In two subjects only the lunch response was significantly improved. One subject showed no effect of exercise. The failure to demonstrate a lowering of glycemia with breakfast appears to be related to the persistent use of fatderived fuels in these subjects. This is suggested by a lower respiratory quotient (RQ), and elevated free fatty acid and 3-hydroxybutyrate concentrations. Plasma “free” insulin and glucagon concentrations could not account for these observations. Thus, the majority of subjects showed improved glucoregulation related to exercise performed postprandially. If adequately insulinized, conventionally treated diabetic individuals can benefit from strategically timed exercise.

Domperidone in the treatment of postoperative vomiting: a double-blind multicenter study

Domperidone was compared with placebo in a multicenter double-blind study of 116 patients (15 to 80 years) with postoperative vomiting. After vomiting had occurred, the patients received either domperidone 10 mg or placebo IV. Patients were then followed for at least 6 hours or until a 2nd injection of domperidone 10 mg from an open supply was needed. The period of time until an additional injection was registered and compared between the 2 treatment groups. Fifty-nine percent of the placebo patients needed a 2nd injection before the end of the 6-hour follow-up, compared with only 35% of the domperidone patients (p less than 0.05). When a 2nd injection was required, the time elapsed before it was needed was longer (p = 0.01) in the domperidone group (median 150 minutes) than in the placebo one (median 120 minutes). There were no significant side-effects.

Postoperative nausea and vomiting treated with domperidone (r 33812) an open and a double-blind study

The effect of domperidone on postoperative nausea and vomiting was evaluated in two consecutive studies. Fifty-eight patients with postoperative nausea and vomiting were included in an open pilot study and 38 other patients in a double-blind trial. In the first study 4 mg of domperidone was found to be significantly superior to 2 mg, in controlling nausea and vomiting. In the double-blind trial, vomiting recurred significantly later in domperidone than in placebo-treated patients. Side-effects were not seen nor reported in either study.