Trust In US Federal, State, And Local Public Health Agencies During COVID-19: Responses And Policy Implications

Public health agencies' ability to protect health in the wake of COVID-19 largely depends on public trust. In February 2022 we conducted a first-of-its-kind nationally representative survey of 4,208 US adults to learn the public's reported reasons for trust in federal, state, and local public health agencies. Among respondents who expressed a "great deal" of trust, that trust was not related primarily to agencies' ability to control the spread of COVID-19 but, rather, to beliefs that those agencies made clear, science-based recommendations and provided protective resources. Scientific expertise was a more commonly reported reason for "a great deal" of trust at the federal level, whereas perceptions of hard work, compassionate policy, and direct services were emphasized more at the state and local levels. Although trust in public health agencies was not especially high, few respondents indicated that they had no trust. Lower trust was related primarily to respondents' beliefs that health recommendations were politically influenced and inconsistent. The least trusting respondents also endorsed concerns about private-sector influence and excessive restrictions and had low trust in government overall. Our findings suggest the need to support a robust federal, state, and local public health communications infrastructure; ensure agencies' authority to make science-based recommendations; and develop strategies for engaging different segments of the public.

Receipt of Recommended Follow-up Care After a Positive Lung Cancer Screening Examination

Importance

Maximizing benefits of lung cancer screening requires timely follow-up after a positive screening test. The American College of Radiology (ACR) Lung CT Screening Reporting and Data System (Lung-RADS) recommends testing and follow-up timing based on the screening result.

Objective

To determine rates of and factors associated with recommended follow-up after a positive lung cancer screening examination by Lung-RADS category.

Design, Setting, and Participants

This prospective cohort study of lung cancer screening examinations performed from January 1, 2015, through July 31, 2020, with follow-up through July 31, 2021, was conducted at 5 academic and community lung cancer screening sites in North Carolina. Participants included 685 adults with a positive screening examination, Lung-RADS categories 3, 4A, 4B, or 4X. Statistical analysis was performed from December 2020 to March 2022.

Exposures

Individual age, race, sex, smoking exposure, year of lung cancer screening examination, chronic obstructive pulmonary disease, body mass index, referring clinician specialty, rural or urban residence.

Main Outcomes and Measures

Adherence, defined as receipt of recommended follow-up test or procedure after the positive screen per ACR Lung-RADS timeframes: 6 months for Lung-RADS 3 and 3 months for Lung-RADS 4A. For Lung-RADS 4B or 4X, adherence was defined as follow-up care within 4 weeks, as ACR Lung-RADS does not specify a timeframe.

Results

Among the 685 individuals included in this study who underwent lung cancer screening with low-dose computed tomography, 416 (60.7%) were aged at least 65 years, 123 (18.0%) were Black, 562 (82.0%) were White, and 352 (51.4%) were male. Overall adherence to recommended follow-up was 42.6% (292 of 685) and varied by Lung-RADS category: Lung-RADS 3 = 30.0% (109 of 363), Lung-RADS 4A = 49.5% (96 of 194), Lung-RADS 4B or 4X = 68.0% (87 of 128). Extending the follow-up time increased adherence: Lung-RADS 3 = 68.6% (249 of 363) within 9 months, Lung-RADS 4A = 77.3% (150 of 194) within 5 months, and Lung-RADS 4B or 4X = 80.5% (103 of 128) within 62 days. For Lung-RADS 3, recommended follow-up was less likely among those currently smoking vs those who quit (adjusted odds ratio [aOR], 0.48; 95% CI, 0.29-0.78). In Lung-RADS 4A, recommended follow-up was less likely in Black individuals vs White individuals (aOR, 0.35; 95% CI, 0.15-0.86). For Lung-RADS 4B or 4X, recommended follow-up was more likely in female individuals vs male individuals (aOR, 2.82; 95% CI, 1.09-7.28) and less likely in those currently smoking vs those who quit (aOR, 0.31; 95% CI, 0.12-0.80).

Conclusions and Relevance

In this cohort study, adherence to recommended follow-up after a positive screening examination was low but improved among nodules with a higher suspicion of cancer and after extending the follow-up timeline. However, the association of extending the follow-up time of screen-detected nodules with outcomes at the population level, outside of a clinical trial, is unknown. These findings suggest that studies to understand why recommended follow-up is lower in Black individuals, male individuals, and individuals currently smoking are needed to develop strategies to improve adherence.

Lung Cancer Screening in Individuals With and Without Lung-Related Comorbidities

Importance

Comorbidities characterize the underlying health status of individuals. In the context of lung cancer screening (LCS), lung-related comorbidities may influence the observed benefits and harms.

Objective

To compare the characteristics of individuals undergoing LCS, the LCS examination result, the cancer detection rate (CDR), and the false-positive rate (FPR) in those with and without lung-related comorbidities.

Design, Setting, and Participants

A prospective cohort study was conducted in 5 academic and community screening sites across North Carolina from January 1, 2014, to November 7, 2020. Participants included 611 individuals screened for lung cancer who completed a 1-page health history questionnaire.

Exposures

Presence of at least 1 self-reported lung-related comorbidity, including chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma, bronchiectasis, pulmonary fibrosis, silicosis, asbestosis, sarcoidosis, and tuberculosis.

Main Outcomes and Measures

The LCS examination result was determined from the radiologist's Lung Imaging Reporting and Data System assessment (negative, 1 or 2; positive, 3 or 4). The age-adjusted CDR and FPR were calculated per 100 LCS examinations, using binary logistic regression.

Results

Among the 611 individuals screened for lung cancer (308 men [50.4%]; mean [SD] age, 64 [6.2] years), 335 (54.8%) had at least 1 lung-related comorbidity. Individuals with vs without lung-related comorbidities were more likely to be female than male (180 of 335 [53.7%] vs 123 of 276 [44.6%]; P = .02), White vs non-White race (275 of 326 [84.4%] vs 193 of 272 [71.0%]; P < .001), and have high school or less education vs greater than a high school education (108 of 231 [46.7%] vs 64 of 208 [30.8%]; P = .001). There were no significant differences in the proportion of positive LCS examinations in those with vs without a lung-related comorbidity at baseline (37 [16.0%] vs 22 [11.1%]; P = .14) or subsequent (40 [12.3%] vs 23 [10.6%]; P = .54) LCS examination. Comparing individuals with vs without lung-related comorbidities, there was no statistically significant difference in the CDR (1.6 vs 1.9 per 100; P = .73) or FPR (13.0 vs 9.3 per 100; P = .16). Of the 17 individuals with lung cancer, 13 patients (76.5%) were diagnosed with stage I lung cancer.

Conclusions and Relevance

The findings of this study suggest that individuals with self-reported lung-related comorbidities undergoing LCS were more likely to be female, of White race, and have less education than those without lung-related comorbidity. Although no statistically significant differences in the proportion of positive examinations, CDR, or FPR by self-reported lung comorbidities were noted, additional studies with larger numbers of individuals undergoing screening are needed to understand LCS outcomes in those with lung-related comorbidities.

Getting Critical Information During the COVID-19 Pandemic: Experiences of Spanish and Chinese Speakers With Limited English Proficiency

People with limited English proficiency in the United States have suffered disproportionate negative health outcomes during the COVID-19 pandemic. Effective communications are critical tools in addressing inequities insofar as they can motivate adoption of protective behaviors and reduce incidence of disease; however, little is known about experiences of communities with limited English proficiency receiving relevant information during COVID-19 or other outbreaks. To address this gap and provide inputs for communication strategies, we completed a study based on 2 novel and nationally representative surveys conducted between June and August 2020 among Spanish and Chinese speakers with limited English proficiency (n = 764 and n = 355, respectively). Results first showed that Spanish and Chinese speakers did not consistently receive information about protective behaviors from key public health and government institutions early in the pandemic. Second, for such information, Spanish and Chinese speakers used a diverse set of information resources that included family and friends, social media, and traditional media from both inside and outside the United States. Third, Spanish and Chinese speakers faced challenges getting COVID-19 information, including receiving media messages that felt discriminatory toward Latinx or Chinese people. Together, these findings suggest gaps in effectively reaching Spanish and Chinese speakers. Data highlight the important role of bilingual materials to support sharing of information between Spanish or Chinese speakers and English speakers within their social networks, and the need for digital news content for traditional and social media. Finally, efforts are needed to address discriminatory messaging in media and to actively counter it in public health communications.

Randomized control trial of unconditional versus conditional incentives to increase study enrollment rates in participants at increased risk of lung cancer

INTRODUCTION

Understanding how incentives and their timing influence study enrollment rates is important to efficient study design and increasing the generalizability of findings. This 2-arm, parallel randomized trial evaluated how conditional vs. unconditional mailed incentives of a $20 gift card affected study enrollment in a sample of participants screened for lung cancer screening.

METHODS

Eligible participants included Black and White adults who underwent lung cancer screening with low-dose CT and had negative screening results at two North Carolina imaging facilities in 2018. We used a stratified randomization scheme, by sex and race, to assign incentive type (conditional vs. unconditional). We used the Tailored Design Method with six points of mailed contact to engage participants. We compared study enrollment rates using chi-square tests and logistic regression analyses.

RESULTS

After adjusting for sex, race, age, smoking status, participant residence, and screening site, participants who received unconditional incentives were 74% more likely to enroll than those who received conditional incentives (adjusted OR = 1.74 (95% CI: 1.01, 3.00).

CONCLUSIONS

Type of incentive can play a role in increasing study enrollment, especially mailed surveys that target individuals who currently or previously smoked. Unconditional incentives may be worth the initial cost to engage study participants.

Patterns and Factors Associated With Adherence to Lung Cancer Screening in Diverse Practice Settings

IMPORTANCE

For lung cancer screening to confer mortality benefit, adherence to annual screening with low-dose computed tomography scans is essential. Although the National Lung Screening Trial had an adherence rate of 95%, current data are limited on screening adherence across diverse practice settings in the United States.

OBJECTIVE

To evaluate patterns and factors associated with adherence to annual screening for lung cancer after negative results of a baseline examination, particularly in centralized vs decentralized screening programs.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study was conducted at 5 academic and community-based sites in North Carolina and California among 2283 individuals screened for lung cancer between July 1, 2014, and March 31, 2018, who met US Preventive Services Task Force eligibility criteria, had negative results of a baseline screening examination (American College of Radiology Lung Imaging Reporting and Data System category 1 or 2), and were eligible to return for a screening examination in 12 months.

EXPOSURES

To identify factors associated with adherence, the association of adherence with selected baseline demographic and clinical characteristics, including type of screening program, was estimated using multivariable logistic regression. Screening program type was classified as centralized if individuals were referred through a lung cancer screening clinic or program and as decentralized if individuals had a direct clinician referral for the baseline low-dose computed tomography scan.

MAIN OUTCOMES AND MEASURES

Adherence to annual lung cancer screening, defined as a second low-dose computed tomography scan within 11 to 15 months after baseline screening.

RESULTS

Among the 2283 eligible individuals (1294 men [56.7%]; mean [SD] age, 64.9 [5.8] years; 1160 [50.8%] aged ≥65 years) who had negative screening results at baseline, overall adherence was 40.2% (n = 917), with higher adherence among those who underwent screening through centralized (46.0% [478 of 1039]) vs decentralized (35.3% [439 of 1244]) programs. The independent factor most strongly associated with adherence was type of screening program, with a 2.8-fold increased likelihood of adherence associated with centralized screening (adjusted odds ratio [aOR], 2.78; 95% CI, 1.99-3.88). Another associated factor was age (65-69 vs 55-59 years: aOR, 1.38; 95% CI, 1.07-1.77; 70-74 vs 55-59 years: aOR, 1.47; 95% CI, 1.10-1.96).

CONCLUSIONS AND RELEVANCE

After negative results of a baseline examination, adherence to annual lung cancer screening was suboptimal, although adherence was higher among individuals who were screened through a centralized program. These results support the value of centralized screening programs and the need to further implement strategies that improve adherence to annual screening for lung cancer.

Low-Dose Anti-Thymocyte Globulin (ATG) Preserves β-Cell Function and Improves HbA1c in New-Onset Type 1 Diabetes

OBJECTIVE

A pilot study suggested that combination therapy with low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte colony-stimulating factor (GCSF) preserves C-peptide in established type 1 diabetes (T1D) (duration 4 months to 2 years). We hypothesized that 1) low-dose ATG/GCSF or 2) low-dose ATG alone would slow the decline of β-cell function in patients with new-onset T1D (duration <100 days).

RESEARCH DESIGN AND METHODS

A three-arm, randomized, double-masked, placebo-controlled trial was performed by the Type 1 Diabetes TrialNet Study Group in 89 subjects: 29 subjects randomized to ATG (2.5 mg/kg intravenously) followed by pegylated GCSF (6 mg subcutaneously every 2 weeks for 6 doses), 29 to ATG alone (2.5 mg/kg), and 31 to placebo. The primary end point was mean area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test 1 year after initiation of therapy. Significance was defined as one-sided P value < 0.025.

RESULTS

The 1-year mean AUC C-peptide was significantly higher in subjects treated with ATG (0.646 nmol/L) versus placebo (0.406 nmol/L) (P = 0.0003) but not in those treated with ATG/GCSF (0.528 nmol/L) versus placebo (P = 0.031). HbA_1c was significantly reduced at 1 year in subjects treated with ATG and ATG/GCSF, P = 0.002 and 0.011, respectively.

CONCLUSIONS

Low-dose ATG slowed decline of C-peptide and reduced HbA_1c in new-onset T1D. Addition of GCSF did not enhance C-peptide preservation afforded by low-dose ATG. Future studies should be considered to determine whether low-dose ATG alone or in combination with other agents may prevent or delay the onset of the disease.

Examining the influence of personal goal interference and attainability on psychological distress in non-metastatic breast cancer patients

The present study investigated the relationship between two goal-related appraisals - perceived cancer-related interference and perceived attainability of important personal goals - and psychological distress among non-metastatic breast cancer patients across the short-term treatment and recovery period. Forty-five women completed self-report questionnaires at approximately 1 and 6 months following surgery. A mixed idiographic-nomothetic goal methodology assessed perceived cancer-related interference and attainability of self-generated important personal goals. Psychological distress symptoms were assessed with the Depression Anxiety Stress Scales short form. Correlation analyses and general linear modelling were used to evaluate the hypothesised relationships over time. Average cancer-related interference and attainability of important personal goals were significantly associated with concurrent depression, anxiety and stress symptoms at 6 months following surgery. Perceived attainability of highly important goals at 6 months post-surgery uniquely predicted change in psychological distress symptoms over time. The findings suggest that low perceived attainability of important personal goals may be an important predictor of elevated distress symptoms across the short-term following surgery. Further insight into the relationship between these negative goal appraisals and psychological functioning among different groups of cancer patients could inform the provision of targeted psychosocial support across the cancer continuum.

Collaborative annotation of genes and proteins between UniProtKB/Swiss-Prot and dictyBase

UniProtKB/Swiss-Prot, a curated protein database, and dictyBase, the Model Organism Database for Dictyostelium discoideum, have established a collaboration to improve data sharing. One of the major steps in this effort was the ‘Dicty annotation marathon’, a week-long exercise with 30 annotators aimed at achieving a major increase in the number of D. discoideum proteins represented in UniProtKB/Swiss-Prot. The marathon led to the annotation of over 1000 D. discoideum proteins in UniProtKB/Swiss-Prot. Concomitantly, there were a large number of updates in dictyBase concerning gene symbols, protein names and gene models. This exercise demonstrates how UniProtKB/Swiss-Prot can work in very close cooperation with model organism databases and how the annotation of proteins can be accelerated through those collaborations.

A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer

BACKGROUND

The outcome of local excision of early rectal cancer using transanal endoscopic microsurgery (TEM) lacks consensus. Screening has substantially increased the early diagnosis of tumours. Patients need local treatments that are oncologically equivalent to radical surgery but safer and functionally superior.

METHODS

A national database, collated prospectively from 21 regional centres, detailed TEM treatment in 487 subjects with rectal cancer. Data were used to construct a predictive model of local recurrence after TEM using semiparametric survival analyses. The model was internally validated using measures of calibration and discrimination.

RESULTS

Postoperative morbidity and mortality were 14.9 and 1.4 per cent respectively. The Cox regression model predicted local recurrence with a concordance index of 0.76 using age, depth of tumour invasion, tumour diameter, presence of lymphovascular invasion, poor differentiation and conversion to radical surgery after histopathological examination of the TEM specimen.

CONCLUSION

Patient selection for TEM is frequently governed by fitness for radical surgery rather than suitable tumour biology. TEM can produce long-term outcomes similar to those published for radical total mesorectal excision surgery if applied to a select group of biologically favourable tumours. Conversion to radical surgery based on adverse TEM histopathology appears safe for p T1 and p T2 lesions.

Niemann-Pick C1 protects against atherosclerosis in mice via regulation of macrophage intracellular cholesterol trafficking

Niemann-Pick C1 (NPC1) is a key participant in cellular cholesterol trafficking. Loss of NPC1 function leads to defective suppression of SREBP-dependent gene expression and failure to appropriately activate liver X receptor-mediated (LXR-mediated) pathways, ultimately resulting in intracellular cholesterol accumulation. To determine whether NPC1 contributes to regulation of macrophage sterol homeostasis in vivo, we examined the effect of NPC1 deletion in BM-derived cells on atherosclerotic lesion development in the Ldlr-/- mouse model of atherosclerosis. High-fat diet-fed chimeric Npc1-/- mice reconstituted with Ldlr-/-Npc1-/- macrophages exhibited accelerated atherosclerosis despite lower serum cholesterol compared with mice reconstituted with wild-type macrophages. The discordance between the low serum lipoprotein levels and the presence of aortic atherosclerosis suggested that intrinsic alterations in macrophage sterol metabolism in the chimeric Npc1-/- mice played a greater role in atherosclerotic lesion formation than did serum lipoprotein levels. Macrophages from chimeric Npc1-/- mice showed decreased synthesis of 27-hydroxycholesterol (27-HC), an endogenous LXR ligand; decreased expression of LXR-regulated cholesterol transporters; and impaired cholesterol efflux. Lower 27-HC levels were associated with elevated cholesterol oxidation products in macrophages and plasma of chimeric Npc1-/- mice and with increased oxidative stress. Our results demonstrate that NPC1 serves an atheroprotective role in mice through regulation of LXR-dependent cholesterol efflux and mitigation of cholesterol-induced oxidative stress in macrophages.

Survey of local immunisation training in England--the case for setting national standards

In June 2003 a questionnaire on immunisation training was sent to the 302 primary care trusts (PCTs) in England to ascertain the frequency and content of immunisation training being offered to healthcare professionals. Fifty-four per cent of the 227 trusts (75%) who replied were concerned about their ability to deliver an immunisation programme. Contributing factors included the lack of a designated training lead, shortage of specialist input, available time, and funding. Of PCTs, 33/219 (15%) were not providing immunisation training sessions for practice nurses, 28/219 (13%) for health visitors, and 30/219 (14%) for school nurses; 67/219 (31%) had no sessions organised for general practitioners. Most 138/175 (79%) PCTs would welcome the introduction of some national minimum standards for immunisation training to assist them in setting up and maintaining a programme, and allocating sufficient resources to it.

Immunogenicity and safety of a low-dose diphtheria, tetanus and acellular pertussis combination vaccine with either inactivated or oral polio vaccine as a pre-school booster in UK children

This open, randomised controlled trial studied the immunogenicity and reactogenicity of two combined low-dose diphtheria, tetanus and acellular pertussis vaccines (Td5aP-IPV, REPEVAX, Aventis Pasteur MSD; and Td5aP, COVAXIS, Aventis Pasteur MSD + OPV, GlaxoSmithKline) in comparison with a standard dose diphtheria pre-school booster vaccine (DT2aP-IPV, TETRAVAC, Aventis Pasteur MSD) in a population of 3.5-5-year-old children administered concomitantly with measles, mumps and rubella vaccine (M-M-R II, Aventis Pasteur MSD). A linked sub-study aimed to evaluate the immunogenicity and reactogenicity of Td5aP-IPV in a population of younger children, aged 3-3.5 years. This study demonstrated non-inferiority of seroprotection rates for diphtheria and tetanus for the study vaccines and comparable immunogenicity for pertussis and polio components of the vaccines. Reactogenicity was similar for all three vaccines. The study vaccines containing low-dose diphtheria antigen (Td5aP-IPV and Td5aP + OPV) are immunogenic and have acceptable reactogenicity for use as a pre-school booster vaccine administered concomitantly with MMR.

Bladder spasm in children after surgery for ureteric reimplantation

The primary aim of this study was to prospectively investigate whether there was an association between the duration of post-operative catheterisation and the incidence of bladder spasm in children following ureteric reimplantation surgery. A secondary aim was to investigate whether other surgical and post-operative factors had an effect on the incidence of bladder spasm.

Distance learning: getting closer all the time

In recent years, distance learning has become an increasingly viable option, and HIM students have benefitted. How does this new way of learning work, and is it working for students? Some instructors and students tell their success stories.

Cost effectiveness of rotavirus vaccination in Australia

OBJECTIVE

Rotavirus gastroenteritis causes substantial morbidity, including hospital admission, in young children. In the context of recent vaccine developments, this study aimed to estimate the cost-effectiveness of a rotavirus vaccination program in Australia.

METHOD

Standard methods of health economic evaluation were used to assess the total cost of rotavirus immunisation (as the difference between estimated vaccination program costs and the cost of disease that would be avoided by immunisation) and relate this to the number of cases of disease that would be prevented. Estimates were made from both societal and health care systems perspectives.

RESULTS

Based on Australian data on disease incidence and cost of hospitalisation, the current annual cost of rotavirus disease is about $26.0 million. Using conservative vaccine efficacy estimates, current immunization uptake rates and a cost of $30 per dose of vaccine, rotavirus immunisation would incur a net societal cost of $2.9 million ($11 per child), at a gross program cost of $21.6 million. These estimates are sensitive to two sources of uncertainty in the estimation of program delivery costs: vaccine price and whether separate immunization visits would be required.

CONCLUSION

A rotavirus immunisation program would be cost-neutral to Australian society at a vaccine price of $26 per dose (or $19 when health care system costs only are considered).

IMPLICATIONS

Rotavirus immunization may be cost-effective in Australia, but considerable uncertainty remains. Policy decisions will depend heavily on pricing of the vaccine and may also need to consider intangible costs not accounted for in this analysis.

Modification of physical movement in old C57BL/6 mice by DHEA and melatonin supplementation

As old age results in reduced physical activity as well as less dehydroepiandrosterone (DHEA) and melatonin (MLT) production, low hormone levels may be a component of inactivity. Therefore, we studied the effects of DHEA and/or MLT supplementation on movement and resting in young and old female C57 black mice. Our results showed for the first time that old female C56BL/6 mice have significantly decreased physical activity. Their average speed and resting time were significantly higher than in young mice, whereas ambulatory time, distance traveled, and body movements when stationary (stereo time) were lower. DHEA supplementation significantly increased stereo time in old mice, while decreasing ambulatory time and distance traveled. MLT supplementation of old mice decreased average speed, resting time, and stereo time compared to untreated, old mice. Supplementation with MLT or DHEA, whose production is reduced in aging, restored physical activity levels in old mice. MLT also increased ambulatory time and distance traveled while reducing body movements of young mice.

Physical inactivity of murine retrovirus infected C57BL/6 mice is prevented by melatonin and dehydroepiandrosterone

LP-BM5 retrovirus infection and hormone synthesis modulate many physiological systems that could affect physical activity. Infection induced oxidative damage and immunodeficiency of female mice which hormone supplement prevented. Therefore, the effects of retrovirus infection and hormone supplementation were assessed on physical activity using a computerized video system. Retroviral infection increased activity when stationary while lowering average speed and resting time. Hormone supplementation partially modified changes due to murine AIDS. Dehydroepiandrosterone (DHEA) or melatonin (MLT) supplementation restored the average speed; ambulatory time and distance traveled of retrovirus infected mice. MLT as well as the combination of DHEA + MLT increased body movement, but decreased average speed and distance traveled. Thus, retrovirus infection had significant effects on physical activity. Further studies into the relationship between the DHEA and/or MLT and physical activity will assert the contribution of these hormones to the treatment of murine AIDS.

Chlorella virus PBCV-1 encodes a homolog of the bacteriophage T4 UV damage repair gene denV

The bacteriophage T4 denV gene encodes a well-characterized DNA repair enzyme involved in pyrimidine photodimer excision. We have discovered the first homologs of the denV gene in chlorella viruses, which are common in fresh water. This gene functions in vivo and also when cloned in Escherichia coli. Photodamaged virus DNA can also be photoreactivated by the host chlorella. Since the chlorella viruses are continually exposed to solar radiation in their native environments, two separate DNA repair systems, one that functions in the dark and one that functions in the light, significantly enhance their survival.

Proliferation of mutators in A cell population

A Lac- strain of Escherichia coli that reverts by the addition of a G to a G-G-G-G-G-G sequence was used to study the proliferation of mutators in a bacterial culture. Selection for the Lac+ phenotype, which is greatly stimulated in mismatch repair-deficient strains, results in an increase in the percentage of mutators in the selected population from less than 1 per 100,000 cells to 1 per 200 cells. All the mutators detected were deficient in the mismatch repair system. Mutagenesis results in a similar increase in the percentage of mutators. Mutagenesis combined with a single selection can result in a population of more than 50% mutators when a sample of several thousand cells is grown out and selected. Mutagenesis combined with two or more successive selections can generate a population that is 100% mutator. These experiments are discussed in relation to ideas that an early step in carcinogenesis is the creation of a mutator phenotype.

Herpes zoster peripheral ulcerative keratitis in patients with the acquired immunodeficiency syndrome

The purpose of this study was to describe the clinical characteristics and course of peripheral ulcerative keratitis (PUK) secondary to herpes varicella-zoster virus in patients with the acquired immunodeficiency syndrome (AIDS). Three AIDS patients with ocular herpes zoster infection (mean age at onset, 33.0 years; range, 30-42) developed PUK. The three patients had skin involvement, and two of them had bilateral keratouveitis. All were treated with high-dose oral acyclovir (4 g/day) with or without topical antiviral therapy. Two of the patients responded well to oral acyclovir, but one of them stopped the treatment, and bilateral progressive outer retinal necrosis and lethal encephalitis developed. The third patient had a recurrent episode of inflammation with PUK, extensive stromal scarring, and deep neovascularization. AIDS patients with herpes varicella-zoster virus infection may have severe and protracted corneal manifestations, including PUK. The correct diagnosis and aggressive early long-term systemic antiviral treatment must be instituted to control inflammation, ulcer progression, and complications.

Immunomodulation by pycnogenol in retrovirus-infected or ethanol-fed mice

Pycnogenol is a commercial mixture of bioflavonoids that exhibits antioxidative activity. The effects of dietary pycnogenol on immune dysfunction in normal mice as well as those fed ethanol or infected with the LP-BM5 murine retrovirus were determined. The ethanol consumption and retrovirus infection caused abnormalities in the function and/or structure of a broad array of cells involved in humoral and cellular immunity. Pycnogenol enhanced in vitro IL-2 production by mitogen-stimulated splenocytes if its production was suppressed in ethanol-fed or retrovirus-infected mice. Mitogenesis of splenocytes did not show a significant change in mice treated with pycnogenol. It reduced the elevated levels of interleukin-6 produced in vitro by cells from retrovirus infected mice and IL-10 secreted by spleen cells from mice consuming ethanol. Natural killer cell cytotoxicity was increased with pycnogenol treatment.

Systemic immunosuppressive therapy and the occurrence of malignancy in patients with ocular inflammatory disease

PURPOSE

To compare the occurrence of malignancy in patients with severe ocular inflammatory disease treated with systemic corticosteroids alone or with systemic immunosuppressive drugs with or without systemic corticosteroids.

METHODS

The clinical records of 543 patients with ocular inflammatory disease treated with systemic corticosteroids and/or immunosuppressive chemotherapy were reviewed in a retrospective cohort study. Characteristics of patients treated with corticosteroids alone were compared with characteristics of patients treated with immunosuppressive agents with or without preceding corticosteroid treatment. The rates of malignancy after initiation of drug therapy were compared using an exact test for incidence rate data.

RESULTS

Compared with patients treated with corticosteroids alone, patients treated with immunosuppressants with or without corticosteroid treatment were older and had more severe systemic disease. During a total of 1261 person-years of follow-up, a malignancy developed in five patients. The rate of malignancy in the immunosuppressant group (4 malignancies during 968 person-years of follow-up) was not significantly different from the rate in the corticosteroids alone group (1 malignancy during 293 person-years of follow-up) (P > 0.90, exact test for incidence rate data).

CONCLUSION

These findings do not support the hypothesis of an increased risk of malignancy in patients with severe ocular inflammatory disease who are treated with systemic immunosuppressive agents compared with patients treated with systemic corticosteroids.

Testicular cancer in fire fighters: a cluster investigation

AIM

To investigate an apparent cluster of four testicular cancer cases in Wellington fire fighters with a view to determining whether there was a common causal factor, and whether the cluster was indicative of an occupational risk for fire fighters generally.

METHOD

Subjects were interviewed about possible risk factors and occupational histories using a structured questionnaire; medical records were reviewed, and diagnoses were verified from the original histological slides. Data on testicular cancer in fire fighters were obtained from the New Zealand cancer registry. Standardised incidence ratios were calculated to assess the likelihood that the cluster had arisen by chance.

RESULTS

All four cancers were verified as germ cell testicular cancers. No common risk factors were apparent from the review of the medical records or from the questionnaire interviews. The only testicular cancers known to have occurred in Wellington fire fighters in the 1980s were the four investigated in this study. Only two of the four cases investigated were registered with the New Zealand cancer registry. The relative risk estimate for Wellington fire fighters for the period 1980-91 was 8.2, with an approximate 95% confidence interval of 2.2-21 (p = 0.002).

CONCLUSION

There was an unusually high risk of testicular cancer in Wellington fire fighters in the 1980s, with no obvious explanations, although chance could not be excluded. Whether this high risk continues in the 1990s would require a separate investigation. At present the weight of evidence does not indicate that fire fighters in other areas of New Zealand also experienced an elevated testicular cancer incidence rate.

Disease relapse in patients with ocular manifestations of Wegener granulomatosis

PURPOSE

To evaluate possible factors associated with disease relapse in patients with ocular manifestations of Wegener granulomatosis.

METHODS

Eight patients with ocular manifestations of Wegener granulomatosis were longitudinally followed for a mean period of 34 months. Serial antineutrophil cytoplasmic antibody (ANCA) levels were determined on all patients.

RESULTS

All eight patients had either scleritis alone or scleritis combined with peripheral ulcerative keratitis. Clinical disease remission was achieved in all patients using immunosuppressive chemotherapy. Five patients had subsequent relapse after treatment withdrawal. The serum ANCA level had failed to revert to normal during remission in four of the five patients who had had relapses. The ANCA levels for all three patients who remained in remission without therapy converted to normal. There was no significant difference in the initial serum ANCA level (P = 0.35) or the mean cumulative cyclophosphamide dose (P = 0.13) between those who had a relapse and those who did not.

CONCLUSION

Failure of ANCA titers to revert to normal levels may be associated with the potential for relapse in patients with ocular manifestations of Wegener granulomatosis.

Iridoschisis and keratoconus

We report herein a patient with iridoschisis and keratoconus. Since the posterior layers of the cornea and the iris stroma have a common embryological deviation, the combination of these two conditions suggests an inter-related pathogenesis. This case is similar to those of patients with progressive essential iris atrophy and keratoconus described by Cavanagh.

Ambulatory care: a decade of change in health care delivery

While the need to realign the continuum and change the delivery system is one of the many factors driving health care reform, it is clear that a major transformation of the delivery system is already under way and that ambulatory care and home care are at the forefront of that movement. This trend is likely to continue regardless of the pace of health reform.

Successful rehabilitation program rests on service utilization

An effective rehabilitation strategy is built upon three fundamentals: translating resident needs into delivered services, managing occupancy and marketing programs, and utilizing existing reimbursement mechanisms to ensure profitability of the venture.

Histomorphometric assessment of the mechanisms for rapid ingrowth of bone to HA/TCP coated implants

The purpose of this work is to use dynamic histomorphometry to evaluate the basic biological mechanisms by which hydroxyapatite/tricalcium phosphate (HA/TCP) implant coatings accelerate bone formation rates. Twenty-five rabbits had an HA/TCP coated cylindrical titanium fiber metal mesh implant surgically placed in the subchondral bone of the proximal tibia and a noncoated implant placed in the contralateral tibia. Twenty-two of these animals had HA/TCP coated cylindrical solid titanium implants placed in the distal femur and an uncoated implant placed in the contralateral femur. The animals were double labeled with vital stains, and sacrificed at 3, 6, 16, or 26 weeks after surgery. Histomorphometric analyses were done of the bone implant interfaces. Both static and dynamic histomorphometric parameters indicate that HA/TCP coatings stimulate faster bone ingrowth to coated fiber metal implants through the early production of woven bone and by subsequent rapid lamellar bone formation rates. Coated fiber metal implants demonstrated significantly more bone ingrowth than noncoated implants through 16 weeks postimplantation, but not by 26 weeks. In solid implants, the differences between coated and noncoated implants are less pronounced and not statistically significant, although there is a trend toward increased bone apposition to the surface of the implants over the first 16 weeks following implantation. The clinical significance of these results is that coated implants may allow earlier return to normal weightbearing.

Economic considerations important in the scale-up of an ovalbumin separation from hen egg-white on the anion-exchange cellulose DE92

The scale-up of the separation of hen egg-white proteins has been investigated using Whatman DE92 anion-exchange cellulose. Having developed suitable chromatographic conditions, a maximum binding capacity of 100 mg protein/ml packed DE92 was determined in a 25-ml column. The process was scaled up 1000-fold and the influence of batch and column techniques on the chromatographic step assessed. Data indicate column processes to be more efficient than batch in the adsorptive stage.

Chromatography of hen egg-white proteins on anion-exchange cellulose at high flow rates using a radial flow column

The influence of column configuration on the separation of hen egg-white proteins using Whatman DE52 and QA52 anion-exchange cellulose has been investigated. Using a 100 ml volume axial flow column (6.6 cm x 4.4 cm i.d.) we achieved flow rates of up to 25 ml/min i.e. 15 bed volumes/h after which higher flow was restricted due to pressure constraints within the system. Under radial flow conditions using a 100 ml column flow rates of up to 150 ml/min i.e. 90 bed volumes/h were achieved using DE52 and QA52. While chromatographic resolution was superior under axial flow at the lower flow rates excellent resolution was maintained at up to 150 ml/min using the radial flow column. This is a consequence of the fast kinetics of adsorption/desorption exhibited by DE52 and QA52. The data indicate that it is the column configuration and not the cellulose matrix which influences flow performance.

Cerebral blood flow changes during sodium-lactate-induced panic attacks

Dynamic single-photon emission computed axial tomography (CAT) with inhaled xenon-133 was used to measure regional cerebral blood flow in 10 drug-free patients with DSM-III-diagnosed panic disorder and in five normal control subjects. All subjects underwent regional cerebral blood flow studies while at rest or during normal saline infusion and during sodium lactate infusion. Six of the 10 patients and none of the control subjects experienced lactate-induced panic attacks. Lactate infusion markedly raised hemispheric blood flow levels in both control subjects and patients who did not panic. Patients who did panic experienced either a minimal increase or a decrease in hemispheric blood flow.

MR appearance of bilateral, spontaneous patellar tendon rupture in systemic lupus erythematosus

Bilateral spontaneous patellar tendon rupture is an unusual complication in patients with systemic lupus erythematosus. The ability of magnetic resonance to detect these tendon abnormalities is demonstrated.

Epibulbar Kaposi sarcoma

This report illustrates the clinical and pathological features of epibulbar Kaposi sarcoma in an adult who had no other cutaneous or systemic manifestations of the disorder.

Comparative properties of bacteriophage phi6 and phi6 nucleocapsid

Nonionic detergent treatments released a nucleocapsid from the enveloped bacteriphage phi6. The nucleocapsid sedimented at nearly the same rate as the whole phage in sucrose density gradients, but the buoyant density in Cs2S04 changed from 1.22 g/cm3 for the whole phage to 1.33 g/cm3 for the nucleocapsid. The detergent completely removed the lipid and 5 of the 10 proteins from the phage. Surface labeling of the phage and nucleocapsid with 125I revealed that protein P3 was on the outer surface of the whole phage and P8 was on the surface of the nucleocapsid. Both the phage and the nucleocapsid were stable between pH 6.0 and 9.5. Low concentrations of EDTA (10-4 M) dissociated the nucleocapsid but had no effect on the whole phage. The nucleocapsid contained all three double-stranded RNA segments, as well as RNA polymerase activity.