Evidence-Based Assessments for Transdiagnostic Eating Disorder Symptoms: Guidelines for Current Use and Future Directions

Eating disorders are severe and often chronic mental illnesses that are associated with high impairment and mortality rates. Recent estimates suggest that eating disorder prevalence rates are on the rise, indicating an increased need for accurate assessment and detection. The current review provides an overview of transdiagnostic eating disorder assessments, including interview, self-report, health and primary care screeners, and technology-based and objective assessments. We focused on assessments that are transdiagnostic in nature and exhibit high impact in the field. We provide recommendations for how these assessments should be used in research and clinical settings. We also discuss considerations that are crucial for assessment, including the use of a categorical versus dimensional diagnostic framework, assessment of eating disorders in related fields (i.e., anxiety and depression), and measurement-based care for eating disorders. Finally, we provide suggestions for future research, including the need for more research on short transdiagnostic screeners for use in health care settings, standardized assessments for ecological momentary assessment, development of state-based assessment of eating disorder symptoms, and consideration of assessment across multiple timescales.

Paisley: Preliminary validation of a novel app-based e-Screener for ASD in children 18-36 months

The purpose of this study was to assess the validity of an autism e-screener, Paisley, when utilized in a clinical research setting via a tablet application. The Paisley application used a series of play-based activities, all of which incorporated varying aspects of the ASD-PEDS. Participants included children (18-36 months; n = 198) referred for evaluation of autism spectrum disorder (ASD) and community providers (n = 66) with differing levels of familiarity with ASD. Community providers administered the Paisley application to children who then completed a comprehensive psychological evaluation. Based on comprehensive evaluation, 75% of children met diagnostic criteria for ASD. Paisley scores were significantly higher for children diagnosed with ASD (15.06) versus those not diagnosed (9.34). The newly determined cutoff ASD-PEDS cutoff score of 13 had significantly higher specificity and positive predictive value than the originally proposed cutoff of 11. Results support the use of Paisley by community providers to identify autism risk in toddlers. Limitations and strengths of the work, as well as opportunities for future clinical validation, are described.

Trends in U.S. self-reported health and self-care behaviors during the COVID-19 pandemic

IMPORTANCE

The COVID-19 pandemic represents a unique stressor in Americans' daily lives and access to health services. However, it remains unclear how the pandemic impacted perceived health status and engagement in health-related behaviors.

OBJECTIVE

To assess changes in self-reported health outcomes during the COVID-19 pandemic, and to explore trends in health-related behaviors that may underlie the observed health changes.

DESIGN

Interrupted time series stratified by age, gender, race/ethnicity, educational attainment, household income, and employment status.

SETTING

United States.

PARTICIPANTS

All adult respondents to the 2016-2020 Behavioral Risk Factor Surveillance System (N = 2,146,384).

EXPOSURE

Survey completion following the U.S. public health emergency declaration (March-December 2020). January 2019 to February 2020 served as our reference period.

MAIN OUTCOMES AND MEASURES

Self-reported health outcomes included the number of days per month that respondents spent in poor mental health, physical health, or when poor health prevented their usual activities of daily living. Self-reported health behaviors included the number of hours slept per day, number of days in the past month where alcohol was consumed, participation in any exercise, and current smoking status.

RESULTS

The national rate of days spent in poor physical health decreased overall (-1.00 days, 95% CI: -1.10 to -0.90) and for all analyzed subgroups. The rate of poor mental health days or days when poor health prevented usual activities did not change overall but exhibited substantial heterogeneity by subgroup. We also observed overall increases in mean sleep hours per day (+0.09, 95% CI 0.05 to 0.13), the percentage of adults who report any exercise activity (+3.28%, 95% CI 2.48 to 4.09), increased alcohol consumption days (0.27, 95% CI 0.18 to 0.37), and decreased smoking prevalence (-1.11%, 95% CI -1.39 to -0.83).

CONCLUSIONS AND RELEVANCE

The COVID-19 pandemic had deleterious but heterogeneous effects on mental health, days when poor health prevented usual activities, and alcohol consumption. In contrast, the pandemic's onset was associated with improvements in physical health, mean hours of sleep per day, exercise participation, and smoking status. These findings highlight the need for targeted outreach and interventions to improve mental health in individuals who may be disproportionately affected by the pandemic.

Development of an App for Tracking Family Engagement With Early Intervention Services: Focus Groups and Pilot Evaluation Study

BACKGROUND

Expedient access to early intervention (EI) systems has been identified as a priority for children with developmental delays, identified disabilities, and other special health care needs. Despite the mandated availability of EI, it remains challenging for families to navigate referral processes and establish appropriate services. Such challenges disproportionately affect families from traditionally underserved communities. Mobile health apps can improve clinical outcomes, increase accessibility to health services, and promote adherence to health-related interventions. Though promising, the implementation of apps within routine care is in its infancy, with limited research examining the components of what makes an effective app or how to reach families most impacted by inequities in health care delivery.

OBJECTIVE

In study 1, we conducted focus groups to access a broad range of perspectives on the process of navigating the EI system, with the dual goals of identifying ways in which a patient-facing app might facilitate this process and identifying barriers to use with traditionally underrepresented and underserved groups. In study 2, focus group findings informed the development of a patient-facing app, which was subsequently tested with a pilot sample of 5 families.

METHODS

In study 1, the focus groups included 29 participants from 4 shareholder groups. Targeted sampling was used to recruit participants from traditionally underrepresented groups. Focus group questions sought information about barriers families experience as they navigate the EI system, ideal features of a patient-facing app designed to track family engagement with the EI system, and potential barriers. Focus group procedures were informed by the Consolidated Framework for Implementation Research framework. In study 2, a pilot app was developed. The app was tested with a sample of 5 families of young children involved in the EI system. Families provided information on app functionality and usability.

RESULTS

Qualitative analysis revealed a desire for increased communication and information about the process of accessing EI services, potential utility of an app for communication purposes, and clear recommendations for app features. Insights from focus groups were used to inform the development of the Family on Track app and related implementation supports. App features included survey customization, timing and delivery of prompts, and questions related to barriers and service satisfaction. Implementation supports include a visual guide for app installation, resources related to common family questions, and availability of study personnel to guide families through installation and provide ongoing support. Field testing provided preliminary information about app usability, including identifying future directions.

CONCLUSIONS

The results of this study could support the development of a new way for the EI system to communicate and connect with families, provide families with a means to communicate satisfaction and frustration, and access the supports they need to be active participants in their child's care.

A Randomized Trial of the Accuracy of Novel Telehealth Instruments for the Assessment of Autism in Toddlers

PURPOSE

Telemedicine approaches to autism (ASD) assessment have become increasingly common, yet few validated tools exist for this purpose. This study presents results from a clinical trial investigating two approaches to tele-assessment for ASD in toddlers.

METHODS

144 children (29% female) between 17 and 36 months of age (mean = 2.5 years, SD = 0.33 years) completed tele-assessment using either the TELE-ASD-PEDS (TAP) or an experimental remote administration of the Screening Tool for Autism in Toddlers (STAT). All children then completed traditional in-person assessment with a blinded clinician, using the Mullen Scales of Early Learning (MSEL), Vineland Adaptive Behavior Scales, 3rd Edition (VABS-3), and Autism Diagnostic Observation Schedule (ADOS-2). Both tele-assessment and in-person assessment included a clinical interview with caregivers.

RESULTS

Results indicated diagnostic agreement for 92% of participants. Children diagnosed with ASD following in-person assessment who were missed by tele-assessment (n = 8) had lower scores on tele- and in-person ASD assessment tools. Children inaccurately identified as having ASD by tele-assessment (n = 3) were younger than other children and had higher developmental and adaptive behavior scores than children accurately diagnosed with ASD by tele-assessment. Diagnostic certainty was highest for children correctly identified as having ASD via tele-assessment. Clinicians and caregivers reported satisfaction with tele-assessment procedures.

CONCLUSION

This work provides additional support for the use of tele-assessment for identification of ASD in toddlers, with both clinicians and families reporting broad acceptability. Continued development and refinement of tele-assessment procedures is recommended to optimize this approach for the needs of varying clinicians, families, and circumstances.

Effects of an air pollution personal alert system on health service usage in a high-risk general population: a quasi-experimental study using linked data

BACKGROUND

There is no evidence to date on whether an intervention alerting people to high levels of pollution is effective in reducing health service utilisation. We evaluated alert accuracy and the effect of a targeted personal air pollution alert system, airAware, on emergency hospital admissions, emergency department attendances, general practitioner contacts and prescribed medications.

METHODS

Quasi-experimental study describing accuracy of alerts compared with pollution triggers; and comparing relative changes in healthcare utilisation in the intervention group to those who did not sign-up. Participants were people diagnosed with asthma, chronic obstructive pulmonary disease (COPD) or coronary heart disease, resident in an industrial area of south Wales and registered patients at 1 of 4 general practices. Longitudinal anonymised record linked data were modelled for participants and non-participants, adjusting for differences between groups.

RESULTS

During the 2-year intervention period alerts were correctly issued on 208 of 248 occasions; sensitivity was 83.9% (95% CI 78.8% to 87.9%) and specificity 99.5% (95% CI 99.3% to 99.6%). The intervention was associated with a 4-fold increase in admissions for respiratory conditions (incidence rate ratio (IRR) 3.97; 95% CI 1.59 to 9.93) and a near doubling of emergency department attendance (IRR=1.89; 95% CI 1.34 to 2.68).

CONCLUSIONS

The intervention was associated with increased emergency admissions for respiratory conditions. While findings may be context specific, evidence from this evaluation questions the benefits of implementing near real-time personal pollution alert systems for high-risk individuals.

Effects of an air pollution personal alert system on health service usage in a high-risk general population: a quasi-experimental study using linked data

BACKGROUND

There is no evidence to date on whether an intervention alerting people to high levels of pollution is effective in reducing health service utilisation. We evaluated alert accuracy and the effect of a targeted personal air pollution alert system, airAware, on emergency hospital admissions, emergency department attendances, general practitioner contacts and prescribed medications.

METHODS

Quasi-experimental study describing accuracy of alerts compared with pollution triggers; and comparing relative changes in healthcare utilisation in the intervention group to those who did not sign-up. Participants were people diagnosed with asthma, chronic obstructive pulmonary disease (COPD) or coronary heart disease, resident in an industrial area of south Wales and registered patients at 1 of 4 general practices. Longitudinal anonymised record linked data were modelled for participants and non-participants, adjusting for differences between groups.

RESULTS

During the 2-year intervention period alerts were correctly issued on 208 of 248 occasions; sensitivity was 83.9% (95% CI 78.8% to 87.9%) and specificity 99.5% (95% CI 99.3% to 99.6%). The intervention was associated with a 4-fold increase in admissions for respiratory conditions (incidence rate ratio (IRR) 3.97; 95% CI 1.59 to 9.93) and a near doubling of emergency department attendance (IRR=1.89; 95% CI 1.34 to 2.68).

CONCLUSIONS

The intervention was associated with increased emergency admissions for respiratory conditions. While findings may be context specific, evidence from this evaluation questions the benefits of implementing near real-time personal pollution alert systems for high-risk individuals.

A randomized, double-blind, placebo-controlled study to evaluate the addition of methotrexate to etanercept in patients with moderate to severe plaque psoriasis

BACKGROUND

Etanercept plus methotrexate combination therapy has not been adequately investigated in psoriasis.

OBJECTIVES

To evaluate etanercept plus methotrexate vs. etanercept monotherapy in patients with moderate to severe plaque psoriasis who had not failed prior methotrexate or tumour necrosis factor-inhibitor therapy.

METHODS

Patients received etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks and were randomized 1 : 1 to receive methotrexate (7·5-15 mg weekly) or placebo. The primary endpoint was the proportion of patients achieving ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) at week 24.

RESULTS

In total, 239 patients were enrolled in each arm. PASI 75 was significantly higher at week 24 for the combination therapy group compared with the monotherapy group (77·3% vs. 60·3%; P < 0·0001). Other PASI improvement scores at week 12 [PASI 75, 70·2% vs. 54·3% (P = 0·01); PASI 50, 92·4% vs. 83·8% (P = 0·01); and PASI 90, 34·0% vs. 23·1% (P = 0·03)] showed similar results as did week 24 PASI 50 (91·6% vs. 84·6%; P = 0·01) and PASI 90 (53·8% vs. 34·2%; P = 0·01). Significantly more patients receiving combination therapy than monotherapy had static Physician's Global Assessment of clear/almost clear at week 12 (65·5% vs. 47·0%; P = 0·01) and week 24 (71·8% vs. 54·3%; P = 0·01). Adverse events (AEs) were reported in 74·9% and 59·8% of combination therapy and monotherapy groups, respectively; three serious AEs were reported in each arm.

CONCLUSIONS

Combination therapy with etanercept plus methotrexate had acceptable tolerability and increased efficacy compared with etanercept monotherapy in patients with moderate to severe psoriasis.

A randomized, double-blind, placebo-controlled study to evaluate the addition of methotrexate to etanercept in patients with moderate to severe plaque psoriasis

BACKGROUND

Etanercept plus methotrexate combination therapy has not been adequately investigated in psoriasis.

OBJECTIVES

To evaluate etanercept plus methotrexate vs. etanercept monotherapy in patients with moderate to severe plaque psoriasis who had not failed prior methotrexate or tumour necrosis factor-inhibitor therapy.

METHODS

Patients received etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks and were randomized 1 : 1 to receive methotrexate (7·5-15 mg weekly) or placebo. The primary endpoint was the proportion of patients achieving ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) at week 24.

RESULTS

In total, 239 patients were enrolled in each arm. PASI 75 was significantly higher at week 24 for the combination therapy group compared with the monotherapy group (77·3% vs. 60·3%; P < 0·0001). Other PASI improvement scores at week 12 [PASI 75, 70·2% vs. 54·3% (P = 0·01); PASI 50, 92·4% vs. 83·8% (P = 0·01); and PASI 90, 34·0% vs. 23·1% (P = 0·03)] showed similar results as did week 24 PASI 50 (91·6% vs. 84·6%; P = 0·01) and PASI 90 (53·8% vs. 34·2%; P = 0·01). Significantly more patients receiving combination therapy than monotherapy had static Physician's Global Assessment of clear/almost clear at week 12 (65·5% vs. 47·0%; P = 0·01) and week 24 (71·8% vs. 54·3%; P = 0·01). Adverse events (AEs) were reported in 74·9% and 59·8% of combination therapy and monotherapy groups, respectively; three serious AEs were reported in each arm.

CONCLUSIONS

Combination therapy with etanercept plus methotrexate had acceptable tolerability and increased efficacy compared with etanercept monotherapy in patients with moderate to severe psoriasis.

Hypovitaminosis D in Chinese type 2 diabetes: lack of impact on clinical metabolic status and biomarkers of cellular inflammation

OBJECTIVE

Low vitamin D (25 OH vitamin D) is implicated in the development of diabetes and the metabolic syndrome. We examined whether hypovitaminosis D has a clinically significant impact on glycaemia, metabolic status and inflammatory markers in Chinese patients with established type 2 diabetes.

METHODS

Characteristics of 109 patients aged over 50 years were stratified by 25 OH vitamin D status. Patients identified as 25 OH vitamin D deficient (<or= 50 nmol/L) received cholecalciferol 2,000 IU daily for three months. Measurement of HbA1c, metabolic syndrome parameters, 25 OH vitamin D, calcium, phosphate, PTH, hsCRP and ferritin were taken at baseline and then 25 OH vitamin D, PTH, calcium, phosphate monthly for three months in those on replacement therapy.

RESULTS

Vitamin D deficiency was common, affecting 36% of patients. There was no impact of hypovitaminosis D on metabolic syndrome status, HbA1c or insulin use (p >or= 0.4 for all) and no association between 25OHVitD and ferritin or hsCRP (p >or= 0.3 for all). Neither BMI nor the metabolic syndrome affected the incremental rise in 25OHVitD levels during supplementation.

CONCLUSION

There is no relationship between hypovitaminosis D and metabolic control or inflammatory markers in established type 2 diabetes.This suggests that at least in Chinese populations, the effect of low vitamin D is not clinically significant once diabetes is established. Future 25OHVitD intervention trials should therefore focus on prevention in pre-diabetes.

Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service

OBJECTIVE

To describe the safety profile of emergency airway management when performed by a prehospital team consisting of a doctor and a paramedic. Success rates, the incidence of difficult airways and the ability of prehospital doctors to determine a difficult airway are reported.

METHODS

A prospective audit and descriptive study of three Australian helicopter emergency medical service (HEMS) bases, over a 9-month period. Doctors completed questionnaires regarding the number of endotracheal intubation (ETI) attempts on patients transported intubated and ventilated, Cormack and Lehane view of the cords during laryngoscopy and the anticipated and actual ease of ETI.

RESULTS

A total of 114 (11.4%) patients transported by the HEMS was intubated and ventilated. Study questionnaires were completed on 89 of the 114 cases (78.1%), of which 32 (36%) were trauma related. HEMS were involved with 43 (48.3%) of the 89 intubations and performed 12.4% (n = 11) out of hospital. The HEMS ETI success rate was 97.6%. No surgical airways were performed. The actual incidence of difficult airways was higher (n = 4, 9.3%) than the anticipated incidence (n = 1, 2.3%). Six patients (14.0%) were successfully intubated by the doctor after the paramedic failed.

CONCLUSIONS

Well-trained doctor paramedic teams, utilising standardised operating procedures, can safely perform rapid sequence induction and ETI in the prehospital and emergency environment. However, prehospital doctors are not always able to anticipate a difficult airway. The complication rate was similar to that in hospital emergency departments and to that of other physician-led HEMS.

Randomized, active-controlled study of once-weekly alendronate 280 mg high dose oral buffered solution for treatment of Paget's disease

Daily oral tablet bisphosphonate therapy for Paget's disease of bone may cause serious upper gastrointestinal adverse events. A once-weekly alendronate 280 mg oral buffered solution was compared with an alendronate 40 mg/day tablet. While both were similarly effective, the tablet appeared to be better tolerated in this study.

INTRODUCTION

Although daily doses of oral bisphosphonates are a generally safe and effective treatment for Paget's disease of bone (PDB), some patients may experience upper gastrointestinal adverse events (UGI AEs) or find the dosing requirements inconvenient and become noncompliant. A once-weekly (OW) oral dose of bisphosphonate in buffered solution (OBS) may be as effective, better tolerated, and more convenient.

METHODS

Sixty-three patients were randomized to either alendronate (ALN) 280 mg OW OBS (n = 42) or an ALN 40 mg/day tablet (n = 21) during a 6-month, randomized, double-blind, active-controlled trial. The primary endpoint was the mean percent decrease in total serum alkaline phosphatase (total ALP) from baseline at 6 months.

RESULTS

There were no significant differences in total ALP between groups during the 6-month period. There was a higher incidence of clinical AEs in the ALN 280 mg OW OBS (79%) vs. the ALN 40 mg/day tablet group (67%), including drug related AEs (48% and 10%, respectively), which led to study discontinuation (19.0% and 10%, respectively).

CONCLUSIONS

Although ALN 280 mg OW OBS was similarly effective as ALN 40 mg/day in reducing total ALP in patients with PDB, the ALN 40 mg/day tablet appears to be better tolerated than ALN 280 mg OW OBS.

Improvements in clinical response between 12 and 24 weeks in patients with rheumatoid arthritis on etanercept therapy with or without methotrexate

Background:

Whereas many patients respond quickly to treatment with tumour necrosis factor (TNF) inhibitors, some patients may experience significant but delayed responses.

Objective:

To evaluate the clinical response between 12 and 24 weeks in subjects with rheumatoid arthritis from the Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes.

Methods:

Clinical response was assessed at 24 weeks in 12-week non-responders, according to American College of Rheumatology (ACR) response criteria. The proportion of subjects who successfully maintained response to 52 weeks was analysed, as were radiographic outcomes.

Results:

Data from 682 subjects were included in the analysis. Non and partial responders in all three groups (etanercept, methotrexate and etanercept plus methotrexate) at week 12 showed an improvement in responses at week 24. Over 80% of the week 24 ACR20/50/70 responders in the etanercept plus methotrexate arm sustained their response to 52 weeks. In the etanercept arms, a delayed clinical response was not associated with increased radiographic progression at week 52.

Conclusion:

A significant proportion of non and partial responders to etanercept with or without methotrexate therapy at week 12 achieved a good clinical response or improved their overall clinical response at week 24. Discontinuing TNF inhibitor therapy at 12 weeks may be premature in some rheumatoid arthritis patients.

Effects of etanercept on C-reactive protein levels in psoriasis and psoriatic arthritis

BACKGROUND

C-reactive protein (CRP), an inflammation biomarker, indicates cardiovascular risk and is elevated in psoriasis. The effect of etanercept on CRP in psoriasis has not been previously examined.

OBJECTIVES

The primary objective was to examine the effect of etanercept on CRP levels from baseline to week 12 compared with placebo. Secondary objectives included assessment of baseline CRP and relationships between CRP and body mass index (BMI), statin drug use, and Psoriasis Area and Severity Index (PASI) scores.

METHODS

A retrospective analysis was conducted of CRP levels from patients with psoriasis who participated in a randomized, double-blind, placebo-controlled, U.S. registrational study. Data were analysed separately if patients self-reported psoriatic arthritis.

RESULTS

Baseline CRP levels were elevated in patients with psoriasis with and without psoriatic arthritis. CRP was significantly reduced in both groups after 12 weeks of etanercept treatment. Patients with psoriasis with psoriatic arthritis and patients with higher BMIs had higher median baseline CRP values and greater reduction of CRP values compared with those without psoriatic arthritis and those with lower BMIs. Etanercept lowered CRP levels in statin users and nonusers. Regression analyses revealed an association between baseline PASI score and baseline CRP independent of BMI in patients with psoriasis.

CONCLUSIONS

Patients with moderate to severe plaque psoriasis, with or without psoriatic arthritis, have increased systemic inflammation demonstrated by elevated CRP levels. In psoriasis without psoriatic arthritis, skin disease activity is associated significantly with CRP elevation, independent of BMI, age and sex. Etanercept reduced CRP levels in all but the normal weight psoriasis group without psoriatic arthritis.

Myalgic encephalomyelitis: a review with emphasis on key findings in biomedical research

This review examines research findings in patients with myalgic encephalomyelitis in light of the current debate about this chronic multiple-symptom, multiorgan, multisystem illness and the conflicting views in medicine. These issues cannot be separated from the political opinions and assertions that conflict with science and medicine, and will be part of this review as they have enormous consequences for scientific and medical research, patients, clinicians, carers and policy makers.

The Genetics of Generalized Osteoarthritis (GOGO) study: study design and evaluation of osteoarthritis phenotypes

PURPOSE

The primary goal of the Genetics of Generalized Osteoarthritis (GOGO) study is to identify chromosomal regions associated with increased susceptibility to generalized osteoarthritis (OA). Here we describe the study design and phenotype of the 2728 participants from the 1145 families recruited for this study.

METHODS

GOGO is an investigator-initiated collaboration involving seven clinical academic sites and sponsored by GlaxoSmithKline. Family ascertainment was carried out between 1999 and 2002. A qualifying family required self-reported Caucasian ethnicity and at least two affected siblings with clinical hand OA. We hypothesized that this clinical phenotype would facilitate identification of participants with multijoint radiographic OA (rOA) in and beyond the hand. The "gold standard" case definition, however, was based on rOA (Kellgren-Lawrence grade > or =2) involving > or =3 hand joints distributed bilaterally and including at least one distal interphalangeal joint, with two of the three involved joints within a joint group (distal interphalangeal, proximal interphalangeal, or carpometacarpal). Radiographs of hips, knees and spine were also obtained. Additional siblings and living parents from qualifying families, both affected and unaffected, were invited to participate.

RESULTS

A total of 2706 participants had complete clinical and radiological examination data. Of these, 2569 participants met clinical examination criteria for affected status; while 1963 (73%) participants met the prespecified radiographic criteria for affected status. This corresponded to a total of 707 families with at least two affected siblings that met the hand rOA criteria. Of those individuals with rOA of the hand, the frequency of rOA at other sites was highest for the knee (51%) and spine (54%), and less common for the hip (25%). Concordance rates among hand affected siblings were greatest for spine (36%) followed by knee (31%) and hip (9%); a total of 53% of the affected sib pairs were concordant for specific patterns of generalized rOA involving the hand and large joints (knees, hips or spine).

CONCLUSIONS

GOGO represents a large multicenter collection of families with multiple joint OA that have been characterized both clinically and radiographically. The GOGO study will employ a comprehensive strategy for genetic screening based upon both qualitative and quantitative radiographic trait analyses, circulating biomarkers in a quantitative trait-based analysis, fine mapping, and candidate gene analysis. This sample should provide sufficient power to detect linkage to OA associated genes.

An analgesic model for assessment of acute pain response in osteoarthritis of the knee

BACKGROUND

Osteoarthritis (OA) is frequently treated only during periods of flare, in which rapid onset of analgesia is the outcome target.

OBJECTIVE

To assess an acute pain model of knee OA in flare.

METHODS

In a multicenter, randomized, double-blind, controlled study, 530 patients aged >or=50 years received valdecoxib 10 mg qd (n=212), rofecoxib 2 5 mg qd (n=208), or placebo (n=110). Pain intensity (PI) was measured on a visual analog scale (VAS) at baseline after a 10-min walk. Patients took their first dose of study medication, rested for 20 min, then measured their PI VAS at 0.5, 1, 1.5, 2, 3, 4, 5, and 6h, each time following a 10-min walk.

RESULTS

PI VAS differences (PID) were significantly greater vs placebo both with valdecoxib and rofecoxib (P<0.05) beginning as early as 3h (intent-to-treat population). The percentage of patients with analgesia onset from 4h was significantly higher with both valdecoxib (55%) and rofecoxib (56%) relative to placebo (40%). Median time to first onset of analgesic was shorter with both valdecoxib and rofecoxib compared with placebo (P=0.104 vs valdecoxib; P=0.036 vs rofecoxib).

CONCLUSIONS

This acute pain model of knee OA flare detected significant pain relief with agents known to relieve pain in OA and placebo within hours after the first treatment dose, allowing assessment of pain relief within hours rather than days or weeks when evaluating analgesic efficacy in OA. This model is undergoing further study to determine optimal walk times, distances, and rates to maximize its sensitivity.

Effect of orlistat on cardiovascular disease risk in obese adults

AIM

The aim of this study is to compare the effect of orlistat vs. placebo on the predicted 10-year cardiovascular disease (CVD) risk in obese people with one or more cardiovascular risk factors treated for 12 months, in conjunction with a fat-reduced, but otherwise ad libitum, diet.

METHODS

A double-blind, randomized, placebo-controlled, parallel study was performed in conjunction with a fat-reduced diet and physical activity advice for 1 year. Participants (n = 339) from eight centres in Australia and New Zealand were randomized to either orlistat (120 mg) three times daily (n = 104 women, 66 men; mean +/- s.d. age = 52.0 +/- 7.5 years, body mass index (BMI) = 37.6 +/- 5.1 kg/m(2)) or placebo three times daily (n = 89 women, 80 men; age = 52.5 +/- 7.4 years, BMI = 38.0 +/- 4.9 kg/m(2)). The primary efficacy criterion was the 10-year risk of developing CVD calculated from the Framingham equation. Secondary efficacy criteria were body weight, waist circumference, blood pressure and serum concentrations of triglycerides, cholesterol (total, LDL and HDL), glucose, insulin and glycated haemoglobin and quality of life.

RESULTS

There was no difference in the change in 10-year CVD risk between orlistat and placebo groups over 1 year. The orlistat group, however, had significant favourable changes in many of the individual CVD risk factors (total cholesterol, LDL-cholesterol, glucose, glycated haemoglobin, insulin, body weight and waist circumference) and one of the domains of quality of life measured by means of the SF-36 questionnaire (vitality), compared to the placebo group. Significant reductions in medication use for hypertension and diabetes were observed in the orlistat group, compared to those in placebo, but there were no significant differences in medication use for blood lipids.

CONCLUSIONS

Orlistat may have reduced CVD risk, as judged by the favourable changes in individual risk factors and reductions in medication use, but the method used in order to measure absolute CVD risk in this study (Framingham CVD equation) was not sensitive enough to detect the changes in this relatively low-risk group (approximately 10% of risk of a CVD event over 10 years).

Articular hypermobility is a protective factor for hand osteoarthritis

OBJECTIVE

Very few studies have evaluated the association of articular hypermobility and radiographic osteoarthritis (OA) in humans. We assessed hypermobility and its relationship to radiographic hand OA in a family-based study.

METHODS

A total of 1,043 individuals were enrolled in the multicenter Genetics of Generalized Osteoarthritis study, in which families were required to have 2 siblings with radiographic OA involving >/=3 joints (distributed bilaterally) of the distal interphalangeal (DIP), proximal interphalangeal (PIP), or carpometacarpal (CMC) joint groups, and OA in at least one DIP joint. Radiographic OA was defined as a score of >/=2 on the Kellgren/Lawrence scale in one or more joints within the group. The Beighton criteria for assessment of hypermobility were recorded on a 0-9-point scale. Hypermobility was defined as a Beighton score of >/=4, a threshold generally used to establish a clinical diagnosis of joint laxity. A threshold of >/=2 was also evaluated to assess lesser degrees of hypermobility. The Beighton score for the present was calculated based on clinical examination, and that for the past was based on recall of childhood hypermobility in the first 2 decades of life. The association of hypermobility and radiographic OA of the PIP, CMC, and metacarpophalangeal joints was evaluated in all participants and in men and women separately. Multiple logistic regression was used to examine the relationship of hypermobility with radiographic OA in each joint group, after adjusting for age and sex. The association of hypermobility and DIP OA was not evaluated, because evidence of DIP OA was required for study inclusion.

RESULTS

Using a threshold Beighton score of 4, 3.7% of individuals were classified as hypermobile based on the present examination, and 7.4% were classified as hypermobile based on the past assessment. A significant negative association between present hypermobility and age was observed. In persons with hypermobility, the odds of OA in PIP joints was lower (for present, odds ratio [OR] 0.34, 95% confidence interval [95% CI] 0.16-0.71; for past, OR 0.43, 95% CI 0.24-0.78). Similar results were obtained using a threshold Beighton score of 2. The lower odds of PIP OA with hypermobility were significant after adjusting for sex and age (for present, OR 0.44, 95% CI 0.20-0.94; for past, OR 0.48, 95% CI 0.26-0.87).

CONCLUSION

This study demonstrated a joint-protective effect of hypermobility for radiographic OA of PIP joints. In contrast to previous studies showing an association of hypermobility and CMC OA, in this cohort there was no evidence for increased odds of OA in any joint group of the hand in association with articular hypermobility.

Fluorescence characteristic study of the ternary complex of fluoroquinolone antibiotics and cobalt (II) with ATP

The results from the measurement of the fluorescence spectra of fluoroquinolone antibiotics including ofloxacin (OF), norfloxacin (NOR) and ciprofloxacin (CIP) complexed with cobalt (II) and ATP give information concerning the antibiotics-nucleotide interactions. From the fluorescence spectral data, it appears that the fluoroquinolone antibiotic cannot directly complex with ATP but indirectly complex with cobalt (II), which is playing an intermediary role. The interaction of fluoroquinolone antibiotic with the nucleotide occurs mainly through the phosphate group. The conclusion offers a more complete mechanism, which is important for understanding the interaction of these drugs with DNA.

Ice storm damage and early recovery in an old-growth forest

We quantified the damage caused by a major ice storm to individual trees in two 1-ha permanent plots located at Mont St. Hilaire in southwestern Québec, Canada. The storm, which occurred in January 1998, is the worst on record in eastern North America; glaze ice on the order of 80-100 mm accumulated at our study site. All but 3% of the trees (DBH > or = 10 cm) lost at least some crown branches, and 35% lost more than half their crown. Damage to trees increased in the order: Tsuga canadensis, Betula alleghaniensis, Ostrya virginiana, Acer saccharum, Fagus grandifolia, Quercus rubra, Betula papyrifera, Acer rubrum, Tilia americana, and Fraxinus americana. Only 22% of the saplings and small trees (4 cm < DBH < 10 cm) escaped being broken or pinned to the ground by falling material. Levels of damage generally were greater in an exposed ridge top forest than in a cove protected from wind. By August 1999 only 53% of the trees had new shoots developing from the trunk or broken branches; among the more dominant canopy trees, Fagus grandifolia had the least sprouting and Acer saccharum and Quercus rubra the most. We anticipate and will monitor both significant turnover in the tree community and some shift in composition of the canopy dominants.

Potential transition state phosphoramidate inhibitors of beta-tubulin as antifilarial agents

Transition state phosphoramidate inhibitors of beta-tubulin were designed as potential antifilarial agents. The reaction of 2-aminobenzimidazole with diisopropyl phosphite and carbon tetrachloride at a low temperature gave the unexpected 1-diisopropoxyphosphoryl-2-aminobenzimidazole, which on heating gave the novel benzimidazole derivative, 2-(diisopropoxyphosphoryl)aminobenzimidazole. Both products were fully characterized and the synthetic procedure to both compounds was optimized. The procedure was used to prepare the related 5-benzoyl-2-(diisopropoxyphosphoryl)aminobenzimidazole and 5-benzoyl-2-(diethoxyphosphoryl)aminobenzimidazole (1d). In a preliminary trial against Brugia pahangi compound 1d was found to have no antifilarial activity. This lack of activity may be attributed to its extreme insolubility and thus low bioavailability. The synthesis of analogous, more soluble, phosphorothioate-substituted benzimidazoles using the same methods may yield compounds with greater antifilarial activity.

Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group

The purpose of this randomized, double-masked, placebo-controlled study was to determine the efficacy and safety of risedronate in the prevention of vertebral fractures in postmenopausal women with established osteoporosis. The study was conducted at 80 study centers in Europe and Australia. Postmenopausal women (n = 1226) with two or more prevalent vertebral fractures received risedronate 2.5 or 5 mg/day or placebo; all subjects also received elemental calcium 1000 mg/day, and up to 500 IU/day vitamin D if baseline levels were low. The study duration was 3 years; however, the 2.5 mg group was discontinued by protocol amendment after 2 years. Lateral spinal radiographs were taken annually for assessment of vertebral fractures, and bone mineral density was measured by dual-energy X-ray absorptiometry at 6-month intervals. Risedronate 5 mg reduced the risk of new vertebral fractures by 49% over 3 years compared with control (p<0.001). A significant reduction of 61% was seen within the first year (p = 0.001). The fracture reduction with risedronate 2.5 mg was similar to that in the 5 mg group over 2 years. The risk of nonvertebral fractures was reduced by 33% compared with control over 3 years (p = 0.06). Risedronate significantly increased bone mineral density at the spine and hip within 6 months. The adverse-event profile of risedronate, including gastrointestinal adverse events, was similar to that of control. Risedronate 5 mg provides effective and well-tolerated therapy for severe postmenopausal osteoporosis, reducing the incidence of vertebral fractures and improving bone density in women with established disease.

Somatic frameshift mutations in the MBD4 gene of sporadic colon cancers with mismatch repair deficiency

Defects of mismatch repair are thought to be responsible for carcinogenesis in hereditary non-polyposis colorectal cancer and about 15% of sporadic colon cancers. The phenotype is seen as microsatellite instability and is known to be caused either by mutations in mismatch repair genes or by aberrant methylation of these genes stabilizing their downregulation. Lack of repair of microsatellite sequence errors, created during replication, leads to a mutation-prone phenotype. Where mutations occur within mononucleotide tracts within exons they cause translation frameshifts, premature cessation of translation and abnormal protein expression. Such mutations have been observed in the TGFbetaRII, BAX, IGFIIR, MSH3 and MSH6 genes in colon and other cancers. We describe here frameshift mutations affecting the gene for the methyl-CpG binding thymine glycosylase, MBD4, in over 40% of microsatellite unstable sporadic colon cancers. The mutations all appear heterozygous but their location would ensure truncation of the protein between the methyl-CpG binding and glycosylase domains, thus potentially generating a dominant negative effect. It is thus possible that such mutations enhance mutation frequency at other sites in these tumours. A suggestion has been made that MBD4 (MED1) mutations may lead to an increased rate of microsatellite instability but this mechanism appears unlikely due to the nature of mutations we have found.

Cytomegalovirus seropositivity is associated with the expansion of CD4+CD28- and CD8+CD28- T cells in rheumatoid arthritis

OBJECTIVE

Previous researchers have found expansion of CD4+CD28- T cells in patients with rheumatoid arthritis (RA) compared to age matched controls, and have identified expanded clones of autoreactive cells within this population. We examine the association of prior cytomegalovirus (CMV) infection (positive serum anti-CMV IgG) with the percentage of CD4+CD28- T cells and CD8+CD28- T cells in patients with RA.

METHODS

A total of 45 patients (36 women, 9 men), mean age of 59 years, with definite RA were studied.

RESULTS

In this group 28 patients were seropositive for CMV and 17 seronegative. Seropositive and seronegative subjects did not differ significantly in age, sex, medication use, or severity of disease. Joint count, Health Assessment Questionnaire, pain score, patient global assessment, physician global assessment, and presence of extraarticular disease served to assess disease severity. Expression of CD4/CD28/CD57 and CD8/CD28/CD57 on lymphocytes was determined by 3 color flow cytometry. (CD28 and CD57 are reciprocally related.) CD4+CD28-CD57+ T cells were expanded only in CMV seropositive patients.

CONCLUSION

The "carrier" phenotype that has been hypothesized based on a 2 population model for the distribution of CD4+CD28- T cells in RA can be explained by prior infection with CMV.

Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users

PURPOSE

To analyze the effectiveness of a 6-month exercise protocol on shoulder pain experienced by wheelchair users during functional activities.

SUBJECTS

Forty-two wheelchair users, 35 males and seven females: average age of 35 years and an average duration of wheelchair use of 14 years.

METHODS

Subjects were randomly assigned to treatment (n=21) and control (n=21) groups. The treatment group received instruction in five shoulder exercises which they performed daily for 6 months. The exercise protocol included two exercises for stretching anterior shoulder musculature and three exercises for strengthening posterior shoulder musculature.

OUTCOME MEASURES

All subjects completed a self-report questionnaire and the Wheelchair Users Shoulder Pain Index (WUSPI) initially and at bimonthly intervals during the 6-month intervention.

RESULTS

Seventy-five per cent of the subjects reported a history of shoulder pain since beginning wheelchair use. The average initial performance-corrected (PC-WUSPI) score of the 42 subjects was 17.7 (+/-21.3) with a range of 0-103.2 points. Over 83% of the subjects (35 of 42) completed the 6-month study. Subjects in the treatment group decreased their PC-WUSPI score by an average of 39.9%, compared to decreases of only 2.5% in the control group.

CONCLUSIONS

These findings supported the effectiveness of this exercise protocol in decreasing the intensity of shoulder pain which interferes with functional activity in wheelchair users.

Effect of environmental tobacco smoke on peak flow variability

This study was undertaken to determine whether exposure to various indoor pollutants is associated with a higher prevalence of respiratory symptoms, a diagnosis of asthma, or more variable peak flow rates. Four hundred and twenty-six children aged 8-11 years in four junior schools at three locations recorded respiratory symptoms and diagnosis of asthma using the ISAAC questionnaire. Daily peak flow measurements were taken during two six-week periods (winter and summer). Symptoms in children with and without asthma were not related to gas fires, cookers, smokers, or pets in the home. However, the variability of lung function, expressed as the coefficient of variation, in all children was increased with a household smoker. Environmental tobacco smoke increases airways variability in children with and without asthma. Its effects were not apparent from a questionnaire completed by parents, and the coefficient of variation of serially measured peak flows was a more sensitive indicator of lung function.

Breast enlargement during chronic antidepressant therapy

Recent reports of mammoplasia during selective serotonin re-uptake inhibitor (SSRI) therapy suggested that this side effect may be more common than previously reported. We examined 59 women receiving > or = 2 months treatment with an SSRI or venlafaxine for changes in breast size in relation to menopausal status, weight gain and duration of drug therapy. Serum prolactin, estradiol and beta-hCG were also measured before and during treatment in a subgroup of patients. Twenty-three out of 59 patients (39%) reported some degree of mammoplasia. Significantly more SSRI vs. venlafaxine patients reported mammoplasia (p < 0.01). Eighty-four percent with mammoplasia had weight gain vs. 30% without mammoplasia (p < 0.001). The rate of mammoplasia was unrelated to age, menopausal status or duration of treatment. Serum prolactin increased during treatment in the paroxetine subgroup (p < 0.03). In conclusion, antidepressant-induced mammoplasia may be more common than previously expected.

Prompt treatment for chemical eye injuries

A chemical injury to the eye requires prompt and effective treatment to minimise permanent damage. This article describes the types of chemical injury and discusses the treatments available.

Insulin response in bulimia nervosa as a marker of nutritional depletion

OBJECTIVE

The aim of this provocation study was to examine insulin, glucose, and cortisol levels in response to a glucose load in bulimia nervosa patients and to relate this to behavior, treatment status, and depressive symptomatology.

METHOD

A 3-hr glucose tolerance test was performed in 15 female patients and in 4 controls. Tests were performed at different stages of treatment and following documented engagement in the patient's usual or previous repertoire of bulimic behaviors in the 24 hr prior to testing. Insulin, glucose, and cortisol levels were assayed at baseline and at 30-min intervals following the glucose load. Presence or absence of significant depressive symptomatology was ascertained.

RESULTS

Three patterns of insulin response were identified: (1) an exaggerated response, (2) a normative response which resembled that of healthy controls, and (3) a blunted pattern. A reciprocal relationship between peak insulin and mean cortisol levels was seen with higher depression scores associated with blunted insulin response. Patients whose response was exaggerated binged and vomited relatively infrequently and were of stable weight. The insulin response of successfully treated patients, abstinent from binging and vomiting for 4 weeks, was similar to that of normal controls. A blunted response occurred in patients who binged and vomited more frequently, whose weight was unstable, and whose baseline eating was chaotic or nonexistent.

DISCUSSION

The exaggerated insulin response was seen as a physiological adaptation to intermittent starvation reversible with treatment, while the blunted insulin response associated with higher cortisol levels was seen to result from more constant nutritional deprivation secondary to greater disturbance of behavior.

Nursing care of the patient with a tracheostomy

Patients who require a tracheostomy have particular needs associated with their care to ensure their safety and well-being. In this article, the author describes the reasons why a patient might have a tracheostomy and provides a detailed account of the anatomy, care and complications associated with it.

Costimulatory activity of human synovial fibroblasts

T cell activation initiated via the CD3/TCR complex requires signals provided by the interaction between costimulatory receptors on T cells and their corresponding ligands on accessory cells. Human dermal fibroblasts are reported to be deficient in this costimulatory activity and normally cannot serve as accessory cells for activation of resting T cells. We examined the contribution of human synovial fibroblasts to costimulatory activity for resting T cells.

METHODS

Synovial fibroblast, dermal fibroblast, and umbilical cord endothelial cell cultures were established. These cell lines were co-cultured with purified peripheral T cells; and T cell activation was assayed using 3H-thymidine.

RESULTS

Culturing resting T cells with synovial fibroblasts resulted in T cell proliferation with either mitogenic (periodate) or alloantigenic stimulation. This activation was dependent on the addition of interleukin 1 and/or gamma interferon.

CONCLUSION

In contrast to dermal fibroblasts, synovial fibroblasts are able to provide costimulatory activity for activation of resting T cells.

In vivo analysis of Pim-1 deficiency

The Pim-1 proto-oncogene encodes a highly conserved serine/threonine phosphokinase which is predominantly expressed in hematopoietic organs and gonads in mammals. Overexpression of Pim-1 predisposes to lymphomagenesis in mice. To develop a further understanding of Pim-1 in molecular terms, as well as in terms of its potential role in hematopoietic development, we have generated mice deficient in Pim-1 function. Pim-1-deficient mice are ostensibly normal, healthy and fertile. Detailed comparative analyses of the hematopoietic systems of the mutant mice and their wild-type littermates showed that they are indistinguishable for most of the parameters studied. Our analyses revealed one unexpected phenotype that correlated with the level of Pim-1 expression: Pim-1 deficiency correlated with a erythrocyte microcytosis, whereas overexpression of Pim-1 in E mu-Pim-1-transgenic mice resulted in erythrocyte macrocytosis. In order to confirm that the observed decrease in erythrocyte Mean Cell Volume (MCV) was attributable to the Pim-1 deficiency, we developed mice transgenic for a Pim-1 gene construct with its own promoter and showed that this transgene could restore the low erythrocyte Mean Cell Volume observed in the Pim-1-deficient mice to near wild-type levels. These results might be relevant to the observed involvement of the Pim-1 gene in mouse erythroleukemogenesis. The surprising lack of a readily observed phenotype in the lymphoid compartment of the Pim-1-deficient mice, suggests a heretofore unrecognized degree of in vivo functional redundancy of this highly conserved proto-oncogene.