Studies of thermoluminescence properties of liquid crystalline N-phenyl substituted phenyl polysiloxane hydroxamic acids

The investigation of thermoluminescence (TL) glow curves in liquid crystalline side chain N-phenyl-substituted phenyl polysiloxane hydroxamic acids (PHAs) has yielded significant insights. These polymers demonstrated TL behavior when exposed to β-radiation between 0 and 220°C, indicating inherent luminescent properties when irradiated. Notably, a dose-dependent relationship was observed in reported derivatized polymers; this study elucidates the diverse TL characteristics exhibited by various liquid crystalline side chain N-phenyl-substituted phenyl PHAs when exposed to β-radiation. Understanding these dose-dependent and dose-independent behaviors enhances the knowledge of their luminescent properties and potential applications in radiation detection.

Gender Disparities in Endowed Professorships Within Orthopaedic Surgery

Background Orthopaedic surgery has the lowest number of full-time faculty positions held by women, at 19%, with endowed chairs among the most coveted and advantageous. We examined the characteristics of endowed professors from the US top 100 orthopaedic academic centers and highest-funded musculoskeletal (MSK) researchers to determine if gender is associated with endowed professorship. Additionally, we sought to determine if gender is associated with increased NIH funding for top-performing musculoskeletal researchers.  Methods Our primary study group included the top 100 orthopaedic academic centers defined by US News World Report and Doximity's rankings. Our secondary study group examined the top MSK researchers, defined as principal investigators, who received >$400,000 in annual NIH funding from 2018 to 2021. Orthopaedic departments included MSK researchers and subspecialties within orthopaedics and medicine. Publicly available sources were used to compile institutional, gender, H-index, citation number, and subspecialty data on endowed professors; statistical comparisons were calculated. Results Within the top 100 orthopaedic academic departments, 4674 faculty were identified. Seven hundred and thirty-three (15.68%) were identified as women, 3941 as men (84.32%). One hundred and ninety-four held endowed professorships; 13 were awarded to women (6.7%), and 185 (95.3%) were awarded to men, with a significant odds ratio (OR) of 2.95, favoring men. For MSK researchers, the OR increases to 11.4. Arthroplasty and sports had the highest numbers of endowments. Significant differences in H-index, publications, and graduation year were identified between men and women for top MSK researchers and orthopaedic-trained surgeons; however, these differences disappeared when considering heterogenous orthopaedic departments that included medicine subspecialties, plastic surgery, hand surgery, and neurosurgery. Additional gender differences were observed in endowment names, with awards commemorating 51.5% men, 7.2% women, and 34% families or groups. Conclusion Gender inequities at the endowment level are substantial, and there are very few women in musculoskeletal medicine to achieve endowments. Differences in H-index, publications, and graduation year between men and women MSK researchers and orthopaedic-trained surgeons, but not combined orthopaedic, PM&R, and medical subspecialty departments, suggest unique challenges in orthopaedic surgery environments and histories that may contribute to endowment disparity. Gender was not found to be associated with funding bias for top-performing musculoskeletal researchers.

Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study

Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.

Bone Bruise Patterns Associated With Pediatric and Adult Anterior Cruciate Ligament Tears Are Different

Purpose

To describe differences in radiographic and magnetic resonance imaging (MRI) findings between adult and pediatric patients with known primary anterior cruciate ligament (ACL) injuries.

Methods

We performed a retrospective analysis of surgical patients with a history of ACL tears treated at our institution over a 7-year period. Patients were divided into 2 cohorts based on age (≤15 years and ≥21 years). Patients' radiographs and MRI studies were used to compare features including fracture incidence, bone bruise pattern, associated ligamentous injuries, and meniscal injuries between the 2 groups. Proportions of associated findings were analyzed using the 2-proportion z test.

Results

Within our cohorts of 52 sex-matched pediatric and adult patients, we found that pediatric patients were more likely to have radiographic evidence of fracture (P = .001) and MRI evidence of lateral femoral condylar bone bruising (P = .012). Adult patients had higher rates of medial femoral condylar bruising (P = .016) and medial proximal tibial bruising (P = .005), as well as popliteal fibular ligament injuries (P = .037), identified on MRI.

Conclusions

In this study, we identified differences in bone bruise patterns between pediatric and adult patients with primary ACL tears. Pediatric patients were more likely to have radiographic evidence of fracture and MRI evidence of lateral femoral condylar bone bruising. Adult patients were more likely to show medial femoral condylar and medial proximal tibial bone bruising, as well as popliteal fibular ligament injuries.

Level of Evidence

Level IV, prognostic case series.

International Multicentre Study of Candida auris Infections

Background:Candida auris has emerged globally as a multi-drug resistant yeast and is commonly associated with nosocomial outbreaks in ICUs. Methods: We conducted a retrospective observational multicentre study to determine the epidemiology of C. auris infections, its management strategies, patient outcomes, and infection prevention and control practices across 10 centres from five countries. Results: Significant risk factors for C. auris infection include the age group of 61–70 years (39%), recent history of ICU admission (63%), diabetes (63%), renal failure (52%), presence of CVC (91%) and previous history of antibiotic treatment (96%). C. auris was commonly isolated from blood (76%). Echinocandins were the most sensitive drugs. Most common antifungals used for treatment were caspofungin (40%), anidulafungin (28%) and micafungin (15%). The median duration of treatment was 20 days. Source removal was conductedin 74% patients. All-cause crude mortality rate after 30 days was 37%. Antifungal therapy was associated with a reduction in mortality (OR:0.27) and so was source removal (OR:0.74). Contact isolation precautions were followed in 87% patients. Conclusions:C. auris infection carries a high risk for associated mortality. The organism is mainly resistant to most azoles and even amphotericin-B. Targeted antifungal therapy, mainly an echinocandin, and source control are the prominent therapeutic approaches.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

BACKGROUND

We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific.

METHODS

Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied.

RESULTS

We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases.

CONCLUSIONS

DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Profiles of multidrug-resistant organisms among patients with bacteremia in intensive care units: an international ID-IRI survey

Evaluating trends in antibiotic resistance is a requisite. The study aimed to analyze the profile of multidrug-resistant organisms (MDROs) among hospitalized patients with bacteremia in intensive care units (ICUs) in a large geographical area. This is a 1-month cross-sectional survey for blood-borne pathogens in 57 ICUs from 24 countries with different income levels: lower-middle-income (LMI), upper-middle-income (UMI), and high-income (HI) countries. Multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan-drug-resistant isolates were searched. Logistic regression analysis determined resistance predictors among MDROs. Community-acquired infections were comparable to hospital-acquired infections particularly in LMI (94/202; 46.5% vs 108/202; 53.5%). Although MDR (65.1%; 502/771) and XDR (4.9%; 38/771) were common, no pan-drug-resistant isolate was recovered. In total, 32.1% of MDR were Klebsiella pneumoniae, and 55.3% of XDR were Acinetobacter baumannii. The highest MDR and XDR rates were in UMI and LMI, respectively, with no XDR revealed from HI. Predictors of MDR acquisition were male gender (OR, 12.11; 95% CI, 3.025-15.585) and the hospital-acquired origin of bacteremia (OR, 2.643; 95%CI, 1.462-3.894), and XDR acquisition was due to bacteremia in UMI (OR, 3.344; 95%CI, 1.189-5.626) and admission to medical-surgical ICUs (OR, 1.481; 95% CI, 1.076-2.037). We confirm the urgent need to expand stewardship activities to community settings especially in LMI, with more paid attention to the drugs with a higher potential for resistance. Empowering microbiology laboratories and reports to direct prescribing decisions should be prioritized. Supporting stewardship in ICUs, the mixed medical-surgical ones in particular, is warranted.

Financial and medical burdens of youth sports specialization - survey of pediatric sports patients

BACKGROUND

The trend towards youth sports specialization has led to increased costs from higher injury rate and from private club fees. The objectives were to characterize the financial and medical burdens of sports specialization with single sport participation or club sports involvement.

METHODS

An 18-item survey on sports participation and musculoskeletal injury was administered to parents of patients visiting the clinic of a pediatric sports medicine orthopaedic surgeon over a three-month period. Comparisons were made between groups to identify differences in medical and financial burdens. Logistic regressions were performed to evaluate odds ratios for binary outcomes.

RESULTS

Club athletes were significantly younger than non-club athletes (12.9 ± 3.1 years versus 14.9 ± 2.8 years, p = .0002) with club athletes starting sports at average of 7.2 ± 3.1 years. Club sports participation (adjusted OR 5.88, 95% CI: 1.10, 31.4) and female sex (adjusted OR 3.47, 95% CI: 1.12, 10.74) were significant predictors of spending > $1000 USD on sports annually. Multisport participation (OR 5.72, 95% CI: 1.21, 26.96) and spending > $1000 on sports annually (OR 17.21, 95% CI: 1.49, 199.25) were significant predictors of presenting to clinic for a sports-related injury. Single sport athletes had a higher number of medical appointments for sports injuries (18.6 ± 23.0 versus 9.3 ± 10.0 for multisport, p = .0042).

CONCLUSIONS

Youth sports specialization is of substantial financial and medical burden to families. This data can help identify areas of intervention to mitigate injury risk and reduce financial barriers to youth sports participation.

Managing adult patients with infectious diseases in emergency departments: international ID-IRI study

We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 ± 0.74. Sepsis (qSOFA ≥ 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 ± 0.963) compared to upper-middle (0.17 ± 0.482) and high-income (0.36 ± 0.714) countries (P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required.

Public Insurance Status Negatively Affects Access to Care in Pediatric Patients With Meniscal Injury

Background:

Non- and underinsured individuals experience poor access to care and treatment delays. Meniscal injury is a common reason for surgical intervention in the pediatric population, and delays in care can lead to progression of the tear and other associated problems.

Purpose:

To investigate the impact of insurance status on access to care and severity of meniscal injury in the pediatric population.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Enrolled in this study were 49 patients receiving care for a meniscal injury between 2016 and 2018 from a safety-net medical system that does not prioritize patients based on insurance status. The patients were stratified into those publicly insured and those privately insured. Access to care was measured as wait time to various points of care: initial injury to clinic, injury to magnetic resonance imaging (MRI), injury to surgery, clinic to MRI, clinic to surgery, and MRI to surgery. The severity of the meniscal tear was measured by findings at the time of arthroscopy, including the type of tear identified, surgery performed, and cartilage injury.

Results:

Publicly insured patients waited a mean 230 days longer (347 vs 117 days; P < .01) to undergo surgery after injury compared with privately insured patients. The mean wait times in all categories except time from MRI to surgery were significantly longer for publicly insured patients, including injury to clinic (212 vs 73 days; P < .01), injury to MRI (260 vs 28 days; P < .001), injury to surgery (347 vs 117 days; P < .01), clinic to MRI (36 vs 3.9 days; P < .001), and clinic to surgery (136 vs 44 days; P < .01). Neither increased wait times nor insurance status were associated with greater surgical repair rate, severe tear type, or cartilage injury.

Conclusion:

Publicly insured pediatric patients waited significantly longer for a diagnosis of meniscal tear compared with privately insured patients, even in a safety-net setting. These delays were not associated with greater tear severity or cartilage changes. Providers in all models of care should recognize that insurance status and the socioeconomic factors it represents prevent publicly insured patients from timely diagnostic points of care and strive to minimize the resulting delayed return to normal activity as well as the potential long-term clinical effects thereof.

Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings

BACKGROUND

Short-term peripheral venous catheter-associated bloodstream infection rates have not been systematically studied in Asian countries, and data on peripheral venous catheter-associated bloodstream infections incidence by number of short-term peripheral venous catheter days are not available.

METHODS

Prospective, surveillance study on peripheral venous catheter-associated bloodstream infections conducted from 1 September 2013 to 31 May 2019 in 262 intensive care units, members of the International Nosocomial Infection Control Consortium, from 78 hospitals in 32 cities of 8 countries in the South-East Asia Region: China, India, Malaysia, Mongolia, Nepal, Philippines, Thailand, and Vietnam. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.

RESULTS

We followed 83,295 intensive care unit patients for 369,371 bed-days and 376,492 peripheral venous catheter-days. We identified 999 peripheral venous catheter-associated bloodstream infections, amounting to a rate of 2.65/1000 peripheral venous catheter-days. Mortality in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.53% and 12.21% in patients with peripheral venous catheter-associated bloodstream infections. The mean length of stay in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.40 days and 7.11 days in patients with peripheral venous catheter and peripheral venous catheter-associated bloodstream infections. The microorganism profile showed 67.1% were Gram-negative bacteria: Escherichia coli (22.9%), Klebsiella spp (10.7%), Pseudomonas aeruginosa (5.3%), Enterobacter spp. (4.5%), and others (23.7%). The predominant Gram-positive bacteria were Staphylococcus aureus (11.4%).

CONCLUSIONS

Infection prevention programs must be implemented to reduce the incidence of peripheral venous catheter-associated bloodstream infections.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

Preparation and in vitro Characterization of Porous Carrier-Based Glipizide Floating Microspheres for Gastric Delivery

Floating microspheres have been utilized to obtain prolonged and uniform release of drug in the stomach for development of once-daily formulations. A controlled-release system designed to increase residence time in the stomach without contact with the mucosa was achieved through the preparation of floating microspheres by the emulsion solvent diffusion technique, using (i) calcium silicate (CS) as porous carrier; (ii) glipizide, an oral hypoglycemic agent; and (iii) Eudragit^® S as polymer. The effects of various formulations and process variables on the internal and external particle morphology, micromeritic properties, in vitro floating behavior, drug loading, and in vitro drug release were studied. The microspheres were found to be regular in shape and highly porous. The prepared microspheres exhibited prolonged drug release (~8 h) and remained buoyant for >10 h. The mean particle size increased and the drug release rate decreased at higher polymer concentrations. No significant effect of the stirring rate during preparation on drug release was observed. In vitro studies demonstrated diffusion-controlled drug release from the microspheres. Microsphere formulation CS4, containing 200 mg calcium silicate, showed the best floating ability (88% buoyancy) in simulated gastric fluid. The release pattern of glipizide in simulated gastric fluid from all floating microspheres followed the Higuchi matrix model and the Peppas-Korsmeyer model.

Patient Characteristics Associated with Use of Monoclonal Antibody Treatment in Women with Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Monoclonal antibodies (MoATB) were FDA approved for the treatment of patients with breast cancer (BrCA) whose tumors over expressed the human epidermal growth factor receptor 2 (HER2) in 1998. We sought to determine if certain patient characteristics and co-morbidities influenced MoATB use in a population-based practice setting of elderly women with metastatic BrCA. Methods: We identified female Medicare beneficiaries aged 66+ years diagnosed with incident metastatic BrCA without prior history for any cancer between 1999 and 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Charlson Co-morbidity index (CCI) and separate conditions within the index were created using linked Medicare claims in the year prior to the BrCA diagnosis. We identified both oral and infused chemotherapy (CH) from the Medicare claims from 1999 to 2006. Patients were categorized into three groups: no CH, MoATB+/-CH, and CH w/out MoATB. We performed bivariate statistics to compare the patient characteristics and comorbidities between the three groups, and the treatments groups only. Results: There were 3,820 women with metastatic BrCA, mean age 77 (SD 7.3) years, 81% were white race, 29% were married and 91% lived in an urban setting. 67% of these women (n=2,562) received no CH, 26% received CH w/out MoATB (n=994) and 7% received MoATB+/-CH (n=264). Overall the CCI was lower for women receiving either treatment as compared to no chemotherapy and between treatment groups for the young old (66-75 years) but not those aged 80+ years. The prevalence of congestive heart failure (CHF) and cerebrovascular disease was significantly lower in women receiving MoATB +/-CH, as compared to only CH, and also lower in both compared to no CH (n=2,462). Few women presenting with COPD or dementia were likely to be treated with either CH and/or MoATB compared to No CH. Other co-morbidity conditions within the CCI were not statistically different between the groups or the cell numbers were too small to analyze. Conclusion: MoATB use in the treatment of metastatic breast cancer steadily increased from 5% in 1999 to 23% in 2004. Use in 2005 was slightly lower but will be recalculated once the 2007 claims are available. In 2008, FDA released a black box warning for trastuzumab, the most frequently prescribed MoATB for BrCA, regarding the potential for the development of cardiomyopathy. Our results suggest that co-morbidities in particular CHF and cerebrovascular disease may influence the decision to use MoATB. Further research is necessary to examine the relationship between co-morbidities and the use of MoATB in the treatment of metastatic breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2057.

Taxane Treatment in Women with Incident Stage IV Breast Cancer

Introduction: The overall benefit of chemotherapy for late stage breast cancer treatment has been demonstrated in clinical trials and “real world” observational studies, but there is less data on chemotherapy use among older women. In addition, estrogen receptor status can influence treatment decisions. Our objective was to explore the clinical and demographic characteristics of women who received chemotherapy, particularly taxanes, in a large population-based cohort of older patients with incident stage IV breast cancer.Methods: Older women (age 66 and over) diagnosed with incident stage IV breast cancer from 1999 to 2005 were identified in the Surveillance, Epidemiology and End Results (SEER) cancer registries. Treatment-related data were linked from Medicare claims. We limited our analysis to ER negative (ER-) women with the assumption that these women would not be receiving tamoxifen as SEER data do not have complete information on receipt of tamoxifen. Receipt of chemotherapy was identified from claims files. Bivariate analyses were performed to compare clinical and demographic characteristics of those who received taxanes, other chemotherapy, or no chemotherapy.Results: Of 3,820 older women diagnosed with incident stage IV breast cancer, 1,518 women (40%) were identified as ER negative, of whom 247 (16%) were treated with taxanes, 312 (21%) with other chemotherapy, and the remainder received neither. Mean age was 78, 84% of the study cohort was white, 27% were married, and 91% lived in urban areas. Fifty four percent of women had HER2 assays performed. Women who received taxanes were substantially younger (Mean=74, SD=5.49) than those who did not (Mean=80, SD=7.79) and had fewer co-morbidities (measured by Charlson co-morbidity index) (bivariate [see above] p=0.0003) than any other group. Individuals who received taxanes were less likely to be married, receive radiation or undergo surgery. Only 8% of those treated with taxanes had 2 or more medical conditions compared to 18% of those receiving other chemotherapy and 74% of those with no chemotherapy. Treatment groups varied in regard to some medical conditions including CHF, cerebrovascular disease, and dementia. For example, only 8% of those receiving taxanes had CHF, compared to 13% among the 'other chemotherapy' group and 78% among those receiving no treatment (bivariate [see above] p=0.0003). A similar trend was revealed with the other medical conditions, with taxane users consistently presenting with lower prevalence for each condition. Interestingly, no one who had dementia received any chemotherapy.Conclusion: Findings from this descriptive study showed that age and co-morbidity were the most important factors associated with receipt of taxanes as well as of other chemotherapy. However, those who received taxanes were the youngest and evidenced the least comorbidity of the 2 groups. Further study is needed to help inform clinicians in making optimum treatment recommendations for their older female patients with incident advanced breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2068.

Chemotherapy Treatment and Survival in Estrogen Receptor Negative Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Although controlled clinical trials have demonstrated a beneficial effect of various chemotherapy regimens on survival in breast cancer (BC), little is known about treatment patterns and survival benefit in the “real world” population of elderly women with metastatic BC. Methods: We identified female Medicare beneficiaries aged ≥66 years with metastatic BC diagnosed from 1999 to 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Patients with a prior history of any cancer were excluded. Treatment-related data were abstracted from linked Medicare claims. Since Medicare claims have incomplete information on oral selective estrogen receptor modulators, we limited our study cohort to estrogen receptor negative (ER-) women. Chemotherapy was defined as the receipt of any chemotherapeutic regimen within 6 months after diagnosis. Initial regimens were characterized based on drugs given during the first 30 days of chemotherapy. We used a continuous-time interval-censored survival analysis to determine the effect of chemotherapy on hazard of any-cause death, controlling for sociodemographic and clinical factors, including proxy measures for performance status. Results: We identified 1518 ER(-) women diagnosed with metastatic BC in SEER. Mean age was 77.6 (SD 7.6) years, 84% were white race and 27% were married at the time of diagnosis. Of the 1518 metastatic ER(-) BC patients, 493 (32%) received chemotherapy. As compared to women who did not receive chemotherapy, women who received chemotherapy were more likely to be younger, married, have lower pre-cancer comorbidity as measured by the Charlson comorbidity index, have seen an oncology specialist and have cancer-directed surgery or radiation prior to chemotherapy. Initial regimens comprised predominantly one (31%) or two (46%) drug classes. The most common regimens were taxanes only (18%), anthracycline+alkylating agents (17%) and antimetabolite+alkylating agent (9%). Overall median followup time was 7 months; 1223 women (81%) died during followup. Median survival time was 5 months among women who did not receive chemotherapy and 15 months among women who received chemotherapy. Chemotherapy was associated with a statistically significant survival benefit (adjusted Hazard Ratio 0.61, 95% confidence interval 0.54, 0.70). Conclusion: In this population-based study of older women, there was a variety of chemotherapy regimens used for metastatic ER(-) BC. Chemotherapy received within 6 months after diagnosis was associated with a 39% reduction in hazard of death. These findings reflect chemotherapy use outside of the clinical trial setting and have important clinical and policy implications for the study of treatments among older women with advanced BC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2064.

Bilateral total knee arthroplasty increases the propensity to trip on an obstacle

Tripping over an obstacle is the most frequent cause of falls. We examined the effects of total knee arthroplasty on obstacle avoidance success rates in older adults. Obstacle avoidance success rates, body mass index, visual acuity, contrast sensitivity, depth perception, and single-leg stance duration were evaluated in 29 subjects who had bilateral total knee arthroplasties (age range, 72.6 +/- 5.4 years) and 27 age-matched healthy control subjects (age range, 70.6 +/- 5.5 years). The patients who had total knee arthroplasties had a lower obstacle avoidance success rate, lower single-leg stance duration, and greater body mass index than control subjects. Age, contrast sensitivity, and depth perception were not different between patients who had total knee arthroplasties and control subjects. Obstacle avoidance success rates decreased linearly as single-leg stance duration decreased in the control group and across all groups, but not in the group that had total knee arthroplasties. Linear relationships between obstacle avoidance success rates and body mass index existed for all subjects but not for the group that had total knee arthroplasties or the control group individually. Total knee arthroplasty reduces obstacle avoidance success rate, suggesting that persons who have total knee arthroplasties have an increased propensity to trip on an obstacle and fall. Increased body mass index and decreased single-leg stance duration in patients who have total knee arthroplasties are associated with a decreased obstacle avoidance success rate.

Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model

PURPOSE

To compare the sensitivity and specificity of technetium-99m dimercaptosuccinic acid (DMSA) single photon emission computed tomography (SPECT), spiral computed tomography (CT), magnetic resonance (MR) imaging, and power Doppler ultrasonography (US) for the detection and localization of acute pyelonephritis by using histopathologic findings as the standard of reference.

MATERIALS AND METHODS

Bilateral vesicoureteric reflux was surgically created in 35 piglets (70 kidneys). One week later, a liquid bacterial culture of Escherichia coli was injected into the bladder. Three days after induction of urinary infection, imaging studies were performed, and the kidneys were removed for histopathologic examination. SPECT images were obtained 2-3 hours after injection of 99mTc-DMSA. Transverse and coronal MR images were obtained with gadolinium-enhanced fast inversion recovery. Transverse CT images were obtained before and after injection of contrast agent. Power Doppler US was performed in longitudinal, transverse, and coronal planes. Each kidney was divided into three zones for correlation of findings.

RESULTS

Histopathologic examination revealed pyelonephritis in 102 zones in 38 kidneys. Sensitivity and specificity for detecting pyelonephritis in the kidneys were 92.1% and 93.8% for SPECT, 89.5% and 87.5% for MR imaging, 86.8% and 87.5% for CT, and 74.3% and 56.7% for US. Sensitivity and specificity for detecting pyelonephritis in the zones were 94.1% and 95.4% for SPECT, 91.2% and 92.6% for MR imaging, 88.2% and 93.5% for CT, and 56.6% and 81.4% for US. The pairwise comparison of these modalities showed no statistically significant difference among them except for US.

CONCLUSION

99mTc-DMSA SPECT, spiral CT, and MR imaging appear to be equally sensitive and reliable for the detection of acute pyelonephritis; power Doppler US is significantly less accurate.

Growth hormone (GH)-releasing peptide-6 requires endogenous hypothalamic GH-releasing hormone for maximal GH stimulation

GH-releasing peptide-6 (GHRP-6) is a potent GH secretagogue that releases GH by uncertain mechanisms. To assess whether GHRH is required for GH release by GHRP-6 in humans, we used the specific antagonist to GHRH (N-Ac-Tyr1,D-Arg2)GHRH(1-29)NH2 (GHRH Ant). We have previously shown that GHRH-Ant (400 microg/kg) blocked the GH response to 0.33 and 3.3 microg/kg boluses of GHRH by 95% and 81%, respectively. Nine healthy men between the ages of 20 and 30 yr were studied on two occasions. They received either saline or GHRH-Ant (400 microg/kg, i.v.) at 0840 h, followed by GHRP-6 (1 microg/kg, i.v. bolus) at 0900 h. Blood was sampled every 10 min from 0800-1100 h. GH responses were measured as the maximal increase over the baseline GH concentration and as the area under the curve. GHRH-Ant eliminated most of the GH response to GHRP-6 [maximal increase over the baseline GH concentration, 33.8 +/- 4.8 vs. 6.2 +/- 1.8 microg/L (mean +/- SEM; P < 0.0001); area under the curve, 1701 +/- 278 vs. 376 +/- 113 microg/min x L (P < 0.001)]. These data show that endogenous GHRH is necessary for most of the GH response to GHRP-6 in humans.

An uncommon cause of peripheral neuropathy

The following case report is of a middle aged man with a progressive neurologic disability who was brought to our emergency department. Caregivers could no longer manage him once he lost the ability to ambulate and became incontinent. At that time his neurologic and hematologic parameters were fairly typical of cobalamin deficiency. We are reporting this case to emphasize that cobalamin deficiency is not always due to pernicious anemia in the elderly or the malnourished alcoholic. Deficiency from uncommon causes can manifest at any age and result in severe morbidity.

Ethnic minorities. The role of health advocates in health visiting teams

An east London project placed health advocates in health visiting teams to explore ways to deliver a better service to ethnic minority clients. Sonia Harding and Neeta Pandya report on the project, funded by London Implementation Zone monies, which resulted in recommendations for the development of the role and practice of health advocates, including independent home visiting.

Feeding, illness and nutritional status of young children in rural Gujarat

Eighty children, aged 0-18 months, were studied over a period of 6 months. Information was obtained from monthly interviews with mothers, when the children were also weighed. Feeding practices, incidence of illness and weight gain were described. The children who were nutritionally most at risk were identified. The average weight of the children was 1 kg less than the NCHS international reference by 3 months, 1.7 kg by 9 months. The majority of mothers did not introduce foods other than breast milk before 9 months. The children from labourers' households gained less weight between 3 and 6 months, had a higher prevalence of malnutrition and more reports of illness than children from non-labourers' households. The implications of these results for workers in child health and nutrition programmes are discussed.