A Development and Implementation of a Preconception Counseling Program for Black Women and Men in the Southeastern United States: A Pilot Protocol

Introduction

Racial/ethnic disparities in maternal mortality rates represent one of the most significant areas of disparities amongst all conventional population perinatal health measures in the U.S. The alarming trends and persistent disparities of outcomes by race/ethnicity and geographic location reinforce the need to focus on ensuring quality and safety of maternity care for all women. Despite complex multilevel factors impacting maternal mortality and morbidity, there are evidence-based interventions that, when facilitated consistently and properly, are known to improve the health of mothers before, during and after pregnancy. The objective of this project is to test implementation of pre-conception counseling with father involvement in community-based settings to improve cardiovascular health outcomes before and during pregnancy in southeastern United States.

Methods and Analysis

This study has two components: a comprehensive needs and assets assessment and a small-scale pilot study. We will conduct a community informed needs and assets assessment with our diverse stakeholders to identify opportunities and barriers to preconception counseling as well as develop a stakeholder-informed implementation plan. Next, we will use the implementation plan to pilot preconception counseling with father involvement in community-based settings. Finally, we will critically assess the context, identify potential barriers and facilitators, and iteratively adapt the way preconception counseling can be implemented in diverse settings. Results of this research will support future research focused on identifying barriers and opportunities for scalable and sustainable public health approaches to implementing evidence-based strategies that reduce maternal morbidity and mortality in the southeastern United States' vulnerable communities.

Discussion

Findings will demonstrate that preconception counseling can be implemented in community health settings in the southeastern United States. Furthermore, this study will build the capacity of community-based organizations in addressing the preconception health of their clients. We plan for this pilot to inform a larger scaled-up clinical trial across community health settings in multiple southeastern states.

Immunogenicity, Reactogenicity, and Safety of AS01E-adjuvanted RSV Prefusion F Protein-based Candidate Vaccine (RSVPreF3 OA) When Co-administered With a Seasonal Quadrivalent Influenza Vaccine in Older Adults: Results of a Phase 3, Open-Label, Randomized Controlled Trial

BACKGROUND

Co-administration of vaccines against respiratory syncytial virus (RSV) and influenza can be considered given their overlapping seasonality, and may increase vaccine uptake and compliance. In this phase 3, open-label, randomized study, we evaluated the immunogenicity, reactogenicity, and safety of the AS01E-adjuvanted RSV prefusion F protein-based candidate vaccine (RSVPreF3 OA) when co-administered with a seasonal quadrivalent influenza vaccine (FLU-QIV) in older adults.

METHODS

Participants aged ≥60 years (randomized 1:1) received either RSVPreF3 OA and FLU-QIV simultaneously on day 1 (Co-Ad group) or FLU-QIV on day 1 followed by RSVPreF3 OA on day 31 (sequential administration [SA] group). The co-primary objectives were to demonstrate noninferiority of RSVPreF3 OA in terms of RSV-A neutralization geometric mean titer (GMT) ratio and FLU-QIV in terms of hemagglutination inhibition GMT ratio for each FLU-QIV strain, when co-administered versus when administered alone at 1-month post-vaccination. Noninferiority was demonstrated if the upper limit of the 95% confidence interview of the group GMT ratio (SA/Co-Ad) was ≤1.5. Secondary descriptive objectives comprised additional immunogenicity assessments, reactogenicity, and safety.

RESULTS

Of the 885 participants who received one dose of the study vaccines, 837 were included in the per protocol set. Demographic and baseline characteristics were balanced between the groups. Both co-primary objectives were met for both vaccines. Reported adverse events in both groups were mild-to-moderate, with a low frequency of grade 3 events.

CONCLUSIONS

Data from this study demonstrate that RSVPreF3 OA can be co-administered with FLU-QIV. Co-administration is well tolerated, with an acceptable safety profile.

CLINICALTRIALS.GOV REGISTRATION

NCT04841577.

Patient Preparation and Radiation Protection Guidance for Adult Patients Undergoing Radioiodine Treatment for Thyroid Cancer in the UK

Radioactive iodine is a highly effective treatment for thyroid cancer and has now been used in clinical practice for more than 80 years. In general, the treatment is well tolerated. However, it can be logistically quite complex for patients due to the need to reduce iodine intake and achieve high levels of thyroid-stimulating hormone prior to treatment. Radiation protection precautions must also be taken to protect others from unnecessary radiation exposure following treatment. It has been well documented by thyroid cancer patient support groups that there is significant variation in practice across the UK. It is clear that some patients are being asked to observe unnecessarily burdensome restrictions that make it more difficult for them to tolerate the treatment. At the instigation of these support groups, a multidisciplinary group was assembled to examine the evidence and generate guidance on best practice for the preparation of patients for this treatment and the management of subsequent radiation protection precautions, with a focus on personalising the advice given to individual patients. The guidance includes advice about managing particularly challenging situations, for example treating patients who require haemodialysis. We have also worked together to produce a patient information leaflet covering these issues. We hope that the guidance document and patient information leaflet will assist centres in improving our patients' experience of receiving radioactive iodine. The patient information sheet is available as Supplementary Material to this article.

Dabrafenib and Trametinib Therapy for Advanced Anaplastic Thyroid Cancer - Real-World Outcomes From UK Centres

AIMS

Anaplastic thyroid cancer (ATC) is a rare but aggressive form of thyroid cancer with a median survival of 4 months. Recent advances in molecular profiling have shown that up to half of ATCs harbour the BRAF-V600E mutation. The aim of this study was to provide real-world data and experience on the use of combination therapy dabrafenib and trametinib in patients with BRAF-V600E-mutated advanced ATC.

MATERIALS AND METHODS

We retrospectively evaluated patients with confirmed BRAF-V600E-mutated ATC, defined as patients with locally advanced or metastatic ATC with no locoregional, radical treatment options. Outcomes measured were overall survival, progression-free survival, response rate, discontinuation rate, dose reduction rate and toxicity data.

RESULTS

Seventeen patients were evaluated and the mean age was 68 years. Ten patients died by the time of censoring. The median duration of follow-up was 12 months (3-43 months). The estimated median overall survival was 6.9 months (95% confidence interval 2.46 months - upper confidence interval not reached) and the median progression-free survival was 4.7 months (95% confidence interval 1.4-7.8 months). Dose interruptions and/or reductions were common, but none of the patients had to permanently discontinue treatment because of toxicities. Severe toxicities (grades 3 and 4) were uncommon.

CONCLUSIONS

This study supports the indication of dabrafenib and trametinib in BRAF-V600E-mutated ATC as an effective and well-tolerated treatment in an historically difficult to treat cancer.

Adult immunization practices, challenges and opportunities in Central America and the Caribbean: Advisory board proceedings

As individuals age, they become increasingly prone to infectious diseases, many of which are vaccine-preventable diseases (VPDs). Adult immunization has become a public health priority in the modern era, yet VPDs vaccination rates for adults are low worldwide. In Central America and Caribbean, national recommendations and vaccination practices in adults differ across countries, and adult vaccination coverage data are limited. An advisory board comprised infectious disease experts, pulmonologists, geriatricians, occupational health, and public health professionals for Central America and Dominican Republic was convened to: a) describe adult immunization practices in these countries; b) discuss challenges and barriers to adult vaccination; and c) find strategies to increase awareness about VPDs. The advisory board discussions reflect that national immunization guidelines typically do not include routine vaccine recommendations for all adults, but rather focus on those with risk factors. This is the case for influenza, pneumococcal, and hepatitis B immunizations. Overall, knowledge lacks about the VPD burden among health-care professionals and the general public. Even more, there is insufficient information on vaccinology for students in medical schools. Actions from the responsible authorities - medical schools and scientific societies which can advocate for vaccination and a better knowledge in vaccinology - can help address these issues. A preventive medicine culture in the workplace may contribute to the advancement of public opinion on vaccination. Promoting vaccine education and research could be facilitated via working groups formed by disease experts, public and private sectors, and supranational authorities, in an ethical and transparent manner.

2139. Immunogenicity, reactogenicity and safety of a Respiratory Syncytial Virus prefusion F (RSVPreF3) candidate vaccine co-administered with the seasonal quadrivalent influenza vaccine in older adults

Background

Respiratory syncytial virus (RSV) can cause severe respiratory disease in older adults (OAs). However, there is no approved vaccine against RSV disease in OAs. Co-administration of vaccines against RSV and influenza could be considered given their overlapping seasonality. Here, we assessed the immunogenicity, reactogenicity and safety of an RSV prefusion F Older Adult (RSVPreF3 OA) investigational vaccine when co-administered with the seasonal quadrivalent influenza vaccine (FLU-QIV) in OAs.

Methods

In this Phase 3, open-label, controlled, multi-country study (NCT04841577), OAs aged ≥ 60 years recruited in New Zealand, Panama and South Africa were randomized 1:1 to receive either RSVPreF3 OA and FLU-QIV simultaneously on day 1 (Co-Ad group), or FLU-QIV on day 1 and RSVPreF3 OA on day 31 (Control group). The co-primary objectives were to demonstrate the non-inferiority of i) RSVPreF3 OA in terms of RSV-A neutralizing antibody geometric mean titers (GMT) ratio and ii) FLU-QIV in terms of hemagglutinin inhibition antibody GMT ratio for each Flu strain when co-administered versus when administered alone. Blood samples were collected from all participants pre vaccination and 1 month post vaccination. Non-inferiority was demonstrated if the upper limit (UL) of the 95% confidence interval (CI) of the group GMT ratio (Control/Co-Ad) was ≤ 1.5. Secondary descriptive outcomes included reactogenicity and safety.

Results

885 participants received at least 1 dose of the study interventions. Of these, 838 were included in the per protocol set at 1 month post vaccination. The demographic characteristics of the participants were similar across groups. The study co-primary objectives were met; for both vaccines, the UL of the 95% CI of the GMT ratio was ≤ 1.5 (Table 1). The observed safety events were balanced between Co-Ad and Control groups (Table 2). The reactogenicity profile of the Co-ad group compared with the Control group was driven by the RSVPreF3 OA investigational vaccine.

Conclusion

Our results support simultaneous seasonal vaccination with RSVPreF3 OA and FLU-QIV in adults ≥ 60 years, as co-administration elicits a statistically non-inferior immune response to the administration of each vaccine alone, with no safety concerns identified.

Disclosures

Nathali Montenegro, MD, GSK: Support for the present abstract/study Lorena Noriega-Aguirre, MD, ScD, Astra Zeneca: Advisor/Consultant|Astra Zeneca: Honoraria|Astra Zeneca: Support for attending meetings and/or travel|Boehringer Ingelheim: Honoraria|Boehringer Ingelheim: Support for attending meetings and/or travel|GSK: Advisor/Consultant|GSK: Support for the present abstract/study|Novartis: Honoraria Mohammed Bensellam, PhD, GlaxoSmithKline Biologicals SA: Agency worker on assignment at GSK Nathalie De Schrevel, PhD, GlaxoSmithKline Biologicals SA: Employee|GlaxoSmithKline Biologicals SA: Ownership Interest Sherine Kuriyakose, MSc, GSK: GSK Employee Axel Lambert, MSc, GSK: GSK Employee Aurélie Olivier, PhD, GlaxoSmithKline Biologicals SA: I’m an employee of GSK Biologicals|GlaxoSmithKline Biologicals SA: Ownership Interest Veronica Hulstrøm, PhD MD, GlaxoSmithKline Biologicals SA: Employee.

Efficacy and safety of the CVnCoV SARS-CoV-2 mRNA vaccine candidate in ten countries in Europe and Latin America (HERALD): a randomised, observer-blinded, placebo-controlled, phase 2b/3 trial

BACKGROUND

Additional safe and efficacious vaccines are needed to control the COVID-19 pandemic. We aimed to analyse the efficacy and safety of the CVnCoV SARS-CoV-2 mRNA vaccine candidate.

METHODS

HERALD is a randomised, observer-blinded, placebo-controlled, phase 2b/3 clinical trial conducted in 47 centres in ten countries in Europe and Latin America. By use of an interactive web response system and stratification by country and age group (18-60 years and ≥61 years), adults with no history of virologically confirmed COVID-19 were randomly assigned (1:1) to receive intramuscularly either two 0·6 mL doses of CVnCoV containing 12 μg of mRNA or two 0·6 mL doses of 0·9% NaCl (placebo) on days 1 and 29. The primary efficacy endpoint was the occurrence of a first episode of virologically confirmed symptomatic COVID-19 of any severity and caused by any strain from 15 days after the second dose. For the primary endpoint, the trial was considered successful if the lower limit of the CI was greater than 30%. Key secondary endpoints were the occurrence of a first episode of virologically confirmed moderate-to-severe COVID-19, severe COVID-19, and COVID-19 of any severity by age group. Primary safety outcomes were solicited local and systemic adverse events within 7 days after each dose and unsolicited adverse events within 28 days after each dose in phase 2b participants, and serious adverse events and adverse events of special interest up to 1 year after the second dose in phase 2b and phase 3 participants. Here, we report data up to June 18, 2021. The study is registered at ClinicalTrials.gov, NCT04652102, and EudraCT, 2020-003998-22, and is ongoing.

FINDINGS

Between Dec 11, 2020, and April 12, 2021, 39 680 participants were enrolled and randomly assigned to receive either CVnCoV (n=19 846) or placebo (n=19 834), of whom 19 783 received at least one dose of CVnCoV and 19 746 received at least one dose of placebo. After a mean observation period of 48·2 days (SE 0·2), 83 cases of COVID-19 occurred in the CVnCoV group (n=12 851) in 1735·29 person-years and 145 cases occurred in the placebo group (n=12 211) in 1569·87 person-years, resulting in an overall vaccine efficacy against symptomatic COVID-19 of 48·2% (95·826% CI 31·0-61·4; p=0·016). Vaccine efficacy against moderate-to-severe COVID-19 was 70·7% (95% CI 42·5-86·1; CVnCoV 12 cases in 1735·29 person-years, placebo 37 cases in 1569·87 person-years). In participants aged 18-60 years, vaccine efficacy against symptomatic disease was 52·5% (95% CI 36·2-64·8; CVnCoV 71 cases in 1591·47 person-years, placebo, 136 cases in 1449·23 person-years). Too few cases occurred in participants aged 61 years or older (CVnCoV 12, placebo nine) to allow meaningful assessment of vaccine efficacy. Solicited adverse events, which were mostly systemic, were more common in CVnCoV recipients (1933 [96·5%] of 2003) than in placebo recipients (1344 [67·9%] of 1978), with 542 (27·1%) CVnCoV recipients and 61 (3·1%) placebo recipients reporting grade 3 solicited adverse events. The most frequently reported local reaction after any dose in the CVnCoV group was injection-site pain (1678 [83·6%] of 2007), with 22 grade 3 reactions, and the most frequently reported systematic reactions were fatigue (1603 [80·0%] of 2003) and headache (1541 [76·9%] of 2003). 82 (0·4%) of 19 783 CVnCoV recipients reported 100 serious adverse events and 66 (0·3%) of 19 746 placebo recipients reported 76 serious adverse events. Eight serious adverse events in five CVnCoV recipients and two serious adverse events in two placebo recipients were considered vaccination-related. None of the fatal serious adverse events reported (eight in the CVnCoV group and six in the placebo group) were considered to be related to study vaccination. Adverse events of special interest were reported for 38 (0·2%) participants in the CVnCoV group and 31 (0·2%) participants in the placebo group. These events were considered to be related to the trial vaccine for 14 (<0·1%) participants in the CVnCoV group and for five (<0·1%) participants in the placebo group.

INTERPRETATION

CVnCoV was efficacious in the prevention of COVID-19 of any severity and had an acceptable safety profile. Taking into account the changing environment, including the emergence of SARS-CoV-2 variants, and timelines for further development, the decision has been made to cease activities on the CVnCoV candidate and to focus efforts on the development of next-generation vaccine candidates.

FUNDING

German Federal Ministry of Education and Research and CureVac.

Highlights of an Expert Advisory Board on Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AE-COPD) in Latin America

Background

Chronic obstructive pulmonary disease (COPD) is a preventable and usually progressive lung disease that affects millions of people worldwide and is the sixth leading cause of death in the Americas. Viral and bacterial respiratory tract infections and air pollution may cause acute exacerbations of COPD (AE-COPD) ranging from mild, moderate to severe. The greatest proportion of the overall COPD burden on the health system is due to disease exacerbations. There is limited evidence regarding the etiology and burden of AE-COPD in Latin America (LATAM).

Methods

To respond to this gap in evidence, an Advisory Board with regional pneumologists and infectious disease experts was convened in September 2018 in Panama City, Panama, to: 1) review the burden of AE-COPD in LATAM; 2) evaluate the etiology of AE-COPD in LATAM; and 3) assess and compare the local/regional guidelines to confirm the etiology, characterize, and manage AE-COPD.

Results

The results of the meeting showed that there is a high prevalence of AE-COPD in LATAM countries, limited evidence on etiology data, and discrepancies in the case definitions and symptomology (ie, severity) classifications used in LATAM.

Conclusion

The Advisory Board discussions further resulted in recommendations for future research on the impact on the epidemiology and burden of disease, on establishing standardized AE-COPD case definition guidelines, and on studying the etiology of both moderate and severe AE-COPD cases.

Prevention of HPV-related oral cancer: assessing dentists' readiness

OBJECTIVES

Epidemiological research indicates an association between the Human Papillomavirus (HPV) with a subset of oral cancers (OC). Dentists may play a role in primary prevention of HPV-related OC by discussing the HPV vaccine with patients. This study assessed dentists' readiness to discuss the HPV vaccine with female patients.

STUDY DESIGN

Cross-sectional web-based survey.

METHODS

A web-based survey based on the Transtheoretical Model was administered among Florida dentists (n = 210).

RESULTS

The majority of participants (97%) fell into the precontemplation and contemplation stages of readiness to discuss the HPV vaccine with patients. Perceived role and liability were determined to be predictive of dentists in contemplation stage as opposed to those in precontemplation (P < 0.05).

CONCLUSIONS

Findings suggest liability and perceived role as processes of change necessary to guide dentists to primary prevention of HPV-related OC despite high levels of knowledge. As public awareness of HPV-related OC increases, dentists may become more involved in primary prevention. Results of the current study may assist in developing intervention strategies for engaging dentists in discussing the HPV vaccine with patients.

Expectations and illusions: a position paper on the relationship between mental health practitioners and social exclusion

Over the last 10 years, the social inclusion agenda has been gaining momentum as a policy driver in mental health services. Prior to the seminal Social Exclusion Unit (SEU) report, Mental Health and Social Exclusion, there was a lack of awareness concerning the pervasive links between social exclusion and mental health problems. In the report, the SEU suggested that mental health practitioners themselves may actually be contributing to this social exclusion. This finding has been given limited coverage in both social inclusion literature and research. The current paper is a positioned commentary further exploring the relationship between practitioners and the social exclusion of mental health service users. A literature review was conducted in order to identify themes among factors which appear to moderate and contribute to this relationship. These factors are presented and implications for inclusive practice are explored.

Examination of psoralens-induced photodermatitis in Wistar rats under scanning electron microscopy

The psoralens are photoactivated plant biosynthetic compounds which are found in several plant families, including common fruits and vegetables. Synthetic forms of the psoralens bergapten (5-methoxypsoralen) and xanthotoxin (8-methoxypsoralen) are extensively used in skin chemotherapy in combination with long-wave ultraviolet radiation (PUVA). Side effects of PUVA therapy are not, however, desirable, and this therapy has been linked with increased incidence of skin cancer in humans. The psoralens are known to be carcinogenic, mutagenic and teratogenic, and to cause photodermatitis. The main objective of this study was to document the effect of PUVA on the epidermis of rats. Female Wistar rats were administered dietary bergapten and/or xanthotoxin (0-200 mg/kg body) and exposed to UVA radiation (45 min./day) for four weeks. At the end of the four-week period the rats were sacrificed; skin samples were taken from the ears and the top part of the tail and fixed for examination by Scanning Electron Microscopy. The animals subjected to PUVA had significantly smaller scales on the tail epidermis (mean scale size for the control 926 mu vs. 725 to 805 mu for the psoralen treatment groups. The rats that received dietary psoralens also had significantly less hair on the ears compared with the control animals (mean number of hairs per millimeter over the ear edge for the control 54.9 vs. 2.00 to 10.7 for the treatment groups). The two compounds were synergistic in their ability to reduce scale size on the tail epidermis.

Drosophila nerve cord culture: a tool for studying neural development

The culture of explanted neural tissues has been a useful tool for the study of cellular and molecular neurobiology in vertebrates. We have developed a technique for the culture of explanted ventral nerve cords from Drosophila embryos. We have examined the morphology and dynamic behaviour of the growth cones that extend from these nerve cords, and the effect of calcium deprivation on the bundling of axons that are regenerated from the explanted tissue. This technique offers a unique opportunity to combine in vitro techniques for neuronal cell culture with the powerful techniques of genetic analysis that are available with Drosophila.

Acquisition of iron by Gardnerella vaginalis

Six Gardnerella vaginalis strains were examined for the ability to utilize various iron-containing compounds as iron sources. In a plate bioassay, all six strains acquired iron from ferrous chloride, ferric chloride, ferrous sulfate, ferric ammonium citrate, ferrous ammonium sulfate, bovine and equine hemin, bovine catalase, and equine, bovine, rabbit, and human hemoglobin. All six strains also acquired iron from human lactoferrin, but not from human transferrin, as determined by a liquid broth growth assay. Siderophore production was detected in eight G. vaginalis strains by the chrome azurol S universal chemical assay. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the cytoplasmic membrane proteins isolated from G. vaginalis 594 grown under iron-replete and iron-restricted conditions revealed several iron-regulated proteins ranging in molecular mass from 33 to 94 kDa. These results indicate that G. vaginalis may acquire iron from iron salts and host iron compounds.

Phosphorylation with protein kinases modulates calcium loading of terminal cisternae of sarcoplasmic reticulum from skeletal muscle

We previously found in single channel studies that ryanodine receptor (RyR) channel activity can be made insensitive to block by Mg2+ when terminal cisternae of sarcoplasmic reticulum, incorporated into planar bilayers, are treated with protein kinase A (PKA) or Ca2+/calmodulin dependent protein kinase type II (CamPK II), and then again made sensitive by treatment with protein phosphatases [Hain J. Nath S. Mayrleitner M. Fleischer S. Schindler H. (1994) Phosphorylation modulates the function of the calcium release channel of sarcoplasmic reticulum from skeletal muscle. Biophys. J., 67, 1823-1833]. In this study, modulation by protein kinases and phosphatases on net Ca2+ uptake by TC is presented. Phosphorylation of TC vesicles with PKA, CamPK II, or protein kinase C (PKC) reduced the calcium loading rate of TC vesicles 3-fold, 2.1-fold and 1.7-fold, respectively, measured in the presence of 1 mM MgCl2. There is no effect when AMP-PNP is substituted for ATP. Phosphorylation of the RyR was also measured by incorporation of [gamma-32P]-phosphate from ATP. A phosphorylation stoichiometry of 1.94 +/- 0.1 (32P/RyR) for PKA, 0.89 +/- 0.08 for CamPK II and 0.95 +/- 0.16 for PKC was obtained under these conditions. A study of the time dependence of phosphorylation with PKA and CamPK shows a direct correlation of reduction in calcium loading rate with increased phosphorylation of the ryanodine receptor. Treatment with protein phosphatase 1 enhanced the calcium loading rate again, after it was reduced by PKA phosphorylation. Investigation of the magnesium dependency shows that even at higher [Mg2+] (6 mM), PKA phosphorylated TC vesicles have a 2.3-fold reduced calcium loading rate indicating insensitivity to block by Mg2+.(ABSTRACT TRUNCATED AT 250 WORDS)

Site progression of loss of attachment over 5 years in 14- to 19-year-old adolescents

The aims of this study were (1) to monitor the progression and patterns of progression of loss of attachment > or = 1 mm on a site basis over a 5-year period in adolescents, and (2) to relate the presence of oral deposits and inflammation to the subsequent development and progression of loss of attachment on a site basis. 167 subjects were examined at ages 14, 16 and 19 years. Loss of attachment > or = 1 mm, plaque, subgingival calculus, gingival bleeding and gingival colour change were assessed on the mesio-buccal sites of the 1st molars, 1st premolars and central incisors. Each site was treated separately in the analysis to avoid the problem of within-subject site dependence. Sites were classed as progressing, non-progressing or fluctuating according to the probing attachment level measurements at each of the 3 examinations. During the 5 years of this study, a total of 542 sites in 128 subjects progressed; 1136 sites in 162 subjects did not progress; 43 sites in 30 subjects had fluctuating attachment level measurements. Sites which subsequently progressed had significantly more plaque, subgingival calculus and gingival inflammation than non-progressing sites at the baseline examination and throughout the study (p < 0.001). Between 55-57% of the maxillary 1st molars and 46-49% of the mandibular incisors progressed. In contrast, there was no progression of loss of attachment on over 80% of the maxillary central incisors and mandibular 1st premolars.

Anesthesia in the emergency setting: Part II. Head and neck, eye and rib injuries

Anesthesia for procedures of the head and neck includes ear field blocks, supraorbital and supratrochlear nerve blocks, infraorbital, mental, mandibular and posterosuperior alveolar nerve blocks. Topical ophthalmic anesthesia is useful in treating a variety of ocular injuries, including corneal abrasion and laceration, chemical/thermal burns, and injuries caused by foreign bodies and contact lenses. The intercostal nerve block is used to manage the pain of rib fractures, thus improving patient comfort, tidal volume and ventilation, and pulmonary toilet.

Anesthesia in the emergency setting: Part I. Hand and foot injuries

Topical application and local infiltration of anesthetic agents are useful for localized areas, while a circular field block provides superficial anesthesia within the encircled area. Regional anesthesia is accomplished by injecting the anesthetic agent near a nerve or nerve group. Useful anesthetic techniques for repair of hand injuries include wrist blocks, intermetacarpal blocks and local infiltration anesthesia. Median nerve block, ulnar nerve block, radial nerve block or a combination of these blocks provides satisfactory anesthesia without inducing muscle paralysis in the anesthetized region. Intermetacarpal digital blocks are used to anesthetize any finger. Local infiltration is useful for closing minor lacerations. For foot injuries, the posterior ankle block is used to anesthetize the sole. The anterior ankle block is used for the dorsum of the foot.

Isolation and partial amino acid sequence of a 78 kDa porcine gastrin-binding protein

1. A 78 kDa protein (p78) has been partially purified from washed membranes isolated from the corpus of porcine gastric mucosa. The purification was monitored by covalent cross-linking of iodinated [Nle15]-gastrin. 2. A single N-terminal sequence extending for 33 amino acids was obtained from the p78 preparation. Partial sequences totalling 192 amino acids were also obtained from 14 tryptic and 3 Staphylococcal V8 peptides. 3. 10 peptides plus the N-terminal sequence were derived from a previously unsequenced protein which was distantly related to the product of the E. coli fadB gene (Baldwin G. S. (1993) Comp. Biochem. Physiol. 104B, 55-61). The remaining 7 peptides were derived from the beta-subunit of the gastric H+/K(+)-ATPase. 4. The gastrin-binding activity remained in association with p78, and could be separated from the beta-subunit of the gastric H+/K(+)-ATPase, during chromatography on tomato lectin-Sepharose. 5. We conclude that p78 binds gastrin, and is a novel member of the enoyl-CoA hydratase/3-hydroxyacyl-CoA dehydrogenase family of enzymes.

Randomized study of preoperative versus postoperative radiation therapy in advanced head and neck carcinoma: long-term follow-up of RTOG study 73-03

This is a report of a 10-year median follow-up of a randomized, prospective study investigating the optimal sequencing of radiation therapy (RT) in relation to surgery for operable advanced head and neck cancer. In May 1973, the Radiation Therapy Oncology Group (RTOG) began a Phase III study of preoperative radiation therapy (50.0 Gy) versus postoperative radiation therapy (60.0 Gy) for supraglottic larynx and hypopharynx primaries. Of 277 evaluable patients, duration of follow-up is 9-15 years, with 7.6% patients lost to follow-up before 7 years. Loco-regional control was significantly better for 141 postoperative radiation therapy patients than for 136 preoperative radiation therapy patients (p = 0.04), but absolute survival was not affected (p = 0.15). When the analysis was restricted to supraglottic larynx primaries (60 postoperative radiation therapy patients versus 58 preoperative radiation therapy patients), the difference for loco-regional control was highly significant (p = .007), but not for survival (p = 0.18). In considering only supraglottic larynx, 78% of loco-regional failures occurred in the first 2 years. Thirty-one percent (18/58) of preoperative patients failed locally within 2 years versus 18% (11/60) of postoperative patients. After 2 years, distant metastases and second primaries became the predominant failure pattern, especially in postoperative radiation therapy patients. This shift in the late failure pattern along with the increased number of unrelated deaths negated any advantage in absolute survival for postoperative radiation therapy patients. The rates of severe surgical and radiation therapy complications were similar between the two arms. Because of an increased incidence of late distant metastases and secondary primaries, additional therapeutic intervention is required beyond surgery and postoperative irradiation to impact significantly upon survival.

Isolation of transferrin from porcine gastric mucosa: comparison with porcine serum transferrin

1. An iron-binding glycoprotein has been purified to homogeneity from porcine gastric mucosa. 2. The molecular weight (80,000), amino acid composition, carbohydrate content, N-terminal amino acid sequence, tryptic map, stoichiometry of iron binding (2 mol/mol), visible absorption spectrum of the ferric complex and chromatographic behaviour of the gastric protein are all strikingly similar to the corresponding properties of porcine serum transferrin. 3. The quantity of the gastric protein (1.3 mg/g wet weight) present in the gastric mucosa suggests that it is not serum transferrin (plasma concentration 1.8 mg/ml) contaminating the tissue. 4. A role for transferrin in the uptake of dietary iron by the gastrointestinal tract is proposed.

DNA analysis by flow cytometry

Accurate quantification of DNA from cells of several species is possible with flow cytometry. When one species is used as a reference, cytometric readings from two or more different species can be compared to obtain relative percent DNA or DNA indices. Differences in DNA from the male and female of the same species also can be measured. The method allows rapid screening of chromosomal abnormalities among large clinical populations, and evaluation of errors of sex determination such as XY sex reversal.

Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group

Between March 1973 and June 1979, patients with advanced operable squamous cell carcinoma of the supraglottic larynx or hypopharynx were randomly allocated to receive either preoperative radiation therapy (5,000 rad) or postoperative radiation therapy (6,000 rad). Patients with oral cavity or oropharynx lesions were randomly assigned either preoperative radiation, postoperative radiation, or definitive radiation therapy (6,500-7,000 rad), with surgery reserved for salvage if residual disease was present 6 weeks after completion of irradiation. Three hundred twenty patients were evaluable with a median follow-up of 60 months. Based on results in 277 patients across all four regions combined, locoregional control was significantly better for patients assigned to receive postoperative radiation therapy (65%) compared with those assigned to receive preoperative radiation therapy (48%, P = 0.04). This was due to a higher rate of both persistent and recurrent local and regional disease in the preoperative group. Survival also showed a trend to be better in the postoperative group (38%) compared with the preoperative group (33%, P = 0.10). Rates of severe surgical and radiation therapy complications were similar overall. Forty-three patients were evaluable for each of the three treatment regimens assigned to patients with oral cavity or oropharynx lesions. Due to the small number of patients available for this portion of the trial, the observed differences for overall survival (4-year percentage 33% overall; 30% preoperative, 36% postoperative, 33% definitive radiation therapy) and for locoregional control (45% overall; 43% preoperative, 52% postoperative, 38% definitive radiation therapy) were not statistically significant. The use of definitive radiation therapy with surgical rescue as an ethically justified alternative treatment for these tumors remains a question for further research.

Identification of a gastrin binding protein in porcine gastric mucosal membranes by covalent cross-linking with iodinated gastrin

A gastrin binding protein (GBP) has been identified in detergent extracts of porcine gastric mucosal membranes by covalent cross-linking to 125I-[Nle15]gastrin with disuccinimidyl suberate. The apparent molecular weight of the cross-linked complex (80,000) is uneffected by reduction suggesting that the GBP is not composed of disulfide-bonded subunits. Subtraction of the molecular weight of 125I-gastrin indicates that the molecular weight of the GBP is 78,000. A similar molecular weight has been observed previously for the gastrin receptor (74,000) on intact canine parietal cells and plasma membranes therefrom, and for the receptor for the related hormone cholecystokinin (76,000-85,000) on pancreatic acinar membranes under reducing conditions. The similarity in molecular weight between the gastrin receptor and the solubilized GBP suggests that the latter protein is probably the gastrin receptor. However, the concentration (2 microM) of [Nle15]gastrin required for 50% inhibition of cross-linking of gastrin to the GBP solubilized in 0.1% Triton X-100 is 200-fold greater than the value (10 nM) observed for the gastrin receptor on isolated canine gastric parietal cells. A lower concentration (0.3 microM) of [Nle15]gastrin was required to inhibit cross-linking in a milder detergent (0.4% digitonin, 0.08% cholate). Thus, the reduced affinity for gastrin of the putative solubilized form of the gastrin receptor appears to be a result of detergent extraction.

Binding of gastrin to gastric transferrin

Binding of 125I-gastrin to porcine gastric transferrin has been demonstrated by covalent cross-linking with disuccinimidyl suberate. The concentration of gastrin required to reduce cross-linking by 50% was approx. 100 microM. The occurrence of both gastrin and gastric transferrin in porcine gastric mucosa and lumen suggests a novel synergistic role for the observed interaction in the uptake of dietary iron.

Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty

A prospective study of displaced femoral neck fractures was conducted with patients randomized into three groups: cemented total hip replacement (THR), cemented hemiarthroplasty (UHR-C), and noncemented hemiarthroplasty (UHR-NC). Eighty-nine patients were treated for displaced (Garden type 3 or 4) fracture with a prosthesis; 39 patients had THR, 37 had UHR-C, and 13 had UHR-NC. No difference was found in the level of pain, ambulation, or aids required between the THR group and the UHR-C group, except for active community ambulators, who demonstrated decreased endurance capability when treated with UHR-C. The patients treated with UHR-NC had increased pain and decreased ambulation and required assistive devices. The most significant complication was dislocation, which occurred in 7 patients with THR and 2 with UHR-C. The mortality rate at 2 years was 18%; all but two of the deaths were in patients with one of five different medical diseases: clinically significant cardiac or pulmonary disease, cancer, alcoholism, or psychosis. The mortality rate was insignificant in patients younger than 70 years of age. Roentgenographic review showed only 2 of 76 cemented stems with progressive cement-bone demarcation, with one patient requiring revision for a loose prosthesis. No evidence of protrusio was seen with the use of the bipolar cap. The uncemented hemiarthroplasties demonstrated lucency between the metal and bone in the proximal femur in 9 of 13 stems. The authors make recommendations regarding hip replacement.

Comparison of the distribution and binding of monoclonal antibodies labeled with 131-iodine or 111-indium

The distribution of two monoclonal antibodies with reactivity against human leukemia/lymphoma associated antigens (BA-1 antibody) and carcinoembryonic antigen (202 antibody) when labeled with 131I or 111In was studied in normal Balb/c mice. The BA-1 antibody of the IgM subclass was labeled with 131I by the micro iodine monochloride method at a 12:1 molar ratio and with 111In by the cyclic DTPA anhydride method at a 10:1 molar ratio. In vitro, the 131I-labeled BA-1 antibody bound 35.5% to 10(7) KM-3 leukemic cells while the 111In-labeled BA-1 antibody bound 29.9% to the same number of KM-3 cells. In vivo, the 111In-labeled BA-1 antibody showed a higher accumulation in liver, spleen, and kidney than the 131I-labeled BA-1 antibody. The 202 antibody of the IgG1 subclass was labeled with 131I at a 5:1 molar ratio and with 111In at a 7:1 molar ratio. In vitro, the 131I-labeled 202 antibody bound 30.9%, 27.4%, and 30.0% to 10(7) CO-112, WIDR, and LS-174T colon cancer cells, respectively. The 111In-labeled 202 antibody bound 20.5%, 30.2%, and 33.6%, respectively to the same number of colon cancer cells. In vivo, the 131I-labeled 202 antibody showed a higher tissue to blood ratio in liver, spleen, and kidney than the 111In-labeled 202 antibody. The data indicate that the relative distribution of 131I-labeled versus 111In-labeled monoclonal antibody may depend on the immunoglobulin subclass of the antibody and the molar ratio used in labeling.

Classification and treatment of dislocations of total hip arthroplasty

A review of 39 dislocations of total hip arthroplasties revealed three causes: positional (Type I); soft tissue imbalance (Type II); and component malposition (Type III). Forty-one percent of hips had a single dislocation, and 59% had multiple dislocations. Reoperation was performed in 42%, with 28%, mostly Type III problems, requiring revision; all had had multiple dislocations. Forty percent of the dislocations resulted in complications that were primarily the result of bedrest for treatment. Based on the cause of dislocation, to reduce complication, component positions are determined by roentgenographic analysis. Positional dislocations (the patient assumes a position that exceeds the mechanical stability of the prosthesis) are treated by four to six weeks' use of the hip brace, which limits flexion and adduction. Soft tissue imbalance, most often a result of failure of fixation of the greater trochanter or an excessive femoral neck cut, can be treated initially by a brace. If recurrent dislocations occur, reattachment of the trochanter and/or revision to a long-neck prosthesis should be considered. Component position errors were successfully treated without revision only if a single acetabular error was present. If the acetabulum is malpositioned in two planes or severe retroversion of the femoral component is present, immediate revision is advisable.

In-111-labeled leukocytes in the diagnosis of rejection and cytomegalovirus infection in renal transplant patients

Indium-111-labeled (In-111) leukocytes have been shown to be useful in the localization of inflammatory processes, including renal transplant rejection. Using previously reported labeling methods, 63 studies with this agent have been performed in 53 renal transplant patients. Indications for study included suspected rejection or cytomegalovirus (CMV) infection. Studies were performed in 33 men and 20 women, with ages ranging from 6 to 68 years. Autologous cells were normally used for labeling, although leukocytes obtained from ABO-compatible donors were used in three subjects. Rectilinear scanner and/or scintillation camera images were obtained at 24 hours after intravenous administration of 0.1 to 0.6 mCi of In-111-leukocytes. There was abnormal uptake of In-111-leukocytes in the transplanted kidney in 11 of 15 cases of rejection. In three additional cases of increased transplant uptake, CMV infection was present in two. Abnormal lung uptake was present in 13 of 14 patients with CMV infection. In four additional cases, increased lung uptake was associated with other pulmonary inflammatory disease. Increased lung activity was not seen in patients with uncomplicated transplant rejection. These results suggest that In-111-leukocyte imaging may be useful in the differential diagnosis of rejection versus CMV infection in renal transplant patients.

Anti-"i" antibody and hemolytic anemia associated with spontaneous cytomegalovirus mononucleosis

Hemolytic anemia occurred in a 23-year-old woman with spontaneous cytomegalovirus mononucleosis who had not received a blood transfusion. The patient's serum gave positive reactions in Coombs' antiglobulin test with human cord erythrocytes but did not react with adult "O" cells. Complement-fixation antibody titers against cytomegalovirus and levels of activity against cord erythrocytes increased as the anemia worsened and remained at high levels when recovery from the anemia occurred.