Outcomes of autologous blood collection prior to bone marrow harvest for matched unrelated donors

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Background: Autologous (auto) blood collection prior to bone marrow (BM) harvest is a common procedure however there is little data to say whether this is beneficial. Methods: This is a retrospective study evaluating the efficacy of pre-op auto blood collection in healthy unrelated donors who underwent BM harvesting at our institution between 9/2009 and 8/2017. Unrelated donors aged 18 or older who underwent their first BM harvest were included. Comparisons were made using two sample t-tests. Results: Among the 73 BM donors, 54 (74%) underwent auto blood collection resulting in 78 units collected. The cohorts with and without auto blood collected were similar in age and gender (mean age 31.0 vs 30.2; female 59% vs 41%). Those with auto blood collected donated larger volumes of marrow (mean 1395 mL vs 799 mL, p = 0.0002). Baseline hemoglobin (Hb) was similar between the cohorts (mean 14.1 g/dL vs 14.0 g/dL, p = 0.87). However, those with auto blood collected had lower pre-harvest (mean 13.1 g/dL vs 13.8 g/dL, p = 0.0430) and post-harvest Hb (mean 10.0 g/dL vs 11.3 g/dL, p = 0.0120). Of the 78 auto blood units collected, 45 units (58%) were used with 92% of women and 56% of men receiving their auto blood post-op. 33 (42%) auto blood units were discarded. Donors who were given back their auto blood were more likely to be female and have lower pre- and post-harvest Hb. Reasons for auto blood transfusion were blood availability (31%), donor post-op symptoms (i.e. hypotension, dizziness, syncope, and bleeding; 23%), intra-operative transient hypotension (26%), post-op anemia (11%) and patient request (9%). None of the patients who were transfused auto blood, or donors without auto blood collection, required allogeneic blood. Conclusions: Based on our results, collection of auto blood prior to bone marrow harvest leads to lower pre-op Hb and increases the likelihood of post-op blood transfusion. In addition, availability of auto blood can lead to over transfusion which may be detrimental to donor health. Although there may be a subset of donors who might benefit, routine auto blood collection prior to bone marrow harvesting is unnecessary and can be potentially hazardous to donors.

A phase II, open-label pilot study evaluating the safety and activity of nal-IRI in combination with 5-FU and oxaliplatin in preoperative treatment of pancreatic adenocarcinoma (NEO-Nal-IRI study)

TPS476

Background: Neoadjuvant treatment for borderline resectable pancreatic cancer (PCa) is increasing in acceptability, but a standard regimen has yet to be established. Multiple studies have demonstrated feasibility and effectiveness of the FOLFIRINOX (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) regimen in the perioperative setting. However, FOLFIRINOX often requires dose modifications, delays and growth factor support due to excessive toxicity which can complicate care delivery when given neoadjuvantly. Irinotecan liposomal injection (Nal-IRI) is FDA approved with a very tolerable safety profile in refractory metastatic PCa. The current study aims to substitute Nal-IRI for traditional irinotecan in the standard FOLFIRINOX regimen and demonstrate safe and effective delivery in the neoadjuvant setting. Methods: This phase II, open-label, single-arm study targets patients with borderline resectable PCa without metastatic disease. Other key eligibility criteria include age ≥ 18 years, measurable disease by RECIST v1.1, adequate cardiac, renal, hepatic function, and Eastern Cooperative Oncology Group performance status of 0 to 1. Patients receive FOLFNal-IRINOX regimen as per table every two weeks for four months followed by disease reassessment. Patients who remain surgical candidates will undergo surgical resection within four to eight weeks following last dose of therapy. The primary endpoint is to assess safety and feasibility of regimen in perioperative setting. Secondary endpoints include R0 resection rate, clinical, biochemical and radiological response rate and patient-reported quality of life as measured by the NCI validated FACT-G scale. Enrollment continues to a maximum of 28 evaluable patients to demonstrate a reduction in historical 30 day postoperative complication rate. FOLFNal-IRINOX regimen. Clinical trial information: NCT03483038. [Table: see text]

Prevalence of enteropathogens in cats with and without diarrhea in four different management models for unowned cats in the southeast United States

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Most cats in shelters, sanctuaries, foster homes, and trap-neuter-return programs carried at least one enteropathogen.

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Tritrichomonas foetus and coronavirus were more common in cats with diarrhea.

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Other bacterial, viral, protozoal, and helminth enteropathogens were present in cats with normal feces and diarrhea.

The objective of this study was to determine the prevalence of enteropathogens in cats with and without diarrhea in four different models for managing unowned cats: short-term animal shelter, long-term sanctuary, home-based foster care, and trap-neuter-return. Fecal samples from 482 cats, approximately half of the cats with normal fecal consistency and half with diarrhea, were tested by zinc sulfate centrifugation and by real-time PCR for a panel of enteropathogens.

At least one enteropathogen of feline or zoonotic importance was detected in a majority of cats, regardless of management model. For most enteropathogens, the presence or absence of diarrhea was not significantly associated with infection, the exceptions being Tritrichomonas foetus in sanctuary cats with diarrhea (26%) and normal fecal consistency (10%), respectively (P ≤ 0.04), and feline coronavirus in foster cats (80% and 58%) (P ≤ 0.001). The types of enteropathogens detected were related to the type of management model, e.g., viral and protozoal infections were most common in shelters, sanctuaries, and foster homes (confinement systems), whereas helminth infections were most common in trap-neuter-return programs (free-roaming cats).

These results suggest that management practices for unowned cats are inadequate for control of enteropathogens and that the presence of diarrhea is a poor indicator of enteropathogen carriage. Risk-management strategies to reduce transmission to people and other animals should focus on sanitation, housing, compliance with preventive care guidelines, periodic surveillance, response to specific enteropathogens, humane population management of free-roaming community cats, public health education, and minimizing the duration and number of cats in mass confinement.

Childhood traumatic experiences and the association with marijuana and cocaine use in adolescence through adulthood

BACKGROUND AND AIMS

Examination of longitudinal relationships between childhood traumatic experiences and drug use across the life-course at the national level, with control of confounding by other forms of trauma, is needed. We aimed to estimate the prevalence of nine typologies of childhood traumas and the cumulative number experienced, correlation between traumas and associations between individual and cumulative number of traumas with drug use during adolescence, emerging adulthood and adulthood.

DESIGN

Secondary data analysis using the National Longitudinal Study of Adolescent to Adult Health.

SETTING

United States.

PARTICIPANTS

A nationally representative sample of individuals in grades 7-12 (aged 11-21 years) during 1994-95, who were re-interviewed during emerging adulthood (2001-02; aged 18-28) and adulthood (2007-08; aged 24-34). The analytical sample comprised 12 288 participants with data at all three waves.

MEASUREMENTS

Nine typologies of childhood traumas: neglect; emotional, physical and sexual abuse; parental incarceration and binge drinking; and witnessing, being threatened with and experiencing violence. Indicators of each were summed to measure cumulative dose. Outcomes were marijuana and cocaine use during adolescence, emerging adulthood and adulthood.

FINDINGS

Approximately half experienced at least one childhood trauma; traumas were not highly correlated. We observed a dose-response relationship between the number of traumas and drug use in adolescence [marijuana, adjusted odds ratio (aOR) one trauma versus none = 1.65, 95% confidence interval (CI) = 1.42, 1.92; two traumas = 2.58, 95% CI = 2.17, 3.06; ≥ four traumas = 6.92, 95% CI = 5.17, 9.26; cocaine, aOR one trauma = 1.87, 95% CI = 1.23, 2.84; two traumas = 2.80, 95% CI = 1.74, 4.51; ≥ four traumas = 9.54, 95% CI = 5.93, 15.38]. Similar dose-response relationships with drug use were observed in emerging adulthood and adulthood. Each individual trauma was associated independently with either marijuana or cocaine use in adolescence, emerging adulthood and/or adulthood.

CONCLUSIONS

Childhood trauma is prevalent in the United States, and individual types as well as the total number experienced are associated significantly with marijuana and cocaine use throughout the life-course.

Child Sexual Abuse and HIV-Related Substance Use and Sexual Risk Across the Life Course Among Males and Females

Child sexual abuse is associated with substance use and sexual risk behaviors during adolescence and adulthood, but no known studies have documented associations across the life course in a nationally representative U.S.

SAMPLE

We used the National Longitudinal Study of Adolescent to Adult Health to measure associations between child sexual abuse and substance use and sexual risk behaviors during adolescence, young adulthood, and adulthood among males and females (n = 11,820). Approximately 10% of females and 7% of males reported child sexual abuse. Associations with substance use were strongest during adolescence and lessened over time. Increased odds of sexual risk among those with a history of child sexual abuse remained consistent through the life course. Significant gender differences existed for some associations (e.g., adulthood multiple partners: males adjusted odds ratio (AOR) = 1.73, 95%CI:1.18, 2.53; females AOR = 1.11, 95%CI:0.79, 1.56). Trauma-informed prevention interventions should address child sexual abuse among both males and females to prevent substance use and sexual risk behavior throughout the life course.

The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use

BACKGROUND

We examined associations between childhood trauma and adulthood prescription pain reliever misuse (PPRM) and injection drug use (IDU) in a nationally-representative U.S. sample to further understanding of factors associated with these epidemics.

METHODS

National Longitudinal Study of Adolescent to Adult Health data (N=12,288) yielded nine childhood traumas: neglect; emotional, physical, sexual abuse; parental incarceration and binge drinking; witnessed, threatened with, and experienced violence. We estimated adjusted odds ratios (AOR) and 95% confidence intervals for the association of each trauma and cumulative trauma and drug initiation in emerging and later adulthood.

RESULTS

Outcome prevalences were 20% (PPRM) and 1% (IDU) in emerging adulthood and 10% PPRM in adulthood. We observed dose-response relationships that varied across outcomes. Cumulative trauma (referent=none) was associated with 34-79% greater odds of PPRM (emerging adulthood) across one to five+ trauma categories. The gradient was most consistent and associations strongest for adulthood PPRM: one trauma AOR=1.46(1.12, 1.91); two AOR=1.71(1.23, 2.36); three AOR=2.16(1.43, 2.36); four AOR=2.70(1.42, 5.62); five+ AOR=3.09(1.52, 6.30). Dose-response was less consistent for IDU, but 4 and 5+ traumas were associated with approximately seven and five times the odds of IDU. Neglect, emotional abuse, and parental incarceration and binge drinking were associated with 25-55% increased odds of PPRM. Sexual abuse and witnessed violence were associated with nearly 3 and 5 times the odds of IDU.

CONCLUSIONS

Associations between childhood trauma and PPRM/IDU highlight the need for trauma-informed interventions for drug users and early trauma screening and treatment for prevention of drug misuse over the life course.

Effects of different orthodontic retention protocols on the periodontal health of mandibular incisors

OBJECTIVES

To test the following two hypotheses: 1) different types of retainers result in distinct levels of biomarkers in gingival crevicular fluid (GCF) and 2) the retainer bonded to all mandibular anterior teeth induces more detrimental outcomes to the periodontium.

SETTING AND SAMPLE POPULATION

The Department of Orthodontics at the University of Florida. The population consisted of individuals in the retention phase of orthodontic treatment.

MATERIAL AND METHODS

This was a cross-sectional study that enrolled 36 individuals. Subjects in group 1 had retainers bonded to the mandibular canines only. Group 2 consisted of individuals having retainers bonded to all mandibular anterior teeth. Group 3 included patients using mandibular removable retainers. After clinical examination, GCF was collected from the mandibular incisor and biomarker levels were compared between the groups.

RESULTS

Plaque accumulation and gingivitis differed significantly among groups, with the highest median values in group 2 subjects. Pairwise comparison of the groups with respect to gingivitis showed significant differences between groups 1 and 2. Significant differences among groups were detected for RANKL, OPG, OPN, M-CSF, MMP-3, and MMP-9. The ratio RANKL/OPG was significantly higher in group 2 subjects, with pairwise comparisons indicating that groups 1 and 2 differed from group 3.

CONCLUSION

An association was found between orthodontic retention groups and GCF biomarker levels, which should be further explored in longitudinal studies. The presence of retainers bonded to all anterior teeth seems to increase plaque accumulation and gingivitis.

A prospective randomized clinical trial into the capacity of a toothpaste containing NovaMin to prevent white spot lesions and gingivitis during orthodontic treatment

Background

White spot lesions and gingivitis represent common, yet challenging, dilemmas for orthodontists. Fluoride has shown some benefit as a protective measure against demineralization; however, this is usually insufficient for orthodontic patients with less than ideal oral hygiene. Dentifrices containing calcium sodium phosphosilicate bioactive glass (NovaMin) have been proposed to aid in prevention of white spot lesions and gingival inflammation. Thus, the purpose of this study was to determine if the use of NovaMin reduces the formation of white spot lesions and improves gingival health in orthodontic patients.

Methods

This was a prospective, double-blind, randomized controlled trial. Forty-eight patients undergoing orthodontic treatment were randomly allocated to two groups. The control group consisted of 24 patients who received over-the-counter fluoride toothpaste (Crest®), while the study group consisted of 24 patients who were given the test dentifrice (ReNew™) containing 5 % NovaMin and fluoride. Patients were followed up for 6 months on a monthly basis. Decalcification, gingival health, plaque, and bacteria levels were evaluated every 3 months. Statistical analysis was performed using both parametric and non-parametric tests to identify differences between groups at different time points.

Results

There were no significant differences between the groups in regard to changes in white spot lesions, plaque, or gingival health (P > 0.05). There was a trend toward improvement in white spot lesions found in subjects using Crest® at the 3-month time point; however, this was not sustained throughout the study.

Conclusions

Our results indicate that a toothpaste containing NovaMin does not differ significantly compared to traditional fluoride toothpaste for improving white spot lesions and gingivitis in orthodontic patients.

Variables affecting orthodontic tooth movement with clear aligners

INTRODUCTION

In this study, we examined the impacts of age, sex, root length, bone levels, and bone quality on orthodontic tooth movement.

METHODS

Clear aligners were programmed to move 1 central incisor 1 mm over the course of 8 weeks. Thirty subjects, ages 19 to 64, were enrolled, and measurements were made on digital models (percentage of tooth movement goal achieved). Morphometric features and bone quality were assessed with cone-beam computed tomography. Data from this study were combined with data from 2 similar studies to increase the power for some analyses.

RESULTS

The mean percentage of tooth movement goal achieved was 57% overall. Linear regression modeling indicated a cubic relationship between age and tooth movement, with a decreasing rate of movement from ages 18 to 35 years, a slightly increasing rate from ages 35 to 50, and a decreasing rate from ages 50 to 70. The final decreasing trend was not apparent for women. As would be expected, the correlation was significant between the percentage of the goal achieved and the cone-beam computed tomography superimposed linear measures of tooth movement. A significant negative correlation was found between tooth movement and the measurement apex to the center of rotation, but bone quality, as measured by fractal dimension, was not correlated with movement.

CONCLUSIONS

The relationship between age and tooth movement is complex and might differ for male and female patients. Limited correlations with cone-beam computed tomography morphology and rate of tooth movement were detected.

Prevalence of serum antibody titers against feline panleukopenia virus, feline herpesvirus 1, and feline calicivirus in cats entering a Florida animal shelter

OBJECTIVE

To determine the proportion of cats entering a Florida animal shelter with serum antibody titers against feline panleukopenia virus (FPV), feline herpesvirus 1 (FHV1), and feline calicivirus (FCV) and to identify factors associated with seropositivity.

DESIGN

Cross-sectional study.

ANIMALS

347 cats admitted to a Florida animal shelter.

PROCEDURES

Within 24 hours after admission to the animal shelter, blood samples were collected from all cats ≥ 8 weeks of age. Serum antibody titers against FPV were determined via a hemagglutination inhibition assay, and those against FHV1 and FCV were determined via virus neutralization assays. Age, sex, environment (urban or rural), source (stray or previously owned), evidence of previous caregiving, health status (healthy or not healthy), and outcome (adoption, transfer, return to owner, or euthanasia) were evaluated as potential factors associated with antibody seropositivity.

RESULTS

Of 347 cats, 138 (39.8%), 38 (11.0%), and 127 (36.6%) had antibody titers ≥ 40, ≥ 8, and ≥ 32 (ie, seropositive) against FPV, FHV1, and FCV, respectively. Factors associated with seropositivity included being neutered, age ≥ 6 months, and being relinquished by an owner. On multivariable analysis, health status at shelter admission, environment, vaccination at shelter admission, and outcome were not associated with seropositivity.

CONCLUSIONS AND CLINICAL RELEVANCE

Most cats were seronegative for antibodies against FPV, FHV1, and FCV at the time of admission to an animal shelter. These findings supported current guidelines that recommend vaccination of all cats immediately after admission to animal shelters, regardless of the source or physical condition.

Monitoring uterine activity during labor: a comparison of 3 methods

OBJECTIVE

Tocodynamometry (Toco; strain gauge technology) provides contraction frequency and approximate duration of labor contractions but suffers frequent signal dropout, necessitating repositioning by a nurse, and may fail in obese patients. The alternative invasive intrauterine pressure catheter (IUPC) is more reliable and adds contraction pressure information but requires ruptured membranes and introduces small risks of infection and abruption. Electrohysterography (EHG) reports the electrical activity of the uterus through electrodes placed on the maternal abdomen. This study compared all 3 methods of contraction detection simultaneously in laboring women.

STUDY DESIGN

Upon consent, laboring women were monitored simultaneously with Toco, EHG, and IUPC. Contraction curves were generated in real-time for the EHG, and all 3 curves were stored electronically. A contraction detection algorithm was used to compare frequency and timing between methods. Seventy-three subjects were enrolled in the study; 14 were excluded due to hardware failure of 1 or more of the devices (n = 12) or inadequate data collection duration (n = 2).

RESULTS

In comparison with the gold-standard IUPC, EHG performed significantly better than Toco with regard to the Contractions Consistency Index (CCI). The mean CCI for EHG was 0.88 ± 0.17 compared with 0.69 ± 0.27 for Toco (P < .0001). In contrast to Toco, EHG was not significantly affected by obesity.

CONCLUSION

Toco does not correlate well with the gold-standard IUPC and fails more frequently in obese patients. EHG provides a reliable noninvasive alternative, regardless of body habitus.

Orthodontic tooth movement with clear aligners

Clear aligners provide a convenient model to measure orthodontic tooth movement (OTM). We examined the role of in vivo aligner material fatigue and subject-specific factors in tooth movement. Fifteen subjects seeking orthodontic treatment at the University of Florida were enrolled. Results were compared with data previously collected from 37 subjects enrolled in a similar protocol. Subjects were followed prospectively for eight weeks. An upper central incisor was programmed to move 0.5 mm. every two weeks using clear aligners. A duplicate aligner was provided for the second week of each cycle. Weekly polyvinyl siloxane (PVS) impressions were taken, and digital models were fabricated to measure OTM. Initial and final cone beam computed tomography (CBCT) images were obtained to characterize OTM. Results were compared to data from a similar protocol, where subjects received a new aligner biweekly. No significant difference was found in the amount of OTM between the two groups, with mean total OTM of 1.11 mm. (standard deviation (SD) 0.30) and 1.07 mm. (SD 0.33) for the weekly aligner and biweekly control groups, respectively (P = 0.72). Over eight weeks, in two-week intervals, material fatigue does not play a significant role in the rate or amount of tooth movement.

Racial disparity in oral and pharyngeal cancer in Florida in 1991-2008: mixed trends in stage of diagnosis

OBJECTIVES

To explore changes in distribution of stage at diagnosis among individuals with oral and pharyngeal cancers over the past two decades and whether the changes differ by race.

METHODS

We obtained 1991-2008 cancer incidence data for nine anatomic sites of the oral and pharyngeal structure from the Florida Cancer Data System. These cancers were grouped into oral squamous cell carcinoma (SCC), pharyngeal SCC, and other head and neck cancers. Annual percent change was calculated for each group to characterize trends in age-adjusted cancer incidence over time by race and stage at diagnosis.

RESULTS

During 1991-2008, the overall age-adjusted oral SCC incidence was decreasing for both races, with a greater decline observed among Blacks. There was a large drop in incidence of regional-stage diagnoses among Blacks. For pharyngeal SCC, the age-adjusted incidence of localized- and regional-stage diagnoses was increasing for Whites during 1991-2008, with the largest increase in the incidence of regional-stage diagnoses. The percentage of localized-stage diagnoses was increasing for both races for oral SCC. A slight increase in percentage of localized-stage diagnoses was observed for Blacks for pharyngeal SCC, whereas no obvious change was observed among Whites.

CONCLUSIONS

Blacks continued to have lower percentages of localized-stage diagnoses than Whites for nearly all sites, but an increasing percentage of localized-stage diagnoses was observed for oral SCC among Blacks. For pharyngeal SCC, the increase in incidence among Whites was accompanied by an increasing percentage of late-stage diagnoses. Coordinated public health approaches with a special emphasis on screening underserved populations are needed.

Parental perception vs. professional assessment of speech changes following premature loss of maxillary primary incisors

PURPOSE

This study's purpose was to compare parental perceptions of children's speech changes with a professional speech assessment following premature extractions of maxillary primary incisors (PEMPI).

METHODS

Healthy 5- to 6-year-olds, with no cognitive and speech delay and who received PEMPI between the ages of 2 and 4 years old at a university-based clinic, were recruited for the study. First, their parents took part in a telephone interview regarding their perceptions of speech changes following the extractions. The children were then invited to undergo individual speech evaluations by a certified speech and language pathologist.

RESULTS

Of 204 patients identified from the database, 57 parental interviews were completed. Sixty percent (34) felt their children sounded different following extractions, and 65% (37) reported difficulty with pronunciation of the "s" sound. For children who were perceived by their parents to sound different, 46% had problems pronouncing words with the letters s and z. For parents who did not perceive speech changes, none of the children had problems with s and z as determined by the professionally conduced speech evaluations (Fisher exact test P=.02).

CONCLUSIONS

Children who undergo premature extractions of maxillary primary incisors show problems articulating words containing s and z, and there is an agreement between parental perceptions and actual disarticulations detected from a professional assessment.

A randomized, placebo-controlled clinical trial on the effects of recombinant human relaxin on tooth movement and short-term stability

INTRODUCTION

Moving teeth rapidly and avoiding posttreatment relapse are fundamental goals of orthodontic treatment. In-vitro and animal studies suggest that the human hormone relaxin might increase the rate of movement and the stability through its effect on the periodontal ligament. The purpose of this study was to compare relaxin and a placebo with regard to tooth movement and stability in human subjects.

METHODS

A single-center, blinded, placebo-controlled, randomized clinical trial was used to examine the effect of relaxin on tooth movement and stability. Forty subjects were randomized 1:1 and received weekly injections of 50 μg of relaxin or a placebo for 8 weeks. Aligners programmed to move a target tooth 2 mm during treatment were dispensed at weeks 0, 2, 4, and 6. Movement was measured weekly on polyvinyl siloxane impressions that were scanned and digitized. The subjects were followed through week 12 to assess relapse.

RESULTS

Tooth movement over the 8-week treatment period did not differ by treatment group (P = 0.995). By using an intent-to-treat analysis, we found that the mean tooth movement for both groups was 0.83 mm (SE, 0.08 for relaxin and 0.09 for the placebo). Relapse from weeks 8 to 12 was the same in both groups (P = 0.986), and the mean was -0.75 (SE, 0.07 for relaxin and 0.08 for theplacebo).

CONCLUSIONS

No differences in tooth movement over 8 weeks of treatment or relapse at 4 weeks posttreatment were detected when comparing subjects who received weekly injections of relaxin with those who received a placebo. In both groups, an average of less than half of the programmed tooth movement was obtained after 8 weeks of treatment. The local doses of relaxin might have been too low to affect tooth movement or short-term relapse.

Intrarater agreement about the etiology of Class II malocclusion and treatment approach

INTRODUCTION

The management of patients with Class II malocclusion has been an ongoing discussion in orthodontics. The aim of this study was to determine whether orthodontists agree among themselves and with each other about the etiology, timing, and difficulty of treating subjects with Class II malocclusion.

METHODS

The initial records of 159 Class II subjects were sent to 8 orthodontists. In this sample, duplicate records of 18 subjects were dispersed. A questionnaire was sent with the records.

RESULTS

The intrarater consistency values were 65% when determining the type of malocclusion, 60% when deciding which arch was at fault, and 81% when determining the need for immediate treatment. Consistency values were 33% regarding case difficulty and 77% regarding phase 2 treatment need. There was a significant negative correlation between the consistency of the orthodontists' responses and the peer assessment rating score.

CONCLUSIONS

We found that practitioners had only moderate agreement among themselves when diagnosing a patient's type of malocclusion and which arch was at fault when a skeletal discrepancy was noted. Intrarater agreement improved as the peer assessment rating score increased, but the correlation was weak, and this was not consistent for all examiners. Because of insufficient intrarater agreement, interrater agreement was not examined.

Trends in incidence of oral and pharyngeal carcinoma in Florida: 1981-2008

OBJECTIVE

While the overall incidence rates of oral and pharyngeal squamous cell carcinoma (SCC) have decreased in the United States, there is evidence of increasing incidence at selected anatomic sites, particularly among younger adults. The objective of this study was to examine trends in incidence rates of oral and pharyngeal cancers in Florida.

METHODS

Using data from the Florida Cancer Data System, we examined the incidence of oral and pharyngeal carcinomas in Florida from 1981 through 2008. Factors of interest included sex, race, and trends over time. Percent change (PC) and annual percent change (APC) were computed to characterize trends over time.

RESULTS

A total of 53,648 cases of oral or pharyngeal cancer were identified from 1981 through 2008. Significant increasing trends were observed only for pharyngeal cancers in males, with significant decreasing trends for pharyngeal cancer in females and oral cancer for both sexes. For tonsil and base of tongue cancers, increasing trends were detected for white males only. Further investigation among white males showed that, except for base of tongue cancer in the 20-44 age group, the incidence of both cancers increased across all age groups, with the largest increase for both sites found in the 45-64 age group.

CONCLUSIONS

This study supports the finding of increasing incidence of SCC of the tonsil and base of tongue in males, in contrast to decreasing trends for most oral and pharyngeal carcinomas. However, we observed that this increase occurred in white males only and the most dramatic increase occurred in the 45-64 age group.

The High School Experience

Results of the Florida High School Exit Survey collected in 2006–2007 and 2007–2008 are presented. Participants include 2,520 students with and without disabilities across 40 school districts. Survey items cover questions relating to employment, postsecondary education and training, daily living, quality of life, agency connections, in-school experiences, and school-based work experiences. Findings suggest that students with disabilities feel better about knowing what they want to do after high school and how to achieve their goals but have few interactions with friends in social activities. Conversely, students without disabilities feel better prepared academically and participate more with friends in social activities. Identifying these trends can assist districts in improving school programs and student outcomes.

Effects of analgesics on orthodontic pain

INTRODUCTION

Our objective was too assess the effectiveness of 3 analgesics (ibuprofen, naproxen sodium, and acetaminophen) and a placebo administered before and after the placement of separators in reducing the severity of postseparator placement pain. We also examined the impact of treatment on chewing efficiency at 24 hours after separator placement.

METHODS

Twenty-four subjects participated in the study. Each subject received 3 of 4 treatments: ibuprofen, naproxen sodium, acetaminophen, or placebo in random order at monthly intervals. The dosing times were 1 hour before separator placement and 3 and 7 hours after separator placement. Before placement, the subjects completed a masticatory efficiency test and a visual analog scale (VAS) for expected pain and pain experienced. A VAS pain diary was kept for 24 hours. Subjects returned to the clinic after 1 week for separator removal.

RESULTS

VAS pain summary scores after separator placement were significantly affected by the administration of ibuprofen (P = 0.0298) and the time after separator placement (P <0.0001). Administering ibuprofen before and after separator placement significantly reduced pain compared with the placebo. The analgesic effects diminished by day 2, resulting in peak pain levels and decreased chewing efficiency. The expected pain after separator placement also played a role in experienced pain; subjects expecting more pain experienced more pain.

CONCLUSIONS

Ibuprofen was superior to the placebo in relieving postseparator pain as measured by the VAS pain summary scores, whereas acetaminophen and naproxen sodium did not significantly differ from the placebo.

An intravascular ultrasound analysis in women experiencing chest pain in the absence of obstructive coronary artery disease: a substudy from the National Heart, Lung and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE)

AIMS

Using intravascular ultrasound (IVUS), we sought to characterize coronary morphology in women with chest pain without major epicardial obstructive coronary artery disease (CAD). We have previously observed an unexpectedly high rate of adverse outcomes among women with chest pain and normal or insignificant obstructive CAD. Information about the presence and characteristics of coronary atherosclerosis in these women could provide insight into the mechanisms related to increased risk, as well as improved diagnosis, prevention, and treatment.

METHODS

Women (n = 100) with suspected ischemia without obstructive CAD (>50% stenosis) underwent IVUS of a left coronary segment with measurements by a core lab masked to clinical and angiographic findings.

RESULTS

Angiograhic core lab analysis found 69.6% of patients had no (≤20%) and 30.4% had minimal (20-<50%) CAD. IVUS segmental images were interpretable by the core lab in 92 women, with 19 (21%) having no atherosclerosis (intimal-medial thickness <0.5 mm). In the remaining 73 women (79%), percent atheroma volume was 27 ± 8% and mean maximum plaque thickness was 0.53 ± 0.22 mm. Thirty-eight women with atherosclerosis (53%) had ≥30% of interrogated vessel involved. The average vessel involvement was 40%, and the maximum plaque thickness was 1.27 mm. The number of risk factors strongly correlated with percent atheroma volume (r = 0.53, P < 0.0001) and percent vessel involvement (r = 0.51, P < 0.0001), with the strongest independent predictor of both being age. Remodeling was assessed in 59/73 women (81%), and 73% had evidence of positive remodeling.

CONCLUSIONS

In symptomatic women without significant luminal obstructive CAD, we observed a high prevalence of atherosclerosis with positive remodeling and preserved lumen size. These findings may help explain increased risk and emphasize need for improved diagnostic and treatment options for women with concealed CAD.

Otologic and audiologic outcomes with the Furlow and von Langenbeck with intravelar veloplasty palatoplasties in unilateral cleft lip and palate

OBJECTIVE

Cleft palate increases the risk of chronic middle ear disease and hearing loss. The goal of this report was to determine which of two palate surgeries and which timing of palate surgery were associated with better otologic and audiologic outcomes in children with unilateral cleft lip and palate at 5 to 6 years of age.

DESIGN

Subjects were randomly assigned to the von Langenbeck with intravelar veloplasty or Furlow palate repair, to palate surgery at 9 to 12 months or 15 to 18 months of age, and to the Spina or Millard lip repair.

SETTING

Centralized, tertiary care craniofacial treatment center.

PATIENTS

A total of 673 infants with unilateral cleft lip and palate.

INTERVENTIONS

Palate and lip were repaired using established techniques. Serial otoscopic and audiometric evaluations were performed.

MAIN OUTCOME MEASURES

Hearing and otoscopic findings at 5 to 6 years old.

RESULTS

There were 370 children available for analysis. Hearing and need for tympanostomy tube placement did not differ by palatoplasty, age at palatoplasty, cheiloplasty, or surgeon. Risk of developing cholesteatoma or perforation was higher with Millard cheiloplasty (odds ratio  =  5.1, 95% confidence interval  =  1.44 to 18.11, p  =  .012). Type and age at palatoplasty were not significantly associated with either the rate of developing these sequelae or the rate of achieving bilaterally normal hearing and ear examinations.

CONCLUSIONS

Type of palatoplasty did not influence otologic and audiologic outcomes in 5- to 6-year-olds with unilateral cleft lip and palate. The potential influence of lip repair on otologic outcomes warrants further investigation.

Lipid-lowering medication use and aggression scores in women: a report from the NHLBI-sponsored WISE study

AIM

The aim of this study was to examine the association between the use of lipid-lowering medication and aggressive responding, hostility, cynicism, and depression scores in women undergoing coronary angiography.

METHODS

The cohort included 498 women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. WISE is a four-center study of women with chest pain who underwent quantitative coronary angiography for suspected myocardial ischemia. The psychosocial indices included the Cook Medley Hostility questionnaire, measuring aggression, hostility, and cynicism, and the Beck Depression Inventory (BDI).

RESULTS

Compared to those not on lipid-lowering medication, women receiving lipid-lowering pharmacotherapy were older (62 vs. 55 years, p < 0.001) and had more hypertension, dyslipidemia, diabetes, and coronary artery disease (CAD, defined as > or =50% stenoses in at least one epicardial artery) (all p < 0.003). Women on lipid-lowering medication had higher aggressive responding scores than those not on medication, 3.0 +/- 1.8 vs. 2.7 +/- 1.7, respectively (age-adjusted p < 0.003). This association persisted after adjustment for coronary risk factors, education, and extent of angiographic disease (CAD) (p < 0.005), and after exclusion of women using psychotropic medications (p < 0.001). Hostility, cynicism, and depression scores did not differ by medication use.

Effect of early treatment on stability of occlusion in patients with Class II malocclusion

INTRODUCTION

The purpose of this study was to evaluate the effect of early treatment on the stability of occlusion in patients with Class II malocclusions. The peer assessment rating (PAR) index was used to evaluate changes in occlusion after treatment of subjects treated in 1 phase or 2 phases. This study was a prospective, randomized, controlled clinical trial.

METHODS

Dental casts were obtained from the participants, who were randomized into 3 phase-1 early treatment groups: bionator, headgear/bite plane, or observation. Phase 2 consisted of continued treatment of the bionator and the headgear/biteplane subjects and comprehensive treatment of the observation subjects. PAR scores were obtained for 208 subjects at end of treatment; 173 (83%) had at least 1 follow-up visit, with a median follow-up time of 5.0 years. PAR scores were calculated for each subject at key treatment and posttreatment time points. Linear mixed-effect models were used to evaluate the impact of phase-1 treatment group, years posttreatment, end of treatment PAR score, and other covariates that could affect stability on the posttreatment PAR score.

RESULTS

Factors significantly affecting posttreatment PAR scores were PAR score at end of treatment (P <.0001), years posttreatment (P =.0064), and PAR score at the start of phase 2. Although phase-1 treatment was not statistically significant, those with early treatment had lower PAR scores at the start of phase 2 than the observation subjects (means [SD]: bionator 17.5 [7.4], headgear/biteplane 15.3 [7.0], observation 22.2 [8.6], P <.0001). Thus, early treatment had an indirect effect.

CONCLUSIONS

Factors that affect posttreatment PAR score stability include PAR score at the end of treatment, years posttreatment, and PAR score at the start of phase-2 treatment. The early treatment modalities have limited positive impact on posttreatment stability PAR scores in Class II malocclusion patients due to their effect on PAR scores at the start of phase-2 treatment.

Phytoestrogens and Coronary Microvascular Function in Women with Suspected Myocardial Ischemia: A Report from the Women's Ischemia Syndrome Evaluation (WISE) Study

AIMS

Soy phytoestrogens are popular, but information on their coronary effects in patients with suspected ischemic heart disease is limited. Accordingly, we investigated the relationship between blood phytoestrogen levels and coronary reactivity in women with suspected myocardial ischemia referred for coronary angiography.

METHODS

Coronary flow velocity reserve (CFVR) and volumetric flow reserve (VFR) to adenosine (ADO) and nitroglycerin (NTG) (nonendothelial-dependent responses) and acetylcholine (ACH) (endothelial-dependent response) were assessed in 106 women from the Women's Ischemia Syndrome Evaluation (WISE). Blood phytoestrogen (daidzein and genistein) and estrogen (estradiol) levels were correlated with coronary reactivity measures.

RESULTS

Participants were mostly postmenopausal (79%), mean age 56 years, and 24% had obstructive coronary artery disease (CAD) at angiography. Genistein blood levels were negatively correlated with nonendothelial-dependent coronary flow responses. The highest genistein tertile (>6.1 ng/mL) had a CFVR of 2.1 +/- 0.5 (mean +/- SD) and VFRADO of 1.0 +/- 0.6, and both were significantly (p= 0.0001) lower compared with the other genistein tertiles combined. Similar associations were noted for CFVR(NTG) and VFR(NTG) (p = 0.03 and p = 0.01, respectively). The highest genistein tertile was associated with lower CFVR(ACH) compared with the other tertiles (p = 0.03). In multivariable modeling, blood genistein levels were significant independent predictors of coronary flow responses to ADO. There were no significant correlations between coronary reactivity variables and daidzein or endogenous estrogen.

CONCLUSIONS

In women with suspected myocardial ischemia, higher genistein blood levels are associated with impaired nonendothelial-dependent and endothelial-dependent coronary microvascular function.

Coronary microvascular reactivity is only partially predicted by atherosclerosis risk factors or coronary artery disease in women evaluated for suspected ischemia: results from the NHLBI Women's Ischemia Syndrome Evaluation (WISE)

BACKGROUND

Altered coronary reactivity is frequent in women with findings of myocardial ischemia without significant obstructive disease. This suggests a defect in coronary microvascular function. The adenosine-related component of this altered reactivity has been described in male and mixed gender populations, while the factors influencing this component of coronary reactivity in symptomatic women have received limited attention. Accordingly, the relationship between adenosine-related microvascular coronary reactivity and risk factors in symptomatic women evaluated for suspected ischemia remains uncertain.

HYPOTHESIS

Abnormal coronary microvascular reactivity to adenosine is predicted by atherosclerosis risk factors in women.

METHODS

As part of the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE), we investigated the relationship between risk factors and coronary microvascular reactivity as flow velocity reserve to intracoronary adenosine (CFVR(Ado)) in 210 women referred for angiography to evaluate suspected ischemia.

RESULTS

Univariate analyses identified associations between CFVR(Ado) and multiple risk conditions; however, after adjusting for age, none remained significant. The best multivariable model using combinations of risk conditions to predict CFVR(Ado) yielded an R2 of only 0.18.

CONCLUSIONS

Among women with suspected ischemia, risk factors account for <20% of observed variability in CFVR(Ado). Therefore, other as yet unidentified factors must primarily account for coronary microvascular reactivity to adenosine.

A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment

INTRODUCTION

The aim of this study was to evaluate the differences in quality of life impacts between subjects treated with Invisalign aligners (Align Technology, Santa Clara, Calif) and those with fixed appliances during the first week of orthodontic treatment.

METHODS

A prospective, longitudinal cohort study involving 60 adult orthodontic patients (33 with Invisalign aligners, 27 with fixed appliances) was completed by using a daily diary to measure treatment impacts including functional, psychosocial, and pain-related outcomes. A baseline survey was completed before the start of treatment; diary entries were made for 7 consecutive days to measure various impacts of the subjects' orthodontic treatment over time. The data were then analyzed for differences between treatment modalities in terms of the subjects' reported impacts from their orthodontic treatment.

RESULTS

The baseline mean values did not differ between groups for pain reports (P = .22) or overall quality of life impact (P = .51). During the first week of treatment, the subjects in the Invisalign group reported fewer negative impacts on overall quality of life (P <.0001). The Invisalign group also recorded less impact in each quality of life subscale evaluated (functional, psychosocial, and pain-related, all P <.003). The visual analog scale pain reports showed that subjects in the Invisalign group experienced less pain during the first week of treatment (P <.0001). The subjects in the fixed appliance group took more pain medications than those in the Invisalign group at days 2 and 3 (both P <.007).

CONCLUSIONS

Adults treated with Invisalign aligners experienced less pain and fewer negative impacts on their lives during the first week of orthodontic treatment than did those treated with fixed appliances.

Perceptions of Orthognathic Surgery Patient's Change in Profile

Objectives: To compare pairs of silhouettes generated from presurgical and 5-year postsurgical cephalometric radiographs to evaluate whether orthodontists, oral surgeons, and lay persons perceive changes in profile resulting from orthodontics and mandibular advancement surgical treatment.

Materials and Methods: A survey-based method of data collection was used to evaluate 15 pairs of silhouettes. These silhouettes included 1 control pair and 14 surgically treated pairs representing mandibular advancements ranging from 0.11 mm to 10.13 mm. Collected data were analyzed to determine whether changes can be perceived and whether these changes were esthetically pleasing.

Results: The control silhouette pair was identified by 104 of 127 evaluators. For the 14 surgical treated silhouette pairs, the vast majority of evaluators (N = 127; 53 orthodontists, 32 oral surgeons, and 42 lay persons) were able to identify changes in profile and individual features. At least one group of evaluators was able to perceive significant (P &lt; .05) improvement in the visual analog scale (VAS) score for all these silhouette pairs, except for the pair with 10.13 mm of mandibular advancement. This silhouette pair, which represented the largest mandibular advancement, was perceived to have a significant (P &lt; .05) worsening in the VAS score by the lay person group. There were significant differences among the groups of evaluators. Esthetic improvement in profile was perceived for 13 of 14 surgically treated silhouette pairs.

Conclusion: In some cases, orthodontists, oral surgeons, and lay persons perceived changes in profile differently.

Preparation and Anesthetic Properties of Propofol Microemulsions in Rats

Background

The lipophilicity of propofol has required dispersion in a soybean macroemulsion. The authors hypothesized that the anesthetic properties of propofol are preserved when reformulated as a transparent microemulsion rather than as a turbid macroemulsion and that the dose-response relation can be selectively modified by altering the microemulsion's surfactant type and concentration.

Methods

Microemulsions of propofol were formulated using purified poloxamer 188 (3%, 5%, 7%), and sodium salt of fatty acids (C(8), C(10), C(12)) in saline and characterized using ternary/binary diagrams, particle sizing, and stability upon dilution. Rats received propofol (10 mg . kg(-1) . min(-1)) as either a microemulsion or a conventional macroemulsion to determine these end points: induction (dose; stunned; loss of lash reflex, righting reflex, withdrawal to toe pinch) and recovery (recovery of lash, righting, withdrawal reflexes). After a 14-day recovery period, rats were crossed over into the opposite experimental limb.

Results

Forty-eight microemulsions (diameter, 11.9-47.7 nm) were formulated. Longer carbon chain length led to a marked increase in the volume of diluent necessary to break these microemulsions. All rats experienced anesthetic induction with successful recovery, although significantly greater doses of propofol were required to induce anesthesia with microemulsions irrespective of surfactant concentration or type than with macroemulsions. The sodium salt of C10 fatty acid microemulsion required the greatest dose and longest time for anesthetic induction.

Conclusion

Propofol microemulsions cause induction in rats similar to that from macroemulsions. The surfactant concentration and type markedly affect the spontaneous destabilization and anesthetic properties of microemulsions, a phenomenon suggesting a mechanism whereby dose-response relation can be selectively modified.

Mental stress provokes ischemia in coronary artery disease subjects without exercise- or adenosine-induced ischemia

OBJECTIVES

The purpose of this study was to investigate the possibility that some patients with coronary artery disease (CAD) but negative exercise or chemical stress test results might have mental stress-induced ischemia. The study population consisted solely of those with negative test results.

BACKGROUND

Mental stress-induced ischemia has been reported in 20% to 70% of CAD subjects with exercise-induced ischemia. Because mechanisms of exercise and mental stress-induced ischemia may differ, we studied whether mental stress would produce ischemia in a proportion of subjects with CAD who have no inducible ischemia with exercise or pharmacologic tests.

METHODS

Twenty-one subjects (14 men, 7 women) with a mean age of 67 years and with a documented history of CAD were studied. All subjects had a recent negative nuclear stress test result (exercise or chemical). Subjects completed a speaking task involving role playing a difficult interpersonal situation. A total of 30 mCi 99mTc-sestamibi was injected at one minute into the speech, and imaging was started 40 min later. A resting image obtained within one week was compared with the stress image. Images were analyzed for number and severity of perfusion defects. The summed difference score based on the difference between summed stress and rest scores was calculated. Severity was assessed using a semiquantitative scoring method from zero to four.

RESULTS

Six of 21 (29%) subjects demonstrated reversible ischemia (summed difference score > or =3) with mental stress. No subject had chest pain or electrocardiographic changes during the stressor. Mean systolic and diastolic blood pressure and heart rate all increased between resting and times of peak stress.

CONCLUSIONS

Mental stress may produce ischemia in some subjects with CAD and negative exercise or chemical nuclear stress test results.

Centrographic analysis of 1-phase versus 2-phase treatment for Class II malocclusion

INTRODUCTION

Cephalometric analyses have been used by orthodontists to track growth and monitor treatment effects. Most of these analyses have normative values to which patients are compared, but some "normal" patients vary quite a bit from the normative values. The centrographic analysis is a visual analysis with no angles to measure or normative values to compare. After a reference plane is developed, the relative position of variable landmarks can be seen.

METHODS

We used the centroid centrographic analysis to study the effects of 1-phase and 2-phase orthodontic treatment. Phase 1 treatment consisted of bionator (n = 66), headgear/biteplane (n = 69), or observation (n = 65) until a Class I molar relationship was achieved or 2 years had elapsed. After 1 year, all subjects underwent full orthodontic treatment with fixed appliances.

RESULTS

Centrographic analysis showed that early treatment has effects on the mandible. However, the differences were not apparent by the end of fixed appliance treatment.

CONCLUSIONS

The skeletal effects of phase 1 treatment disappear by the end of fixed appliance treatment.

Depressive Symptoms and Heart Rate Variability in Postmenopausal Women

BACKGROUND

Depressive symptoms have been associated with increased cardiac morbidity and mortality rates, but the pathophysiologic mechanism linking depressive symptoms to cardiovascular outcome has yet to be fully understood. Lower heart rate variability has also been associated with increased risk of cardiac events in healthy individuals and in patients with coronary artery disease. Findings regarding a relationship between depressive symptoms and heart rate variability that could explain increased cardiovascular risk have been inconsistent across studies.

METHODS

As an ancillary study to the Women's Health Initiative Observational Study, 3372 postmenopausal women aged 50 to 83 years were enrolled for further evaluation using 24-hour ambulatory electrocardiographic monitoring. A shortened version of the Center for Epidemiological Studies Depression Scale and the Diagnostic Interview Schedule were administered. Women with adequate electrocardiographic data and depressive symptom information and without coronary artery disease were analyzed (n = 2627).

RESULTS

Two hundred sixty-nine women (10.2%) had depressive symptoms as measured using the 2 instruments. Women with depressive symptoms had a higher mean +/- SD heart rate (77.4 +/- 9.6 vs 75.5 +/- 8.5 beats/min) and lower heart rate variability than women without depressive symptoms. All differences remained significant after adjusting for age (P<.01).

CONCLUSIONS

Women with depressive symptoms had significant reductions in heart rate variability and higher heart rates, suggestive of increased sympathetic tone. These findings may contribute to the increased cardiac morbidity and mortality rates associated with depression in other studies.

Association between β-adrenergic receptor polymorphisms and their G-protein-coupled receptors with body mass index and obesity in women: a report from the NHLBI-sponsored WISE study

OBJECTIVES

The beta-adrenergic receptor (betaAR) genes are candidate genes for obesity because of their roles in energy homeostasis and promotion of lipolysis in human adipose tissue. Objective is to determine the association between obesity and polymorphisms in genes of the beta(1)AR (ADRB1), beta(2)AR (ADRB2), beta(3)AR (ADRB3), Gs protein alpha (GNAS1), to which all three beta-receptors couple and the G protein beta3 subunit (GNB3), to which beta(3)ARs couple.

DESIGN

A case-control genetic association study.

SUBJECTS

A total of 643 black or white women enrolled in Women's Ischemia Syndrome Evaluation (WISE) study.

MEASUREMENTS

Genotypes were determined by PCR with single primer extension. Associations between genotype and body mass index (BMI), waist-to-hip ratio (WHR), waist circumference, and obesity were made.

RESULTS

Polymorphisms in the three betaAR genes, GNAS1, and GNB3 were not associated with BMI, WHR, waist circumference, or obesity. Linear and logistic regression analyses found no contribution of either genotype or haplotype with anthropometric measurements or obesity.

CONCLUSIONS

Our study suggests that among American women with suspected coronary heart disease, polymorphisms in the betaARs and their G-protein-coupled receptors do not contribute to increased BMI, WHR, waist circumference, or obesity. Given that 50% of all women die from coronary heart disease, and a higher percentage have heart disease during their lifetime, our results are likely generalizable to many American women.

Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE)

BACKGROUND

Coronary vascular dysfunction has been linked to atherosclerosis and adverse cardiovascular outcomes in men, but these relationships have not been firmly established in women.

METHODS AND RESULTS

As part of the Women's Ischemia Syndrome Evaluation (WISE) sponsored by the National Heart, Lung, and Blood Institute, 163 women referred for clinically indicated coronary angiography underwent coronary reactivity assessment with quantitative coronary angiography and intracoronary Doppler flow before and after intracoronary administration of acetylcholine, adenosine, and nitroglycerin and were then followed up for clinical outcomes. History of hypertension was present in 61%, dyslipidemia in 54%, diabetes in 26%, and current tobacco use in 21% of women enrolled. Seventy-five percent had no or only mild epicardial coronary artery disease (CAD). Over a median follow-up of 48 months, events occurred in 58 women. On bivariate analysis, women with an event had significantly less change in coronary cross-sectional area (DeltaCSA) in response to acetylcholine (P=0.0006) and nitroglycerin (P=0.04). In addition, women with abnormal coronary dilator response to acetylcholine had less time free from cardiovascular events (P=0.004). In multivariable analysis, after controlling for age, hypertension, diabetes, dyslipidemia, tobacco use, and CAD severity, %DeltaCSA with acetylcholine (P=0.001) independently predicted events. When the outcome was restricted to only death, myocardial infarction, congestive heart failure, and stroke, %DeltaCSA with acetylcholine remained a significant predictor (P=0.006).

CONCLUSIONS

In women in this study, impaired coronary vasomotor response to acetylcholine was independently linked to adverse cardiovascular outcomes regardless of CAD severity.

Hormone Replacement, Race, and Psychological Health in Women: A Report from the NHLBI-Sponsored WISE Study

PURPOSE

We analyzed the impact of hormone replacement therapy (HRT) on psychological factors in white and black women. We hypothesized that both groups of women would have fewer symptoms of depression and lower hostility scores associated with HRT use.

METHODS

The cohort included 463 postmenopausal women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. WISE is a four-center study of women with chest pain who underwent quantitative coronary angiography for suspected ischemia. The psychosocial indices included the Beck Depression Inventory (BDI) and the Cook Medley Hostility questionnaire measuring cynicism, hostility, and aggression.

RESULTS

There were no differences by race in use, duration, and type of HRT or presence of menopausal symptoms. There were differences by race in baseline psychological measurements, with black women exhibiting higher BDI scores and higher total Cook Medley scores (p = 0.03) than white women. Use of HRT was consistently associated with better psychological health in white women, with fewer symptoms of depression and lower aggression and cynicism scores (p < 0.04). Black women with menopausal symptoms who used HRT had significantly lower hostility (p < 0.01) and cynicism scores (p < 0.05) than black women who did not use HRT. The presence of menopausal symptoms and hysterectomy status were significant independent predictors of HRT use for both white and black women (p < 0.05).

CONCLUSIONS

We observed racial differences in associations between HRT use and psychological health. Within the white but not the black HRT users, there were fewer symptoms of depression and lower aggression and cynicism scores.

Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored WISE Study

AIMS

Our goal was to evaluate health-related quality of life (QOL) in women undergoing angiography for suspected ischaemia.

METHODS AND RESULTS

QOL measurements were obtained in 406 women with chest pain symptoms in the Women's Ischemia Syndrome Evaluation (WISE). QOL measures included a general rating (GR), Duke Activity Status Index (DASI), and the Beck Depression Inventory (BDI). Higher scores on the GR and DASI are indicative of better QOL and functioning. Higher scores on the BDI indicate more symptoms of depression. Women were stratified by the presence and absence of obstructive angiographic coronary artery disease (CAD) and by the presence and absence of myocardial ischaemia. Women with angiographic obstructive CAD had lower DASI and higher BDI scores compared to women without obstructive CAD (both P<0.05). Stratification by the presence and absence of ischaemia demonstrated that women with ischaemia had better QOL, evidenced by higher GR QOL scores and lower BDI scores (both P<0.05) than women without ischaemia. Symptoms of angina were significant independent predictors of QOL scores (P<0.001).

CONCLUSIONS

Chest pain symptoms have a significant impact on health-related QOL in women undergoing coronary angiography for suspected myocardial ischaemia andare more important determinants of QOL than the underlying conditions of CAD or ischaemia.

Beta 1-adrenergic receptor polymorphisms and antihypertensive response to metoprolol

OBJECTIVES

Marked interpatient variability exists in blood pressure response to beta-blocker monotherapy. We tested the hypothesis that 2 common polymorphisms in the gene for beta(1)-adrenergic receptor are associated with antihypertensive response to metoprolol in patients with uncomplicated hypertension.

METHODS

Forty hypertensive men and women aged 35 to 65 years were studied. Baseline studies included 24-hour ambulatory blood pressure monitoring. Patients took 50 mg metoprolol twice daily with weekly titration to response or 200 mg twice daily. After a minimum of 4 weeks at stable dose, treatment phase 24-hour ambulatory blood pressure monitoring was repeated. The codon 49 and 389 genotypes for beta(1)-adrenergic receptor were determined by polymerase chain reaction with restriction fragment length polymorphism. Multilinear regression was performed to determine the impact of genotype and other variables on blood pressure response to metoprolol.

RESULTS

Patients homozygous for Arg at codon 389 had a nearly 3-fold greater reduction in daytime diastolic blood pressure (-13.3% +/- 8.4% versus -4.5% +/- 8.2%, P =.0018) compared with those who carried the variant allele. The haplotype pair (diplotype) for beta(1)-adrenergic receptor was also a significant predictor of response, with patients having the Ser49Arg389/Ser49Arg389 diplotype demonstrating a decline in blood pressure of 14.7 mm Hg versus 0.5 mm Hg in patients with the Gly49Arg389/Ser49Gly389 diplotype. In multiregression analysis, baseline daytime diastolic blood pressure, codon 389 genotype, and codon 49 genotype were significant predictors of blood pressure after treatment.

CONCLUSIONS

Our data suggest that beta(1)-adrenergic receptor polymorphisms are important determinants of antihypertensive response to metoprolol. In the future, codon 49 and 389 genotypes or beta(1)-adrenergic receptor haplotypes might be used to predict the diastolic blood pressure response to metoprolol in patients with hypertension.

Comparison of peer assessment ratings (PAR) from 1-phase and 2-phase treatment protocols for Class II malocclusions

The purpose of this study was to compare the dentoalveolar outcomes after 1-phase and 2-phase orthodontic treatment of Class II malocclusions. Class II subjects (n = 208) were randomized to 1-phase or 2-phase treatment with either bionator or headgear/biteplate. The peer assessment rating (PAR) was calculated from pretreatment, prephase 2, and final study models. Chi-square, Kruskal-Wallis, and Wilcoxon rank sum tests were used to evaluate the differences among treatment groups, sexes, races, pretreatment, mandibular plane angle, severity, and compliance. Spearman rank correlation coefficients were used to examine relationships between PAR at different times. The dropout rate of 24.6% did not adversely affect the ability to detect differences of clinical importance or impact treatment groups disproportionately. There were no significant differences with respect to initial PAR or final PAR among the 3 treatment protocols. The 2 early treatment groups had lower PAR scores than the 1-phase group before phase 2 (P =.0001). Lower PAR scores were achieved at both the beginning and end of phase 2 in girls (P =.03; P =.02, respectively). There were differences in the pre-phase-2 and post-phase-2 PAR scores based on initial severity (P =.0006; P =.02, respectively), with greater improvement in the patients whose malocclusions were less severe initially. Mandibular plane angle had no effect on pre-phase-2 or post-phase-2 PAR scores. These results do not support the hypothesis that different dentoalveolar outcomes are obtained between 2-phase and 1-phase treatment of Class II malocclusions.

Dobutamine pharmacodynamics during dobutamine stress echocardiography and the impact of beta-blocker withdrawal: a report from the Women's Ischemic Syndrome Evaluation Study

STUDY OBJECTIVES

To determine the pharmacodynamic parameters of dobutamine during dobutamine stress echocardiography (DSE) and to determine how beta-blocker withdrawal the evening before DSE affects responses to dobutamine during DSE.

DESIGN

Retrospective analysis.

SETTING

University medical center.

PATIENTS

One hundred thirty-six women who had chest pain or other symptoms suggestive of myocardial ischemia and were considered to have a clinical indication for coronary angiography

MEASUREMENTS AND MAIN RESULTS

Patients underwent DSE with dobutamine dosages titrated from 5 to 40 microg/kg/minute. The infusion was terminated if the patient reached target heart rate or symptoms developed. Those taking beta-blockers withheld their doses the evening before DSE. Traditional pharmacodynamic modeling revealed a wide range in responses to dobutamine. Data for 62% of patients not taking beta-blockers were described by the Emax (maximum heart rate response to dobutamine) model, whereas data for only 39% of patients taking beta-blockers were best described by this model (p = 0.01). Patients taking beta-blockers also had a smaller mean increment in left ventricular ejection fraction (10.8% +/- 4.2% vs 14.1% +/- 9.3%, p < 0.01), a trend toward a higher ED50 (dobutamine dosage rate causing half the maximum heart-rate response; median 16.8 microg/kg/min, p = 0.12) and a lower sigmoidicity factor determining the shape of the curve (median 2.1, p = 0.03).

CONCLUSION

The response to dobutamine exhibits wide interpatient variability, even in the absence of beta-blockade. Nonetheless, in the absence of beta-blockers, in most patients the dobutamine response reaches a plateau by the time the maximum infusion rate (40 microg/kg/min) is reached. Withdrawal of beta-blockers the evening before DSE may be inadequate time for elimination of beta-blocker effect, requiring the addition of atropine to achieve the desired response during DSE.