An mHealth Platform for People With HIV Receiving Care in Washington, District of Columbia: Qualitative Analysis of Stakeholder Feedback

BACKGROUND

HIV viral suppression and retention in care continue to be challenging goals for people with HIV in Washington, District of Columbia (DC). The PositiveLinks mobile app is associated with increased retention in care and viral load suppression in nonurban settings. The app includes features such as daily medication reminders, mood and stress check-ins, an anonymized community board for peer-to-peer social support, secure messaging to care teams, and resources for general and clinic-specific information, among other features. PositiveLinks has not been tailored or tested for this distinct urban population of people with HIV.

OBJECTIVE

This study aimed to inform the tailoring of a mobile health app to the needs of people with HIV and their providers in Washington, DC.

METHODS

We conducted a 3-part formative study to guide the tailoring of PositiveLinks for patients in the DC Cohort, a longitudinal cohort of >12,000 people with HIV receiving care in Washington, DC. The study included in-depth interviews with providers (n=28) at study clinics, focus groups with people with HIV enrolled in the DC Cohort (n=32), and a focus group with members of the DC Regional Planning Commission on Health and HIV (COHAH; n=35). Qualitative analysis used a constant comparison iterative approach; thematic saturation and intercoder agreement were achieved. Emerging themes were identified and grouped to inform an adaptation of PositiveLinks tailored for patients and providers.

RESULTS

Emerging themes for patients, clinic providers, and COHAH providers included population needs and concerns, facilitators and barriers to engagement in care and viral suppression, technology use, anticipated benefits, questions and concerns, and suggestions. DC Cohort clinic and COHAH provider interviews generated an additional theme: clinic processes. For patients, the most commonly discussed potential benefits included improved health knowledge and literacy (mentioned n=10 times), self-monitoring (n=7 times), and connection to peers (n=6 times). For providers, the most common anticipated benefits were improved communication with the clinic team (n=21), connection to peers (n=14), and facilitation of self-monitoring (n=11). Following data review, site principal investigators selected core PositiveLinks features, including daily medication adherence, mood and stress check-ins, resources, frequently asked questions, and the community board. Principal investigators wanted English and Spanish versions depending on the site. Two additional app features (messaging and documents) were selected as optional for each clinic site. Overall, 3 features were not deployed as not all participating clinics supported them.

CONCLUSIONS

Patient and provider perspectives of PositiveLinks had some overlap, but some themes were unique to each group. Beta testing of the tailored app was conducted (August 2022). This formative work prepared the team for a cluster randomized controlled trial of PositiveLinks' efficacy. Randomization of clinics to PositiveLinks or usual care occurred in August 2022, and the randomized controlled trial launched in November 2022.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37748.

Angular Correlations in the β Decay of ^{8}B: First Tensor-Current Limits from a Mirror-Nucleus Pair

We present the first measurement of the α-β-ν angular correlation in the Gamow-Teller β^{+} decay of ^{8}B. This was accomplished using the Beta-decay Paul Trap, expanding on our previous work on the β^{-} decay of ^{8}Li. The ^{8}B result is consistent with the V-A electroweak interaction of the standard model and, on its own, provides a limit on the exotic right-handed tensor current relative to the axial-vector current of |C_{T}/C_{A}|^{2}<0.013 at the 95.5% confidence level. This represents the first high-precision angular correlation measurements in mirror decays and was made possible through the use of an ion trap. By combining this ^{8}B result with our previous ^{8}Li results, we demonstrate a new pathway for increased precision in searches for exotic currents.

Development of an mHealth App to Support the Prevention of Sexually Transmitted Infections Among Black Men Who Have Sex With Men Engaged in Pre-exposure Prophylaxis Care in New Orleans, Louisiana: Qualitative User-Centered Design Study

BACKGROUND

Sexual health disparities exist for Black men who have sex with men (BMSM) in New Orleans, Louisiana. Rates of sexually transmitted infections (STIs) are high for both BMSM and those taking HIV pre-exposure prophylaxis (PrEP).

OBJECTIVE

In this study, we introduced an existing PrEP adherence app to new potential users-BMSM engaged in PrEP care in New Orleans-to guide app adaptation with STI prevention features and tailoring for the local context.

METHODS

Using a user-centered design, we conducted 4 focus group discussions (FGDs), with interim app adaptations from December 2020 to March 2021. During the FGDs, a video of the app, app website, and mock-ups were shown to participants. We asked about facilitators of and barriers to STI prevention in general, current app use, impressions of the existing app, new app features to potentially facilitate STI prevention, and how the app should be tailored for BMSM. We used applied qualitative thematic analysis to identify themes and needs of the population.

RESULTS

Overall, 4 FGDs were conducted with 24 BMSM taking PrEP. We grouped themes into 4 categories: STI prevention, current app use and preferences, preexisting features and impressions of the prep'd app, and new features and modifications for BMSM. Participants noted concern about STIs and shared that anxiety about some STIs was higher than that for others; some participants shared that since the emergence of PrEP, little thought is given to STIs. However, participants desired STI prevention strategies and suggested prevention methods to implement through the app, including access to resources, educational content, and sex diaries to follow their sexual activity. When discussing app preferences, they emphasized the need for an app to offer relevant features and be easy to use and expressed that some notifications were important to keep users engaged but that they should be limited to avoid notification fatigue. Participants thought that the current app was useful and generally liked the existing features, including the ability to communicate with providers, staff, and each other through the community forum. They had suggestions for modifications for STI prevention, such as the ability to comment on sexual encounters, and for tailoring to the local context, such as depictions of iconic sights from the area. Mental health emerged as an important need to be addressed through the app during discussion of almost all features. Participants also stressed the importance of ensuring privacy and reducing stigma through the app.

CONCLUSIONS

A PrEP adherence app was iteratively adapted with feedback from BMSM, resulting in a new app modified for the New Orleans context and with STI prevention features. Participants gave the app a new name, PCheck, to be more discreet. Next steps will assess PCheck use and STI prevention outcomes.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Evaluation of the implementation and effectiveness of a mobile health intervention to improve outcomes for people with HIV in the DC Cohort: a study protocol for a cluster randomized controlled trial

Background

Gaps remain in achieving retention in care and durable HIV viral load suppression for people with HIV in Washington, DC (hereafter DC). Although people with HIV seeking care in DC have access to a range of supportive services, innovative strategies are needed to enhance patient engagement in this setting. Mobile health (mHealth) interventions have shown promise in reaching previously underengaged groups and improving HIV-related outcomes in various settings.

Objective

This study will evaluate the implementation and effectiveness of a clinic-deployed, multifeature mHealth intervention called PositiveLinks (PL) among people with HIV enrolled in the DC Cohort, a longitudinal cohort of people with HIV receiving care in DC. A cluster randomized controlled trial will be conducted using a hybrid effectiveness-implementation design and will compare HIV-related outcomes between clinics randomized to PL versus usual care.

Methods

The study aims are threefold: (1) We will perform a formative evaluation of PL in the context of DC Cohort clinics to test the feasibility, acceptability, and usability of PL and tailor the platform for use in this context. (2) We will conduct a cluster randomized controlled trial with 12 DC Cohort clinics randomized to PL or usual care (n=6 [50%] per arm) and measure the effectiveness of PL by the primary outcomes of patient visit constancy, retention in care, and HIV viral load suppression. We aim to enroll a total of 482 participants from DC Cohort clinic sites, specifically including people with HIV who show evidence of inconsistent retention in care or lack of viral suppression. (3) We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to measure implementation success and identify site, patient, provider, and system factors associated with successful implementation. Evaluation activities will occur pre-, mid-, and postimplementation.

Results

Formative data collection was completed between April 2021 and January 2022. Preliminary mHealth platform modifications have been performed, and the first round of user testing has been completed. A preimplementation evaluation was performed to identify relevant implementation outcomes and design a suite of instruments to guide data collection for evaluation of PL implementation throughout the trial period. Instruments include those already developed to support DC Cohort Study activities and PL implementation in other cohorts, which required modification for use in the study, as well as novel instruments designed to complete data collection, as guided by the CFIR and RE-AIM frameworks.

Conclusions

Formative and preimplementation evaluations will be completed in spring 2022 when the trial is planned to launch. Specifically, comprehensive formative data analysis will be completed following data collection, coding, preliminary review, and synthesis. Corresponding platform modifications are ready for beta testing within the DC Cohort. Finalization of the platform for use in the trial will follow beta testing.

Trial Registration

ClinicalTrials.gov NCT04998019; https://clinicaltrials.gov/ct2/show/NCT04998019

International Registered Report Identifier (IRRID)

PRR1-10.2196/37748

Role of Cannabinoids and Terpenes in Cannabis-Mediated Analgesia in Rats

Introduction: Cannabis sativa has been used for centuries in treating pain. However, the analgesic role of many of its constituents including terpenes is unknown. This research examined the contributions of terpenes (volatile oil) and cannabinoids in cannabis-mediated analgesia in rats. Methods: Animals received intraperitoneal administration of either vehicle, 10.0 or 18.0 mg/kg morphine, or various doses of the extract without terpenes, isolated terpenes, Δ⁹-tetrahydrocannabinol (THC), or the full extract. Thirty minutes later animals were tested on hotplate and tail-flick tests of thermal nociception. One week later, rats received a second administration of test articles and were tested 30 min later in the abdominal writhing test of inflammatory nociception. Results: In the thermal assays, hotplate and tail-flick latencies for morphine-treated rats were dose dependent and significantly higher than vehicle-treated animals. All the cannabinoid compounds except for the isolated terpenes produced dose-dependent increases in hotplate and tail-flick latencies. In the inflammatory nociceptive assay, animals treated with vehicle and isolated terpenes demonstrated increased abdominal writhing, whereas all the cannabinoid compounds significantly decreased abdominal writhing responses. Conclusions: Overall, THC alone produced robust analgesia equivalent to the full cannabis extract, whereas terpenes alone did not produce analgesia. These data suggest the analgesic activity of cannabis is largely mediated by THC, whereas terpenes alone do not cause alterations in cannabis-mediated analgesia.

Organelle reorganization in bovine oocytes during dominant follicle growth and regression

BACKGROUND

We tested the hypothesis that organelles in bovine oocytes undergo changes in number and spatial distribution in a manner specific for phase of follicle development.

METHODS

Cumulus-oocyte-complexes were collected from Hereford heifers by ultrasound-guided follicle aspiration from dominant follicles in the growing phase (n = 5; Day 0 = ovulation), static phase (n = 5), regressing phase (n = 7) of Wave 1 and from preovulatory follicles (n = 5). Oocytes were processed and transmission electron micrographs of ooplasm representing peripheral, perinuclear and central regions were evaluated using standard stereological methods.

RESULTS

The number of mitochondria and volume occupied by lipid droplets was higher (P < 0.03) in oocytes from regressing follicles (193.0 ± 10.4/1000 μm(3) and 3.5 ± 0.7 %) than growing and preovulatory stages (118.7 ± 14.4/1000 μm(3) and 1.1 ± 0.3 %; 150.5 ± 28.7/1000 μm(3) and 1.6 ± 0.2 %, respectively). Oocytes from growing, static and preovulatory follicles had >70 % mitochondria in the peripheral regions whereas oocytes from regressing follicles had an even distribution. Oocytes from growing follicles had more lipid droplets in peripheral region than in central region (86.9 vs. 13.1 %). Percent surface area of mitochondria in contact with lipid droplets increased from growing (2.3 %) to static, regressing or preovulatory follicle stage (8.9, 6.1 and 6.2 %). The amount, size and distribution of other organelles did not differ among phases (P > 0.11).

CONCLUSIONS

Our hypothesis was supported in that mitochondrial number increased and translocation occurred from a peripheral to an even distribution as follicles entered the regressing phase. In addition, lipid droplets underwent spatial reorganization from a peripheral to an even distribution during the growing phase and mitochondria-lipid contact area increased with follicle maturation.

Limit on Tensor Currents from ^{8}Li β Decay

In the standard model, the weak interaction is formulated with a purely vector-axial-vector (V-A) structure. Without restriction on the chirality of the neutrino, the most general limits on tensor currents from nuclear β decay are dominated by a single measurement of the β-ν[over ¯] correlation in ^{6}He β decay dating back over a half century. In the present work, the β-ν[over ¯]-α correlation in the β decay of ^{8}Li and subsequent α-particle breakup of the ^{8}Be^{*} daughter was measured. The results are consistent with a purely V-A interaction and in the case of couplings to right-handed neutrinos (C_{T}=-C_{T}^{'}) limits the tensor fraction to |C_{T}/C_{A}|^{2}<0.011 (95.5% C.L.). The measurement confirms the ^{6}He result using a different nuclear system and employing modern ion-trapping techniques subject to different systematic uncertainties.

Thrombocytopenia in Patients with Gastric Varices and the Effect of Balloon-occluded Retrograde Transvenous Obliteration on the Platelet Count

OBJECTIVES

Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration (BRTO) have aggravated splenomegaly, which potentially may cause worsening thrombocytopenia. The aim of the study is to determine the prevalence and degree of thrombocytopenia in patients with gastric varices associated with gastrorenal shunts undergoing BRTO, to determine the prognostic factors of survival after BRTO (platelet count included), and to assess the effect of BRTO on platelet count over a 1-year period.

MATERIALS AND METHODS

This is a retrospective review of 35 patients who underwent BRTO (March 2008-August 2011). Pre- and post-BRTO platelet counts were noted. Potential predictors of bleeding and survival (age, gender, liver disease etiology, platelet count, model for end stage liver disease [MELD]-score, presence of ascites or hepatocellular carcinoma) were analyzed (multivariate analysis). A total of 91% (n = 32/35) of patients had thrombocytopenia (<150,000 platelet/cm(3)) pre-BRTO. Platelet counts at within 48-h, within 2 weeks and at 30-60 days intervals (up to 6 months) after BRTO were compared with the baseline pre-BRTO values.

RESULTS

35 Patients with adequate platelet follow-up were found. A total of 92% and 17% of patients had a platelet count of <150,000/cm(3) and <50,000/cm(3), respectively. There was a trend for transient worsening of thrombocytopenia immediately (<48 h) after BRTO, however, this was not statistically significant. Platelet count was not a predictor of post-BRTO rebleeding or patient survival. However, MELD-score, albumin, international normalized ratio (INR), and etiology were predictors of rebleeding.

CONCLUSION

Thrombocytopenia is very common (>90% of patients) in patients undergoing BRTO. However, BRTO (with occlusion of the gastrorenal shunt) has little effect on the platelet count. Long-term outcomes of BRTO for bleeding gastric varices using sodium tetradecyl sulfate in the USA are impressive with a 4-year variceal rebleed rate and transplant-free survival rate of 9% and 76%, respectively. Platelet count is not a predictor of higher rebleeding or patient survival after BRTO.

First results from the CARIBU facility: mass measurements on the r-process path

The Canadian Penning Trap mass spectrometer has made mass measurements of 33 neutron-rich nuclides provided by the new Californium Rare Isotope Breeder Upgrade facility at Argonne National Laboratory. The studied region includes the 132Sn double shell closure and ranges in Z from In to Cs, with Sn isotopes measured out to A=135, and the typical measurement precision is at the 100 ppb level or better. The region encompasses a possible major waiting point of the astrophysical r process, and the impact of the masses on the r process is shown through a series of simulations. These first-ever simulations with direct mass information on this waiting point show significant increases in waiting time at Sn and Sb in comparison with commonly used mass models, demonstrating the inadequacy of existing models for accurate r-process calculations.

Tensor interaction limit derived from the α-β-ν[over ¯] correlation in trapped 8Li ions

A measurement of the α-β-ν[over ¯] angular correlation in the Gamow-Teller decay (8)Li→(8)Be(*)+ν[over ¯]+β, (8)Be(*)→α+α has been performed using ions confined in a linear Paul trap surrounded by silicon detectors. The energy difference spectrum of the α particles emitted along and opposite the direction of the β particle is consistent with the standard model prediction and places a limit of 3.1% (95.5% confidence level) on any tensor contribution to the decay. From this result, the amplitude of any tensor component C(T) relative to that of the dominant axial-vector component C(A) of the electroweak interaction is limited to |C(T)/C(A)|<0.18 (95.5% confidence level). This experimental approach is facilitated by several favorable features of the (8)Li β decay and has different systematic effects than the previous β-ν[over ¯] correlation results for a pure Gamow-Teller transition obtained from studying (6)He β decay.

β-delayed neutron spectroscopy using trapped radioactive ions

A novel technique for β-delayed neutron spectroscopy has been demonstrated using trapped ions. The neutron-energy spectrum is reconstructed by measuring the time of flight of the nuclear recoil following neutron emission, thereby avoiding all the challenges associated with neutron detection, such as backgrounds from scattered neutrons and γ rays and complicated detector-response functions. (137)I(+) ions delivered from a (252)Cf source were confined in a linear Paul trap surrounded by radiation detectors, and the β-delayed neutron-energy spectrum and branching ratio were determined by detecting the β(-) and recoil ions in coincidence. Systematic effects were explored by determining the branching ratio three ways. Improvements to achieve higher detection efficiency, better energy resolution, and a lower neutron-energy threshold are proposed.

Delayed procedural learning in α7-nicotinic acetylcholine receptor knockout mice

The α7-nicotinic acetylcholine receptor (nAChR) has long been a procognitive therapeutic target to treat schizophrenia. Evidence on the role of this receptor in cognition has been lacking, however, in part due to the limited availability of suitable ligands. The behavior of α7-nAChR knockout (KO) mice has been examined previously, but cognitive assessments using tests with cross-species translatability have been limited to date. Here, we assessed the cognitive performance of α7-nAChR KO and wild-type (WT) littermate mice in the attentional set-shifting task of executive functioning, the radial arm maze test of spatial working memory span capacity and the novel object recognition test of short-term memory. The reward motivation of these mutants was assessed using the progressive ratio breakpoint test. In addition, we assessed the exploratory behavior and sensorimotor gating using the behavioral pattern monitor and prepulse inhibition, respectively. α7-nAChR KO mice exhibited normal set-shifting, but impaired procedural learning (rule acquisition) in multiple paradigms. Spatial span capacity, short-term memory, motivation for food, exploration and sensorimotor gating were all comparable to WT littermates. The data presented here support the notion that this receptor is important for such procedural learning, when patterns in the environment become clear and a rule is learned. In combination with the impaired attention observed previously in these mice, this finding suggests that agonist treatments should be examined in clinical studies of attention and procedural learning, perhaps in combination with cognitive behavioral therapy.

Toll like receptor-4 expression in lipopolysaccharide induced lung inflammation

Bacterial lipopolysaccharides (LPS) initiate immune response through Toll-like receptor 4 (TLR4). Because many a times host is confronted with secondary bacterial challenges, it is critical to understand TLR4 expression following initial provocation. We studied TLR4 expression in rats at various times after intra-tracheal instillation of LPS. Although TLR4 mRNA was undetectable in normal lungs, it increased at 6h and 12h and declined at 36h post-LPS treatment. Western blots showed TLR4 protein at all time points. Immunohistochemistry localized TLR4 in alveolar septal cells, bronchial epithelium, macrophages and endothelium of large and peribronchial blood vessels. Dual label immunoelectron microscopy showed co-localization of TLR4 and LPS in the cytoplasm and nucleus of various lung and inflammatory cells. Nuclear localization of TLR4 was confirmed with Western blots on lung nuclear extracts. We conclude that TLR4 expression in lung is sustained up to 36 hours and that TLR4 and LPS are localized in the cytoplasm and nuclei of lung cells.

Association between hyperhomocysteinaemia and abdominal aortic aneurysm

Background

Hyperhomocysteinaemia is associated with occlusive vascular disease. In vitro evidence has demonstrated the induction of a serine elastase by homocysteine in vascular smooth muscle. Anecdotal evidence from case reports and post-mortem studies has suggested an association with abdominal aortic aneurysm (AAA). The aim was to determine the prevalence of hyperhomocysteinaemia in patients with AAA.

Methods

Some 120 subjects (60 controls and 60 patients with AAA) were studied prospectively. Epidemiological, clinical and haematological data were collected. Patients were defined as having AAA if ultrasonographic measurement of the aorta was greater than 4·5 cm. Those with evidence of occlusive peripheral vascular disease or an ankle: brachial pressure index lower than 0·8 were excluded. Homocysteine was measured with a commercial high-pressure liquid chromatography analyser. The reference range from age-matched controls was 8·9–14·3 µmol l−1.

Results

The median(s.d.) value of homocysteine for patients was significantly higher than that for the control group: 13·1(7·88) versus 10·9(5·07) µmol l−1 (P = 0·03, Mann–Whitney U test). Hyperhomocysteinaemia (homocysteine concentration greater than 14·3 µu;mol l−1) was present in 48 per cent of patients with AAA, compared with 24 per cent of the control population (P &lt; 0·01, χ2 test). There were no significant differences between groups with regard to age, folate levels, vitamin B12 concentration or renal function.

Conclusion

These results strongly suggest an association between hyperhomocysteinaemia and AAA. If studies currently ongoing demonstrate a causal relationship between hyperhomocysteinaemia and vascular disease progression, it raises the possibility of treating small aneurysms with vitamin supplementation to slow their growth.

Educational programs in radiologic technology

This article reports on a survey of educational programs in radiography, nuclear medicine, radiation therapy and sonography. The purpose of the survey was to help educators validate their individual program requirements by providing a profile of educational programs in each discipline. Survey results demonstrate similarities in program length, academic system, faculty teaching load and enrollment size. Major differences were found in clinical hour requirements and credit hour conversion.

Predicting the outcome of twin block functional appliance treatment: a prospective study

A prospective study was undertaken to investigate the relationship between various measured pre-treatment parameters and the reduction in overjet achieved when using a twin block functional appliance. Forty-three subjects were fitted with a twin block functional appliance, and a number of pre-treatment clinical and radiographic morphological features were recorded. The functional appliance wear was monitored for 6 months and any individual who did not co-operate with wear was excluded from the subsequent analysis. Multiple regression analysis with stepwise inclusion was used to relate the percentage reduction in overjet achieved by functional appliance wear to any of the pre-treatment parameters. The data from 22 individuals was included in the final analysis. The overbite and SNB angle were the most strongly related variables to percentage reduction in overjet. These were then used to construct a predictive equation for the expected percentage reduction in overjet: Percentage reduction in overjet in 6 months = 132 + 4.9x1 - 1.4x2, where x1 = overbite and x2 = SNB. The pre-treatment overbite was, in isolation, the most influential feature in predicting the percentage of overjet reduction.

Multicenter study of lamivudine therapy for hepatitis B after liver transplantation. Lamivudine Transplant Group

Hepatitis B after liver transplantation is often fatal, and no proven medical therapy exists for this condition. We chose to study the potential efficacy of lamivudine therapy for patients with chronic hepatitis B after liver transplantation. Fifty-two patients with chronic hepatitis B after liver transplantation were treated in an open label, multicenter study. Each had detectable hepatitis B virus (HBV) DNA in serum and 45 (87%) had detectable serum hepatitis B e antigen before treatment. Patients were treated for 52 weeks with lamivudine (100 mg daily). The primary endpoint was undetectability of HBV DNA; secondary endpoints included normalization of serum alanine transaminase (ALT) levels, disappearance of hepatitis B e antigen, and improvement in liver histology. After treatment, 60% of patients had undetectable HBV DNA by solution hybridization assay, 14 (31%) of the initially positive patients lost hepatitis B e antigen; hepatitis B surface antigen was undetectable in 3 (6%); and serum ALT levels normalized in 71%. Blinded histological assessments showed improvement in the histological activity index (P =.007 for periportal necrosis,.001 for lobular necrosis, and.013 for portal inflammation). YMDD variants of HBV, potentially associated with drug resistance, were detected in 14 (27%) of the patients. Repeat liver biopsies in 7 patients with the mutated virus were unchanged in 2, improved in 2, and worse in 3. We conclude that lamivudine is a potentially effective therapy for hepatitis B after liver transplantation.

Solitary renal myofibromatosis: an unusual cause of infantile hypertension

INTRODUCTION

Renovascular disease accounts for the vast majority of cases of infantile hypertension with complications resulting from umbilical arterial catheterization predominating in the neonatal period and fibrodysplastic lesions of the renal artery predominating outside the neonatal period. We report a previously undescribed cause of renovascular hypertension: solitary renal myofibromatosis.

CASE REPORT

A 9-month-old male infant was transported to the intensive care unit at Children's Hospital in Denver, Colorado, for evaluation and treatment of a dilated cardiomyopathy and severe systemic hypertension. The child was full-term with no perinatal problems. Specifically, the child never required umbilical arterial catheterization. He was well until 6 months of age when his parents noted poor weight gain. At 9 months of age, he was evaluated at the referral hospital for failure to thrive. On examination he was noted to have a blood pressure of 170/110 mm Hg, but no other abnormalities. A chest radiograph showed cardiomegaly. Laboratory studies demonstrated normal electrolytes, blood urea nitrogen, and creatinine. However, urinalysis demonstrated 4+ protein without red blood cells. An echocardiogram showed severe left ventricular dilatation with an ejection fraction of 16%. On admission the child was noted to be cachectic. His vital signs, including blood pressure, were normal for age. The physical examination was unremarkable. Serum electrolytes, blood urea nitrogen, and creatinine were normal. Echocardiographic studies suggested a dilated hypertrophic cardiomyopathy. He was started on digoxin and captopril. Subsequently, he demonstrated episodic hypertension ranging from 170/90 to 220/130 mm Hg. A repeat echocardiogram 24 hours after admission demonstrated a purely hypertrophic cardiomyopathy. Verapamil and nifedipine were added to the treatment regimen in an effort to better control the blood pressure without success. Urine and blood for catecholamines and plasma renin activity, respectively, were sent and treatment with phentolamine instituted because of a possible pheochromocytoma. A spiral abdominal computerized tomographic scan revealed a markedly abnormal right kidney with linear streaky areas of calcification around the hilum and also an area of nonenhancement in the posterior upper pole. The adrenals and the left kidney were normal. Doppler ultrasound revealed a decrease in right renal arterial flow. The urinary catecholamines were normal and surgery was scheduled after the blood pressure was brought under control by medical treatment. At surgery, tumorous tissue and thrombosis of the renal artery were found in the right upper pole. A right nephrectomy was performed. Pathologic examination of the kidney showed the presence of a diffuse spindle cell proliferation in the interstitium of the kidney. The angiogenic/angiocentric character of the proliferation was demonstrated in several large renal vessels. The lumen of most vessels was narrowed and some vessels were totally occluded with recanalization and dystrophic calcifications observed. Immunostaining of the tumor demonstrated strong desmin and vimentin positivity and minimal actin positivity in the spindle cells. Mitotic activity was not noted in the spindle cell process. These pathologic changes were consistent with a diagnosis of infantile myofibromatosis (IM). The child's preoperative plasma renin activity was 50 712 ng/dL/h (reference range, 235-3700 ng/dL/h).

DISCUSSION

The causes of systemic hypertension in infancy are many although renal causes are by far the most common. Renal arterial stenosis or thrombosis accounts for 10% to 24% of cases of infantile hypertension. Renal artery thrombosis is usually a consequence of umbilical arterial catheterization, which can also lead to embolization of the renal artery. Renal artery stenosis may result from fibrodysplastic lesions (74%), abdominal aortitis (9%), a complication of renal transplantation (5%), and ren

A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996

BACKGROUND

Two previous reports have summarized the content, institutional affiliations, academic training and funding sources for articles published in the Journal of Manipulative and Physiological Therapeutics (JMPT) from 1978-1986 and 1987-1988.

OBJECTIVES

(a) to quantitatively assess the types of articles published in the JMPT from 1989-1996; (b) to identify the affiliations of contributors to the JMPT during this period; (c) to identify the academic backgrounds of contributors to the JMPT from 1989-1996; (d) to identify funding sources for scholarly works published in the JMPT during this period; (e) to identify the proportionate contributions of female authors; (f) to assess the proportion of articles contributed, i.e., foreign vs. domestic sources; and (g) to compare findings for the JMPT from 1989-1996 with similar data for 1978-1988.

STUDY DESIGN

Survey of the contents of the JMPT from 1989-1996.

METHODS

The contents of the 69 issues of the JMPT from 1989-1996 were reviewed by all authors. Characteristics extracted included category of the article, academic backgrounds of authors, institutional affiliations of authors, funding sources, gender of authors and nation(s) of origin of articles.

RESULTS

The annual rate of published contributions to the Journal has more than doubled compared with its first 11 yr of publication, and the proportion of original data reports has grown slightly. Controlled and quasicontrolled clinical trials were 7 times more numerous (n = 28 articles) during the past 8 yr. Chiropractic colleges were the most frequently mentioned affiliation of authors, followed by private practice and nonchiropractic colleges. Collaborative articles submitted by authors at two or more chiropractic colleges grew from only 4 articles from 1978-1988 to 31 articles from 1989-1996. As in previous years, the National College of Chiropractic continued to be the most frequently mentioned academic affiliation of authors. The numbers of articles contributed by those holding scientific (e.g., PhD) and medical degrees have grown substantially. The number of articles mentioning financial support grew from 78 from 1978-1988 to 179 from 1989-1996, and 58 new funding sources were identified. The Foundation for Chiropractic Education and Research continues to be the most frequently mentioned source of funding. Of all articles published in the JMPT from 1989-1996, 21% were authored or coauthored by women. Of 1050 articles, 286 (27%) were authored or coauthored by individuals residing outside the United States of America.

CONCLUSIONS

Substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical. Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline.

Pediatric bronchioloalveolar carcinoma: a favorable pediatric malignancy?

Primary pulmonary tumors are infrequent in children. Bronchioloalveolar carcinoma has been documented rarely in the pediatric population. Before this report, there have been only three cases of bronchioloalveolar carcinoma in patients less than 16 years of age. Our two cases represent two of the youngest cases (ages 6 and 15 years) reported with bronchioloalveolar carcinoma. They illustrate many of the typical findings of this disease including clinical presentation, diagnostic difficulty, and better prognosis compared with other pulmonary malignancies. This neoplasm appears to have a favorable outcome in childhood.

Retransplantation of patients with severe posttransplant hepatitis B in the first allograft

BACKGROUND

The outcome of orthotopic liver transplantation (OLTX) in patients retransplanted for severe hepatitis B virus (HBV) in the first allograft has been poor due to high rates of HBV reinfection and even more aggressive disease in the second graft. Recent data suggest that hepatitis B immunoglobulin (HBIg) given after transplantation can be successful in delaying or preventing HBV reinfection in patients transplanted for chronic hepatitis B cirrhosis. We report the successful retransplantation of patients who developed recurrent or de novo hepatitis B after OLTXY.

METHODS

Using similar HBIg regimens, two centers retransplanted seven patients after they developed recurrent or de novo hepatitis B in the first allograft. At retransplantation all seven patients were HBs antigen (Ag) positive; four patients were positive for HBeAg and HBV DNA by immunoblot assay, two patients were negative for HBeAg and HBV DNA, and one patient was positive for HBV DNA and negative for HBeAg. All patients were either HDV Ag or anti-HDV negative. One patient was anti-HCV positive. All patients received HBIg infusions after retransplantation to maintain serum anti-HBs levels >500 IU/L indefinitely.

RESULTS

After retransplantation, six of seven patients are alive (86%): all are without evidence of HBV recurrence with serum negative for HBsAg, HBeAg, and HBV DNA by immunoblot assay. Liver biopsies are normal on routine studies with immunohistochemical stains for HBcAg and HBsAg also being negative. Mean follow-up of these six patients is 40.1 months (range 21-63 months). One patient (14%) developed HBV reinfection 7 months after his second transplant, in spite of maintaining target anti-HBs levels. He maintained stable liver function with minimal evidence of clinical hepatitis B, but died 8 months later from an unrelated stroke.

CONCLUSIONS

We conclude that patients with recurrent or de novo hepatitis B after OLTX can be successfully retransplanted using aggressive immunoprophylaxis to prevent HBV reinfection. The failure of HBIg therapy in one patient underscores the need for other effective adjunctive anti-HBV modalities.

NADH oxidase activity from sera altered by capsaicin is widely distributed among cancer patients

A cancer-specific form of NADH oxidase inhibited or stimulated by 1 or 100 microM capsaicin (8-methyl-N-vanillyl-6-noneamide) is present in sera from cancer patients. The capsaicin-inhibited NADH oxidase activity appears to be absent from sera of individuals free of cancer. The capsaicin-inhibited activity is present both in freshly collected sera and in sera stored frozen for varying periods of time. For the latter, an assay was carried out under renaturing conditions in the presence of NADH and reduced glutathione followed by dilute hydrogen peroxide. Inhibition was half maximal at about 1 microM capsaicin. The capsaicin-inhibited activity was found in sera over a broad spectrum of cancer patients including patients with solid cancers (e.g., breast, prostate, lung, ovarian) as well as with leukemias and lymphomas.

The effect of cryopreservation on the lethal mutation rate in Drosophila melanogaster

Although cryopreservation is routinely used for the storage of a range of biological organisms, few studies have been conducted to determine whether cryopreservation increases the frequency of mutation. A procedure for the cryopreservation of Drosophila melanogaster embryos has recently been developed. Cryopreservation of D. melanogaster is of special interest to geneticists and evolutionary biologists because it would make it possible to assay control and experimental populations simultaneously during long-term studies. Before cryopreserved embryos can be used for such studies, it is first necessary to show that cryopreservation is not mutagenic. We tested for mutagenic effects or cryopreservation in D. melanogaster embryos with an X-linked, recessive lethal assay. The mutation rates of cryopreserved and control flies were not significantly different. We can be 95% certain that cryopreservation does not increase mutation by a factor greater than 2.39. This is the first quantitative estimate of the mutagenic effect of cryopreservation on the germ line of a metazoan. The results are reassuring when considering the genetic impact of cryopreservation on mammalian gametes and embryos.

Cysteine supplementation and reduction of total parenteral nutrition-induced hepatic lipid accumulation in the weanling rat

Total parenteral nutrition (TPN)-induced hepatic steatosis is the most common complication of TPN administration to humans. The mechanism of TPN-induced hepatic steatosis has not been studied in young mammals. The goal of this study was to determine the mechanism of TPN-induced hepatic steatosis in the weanling rat and the effect of supplementation of TPN with choline and/or cysteine on TPN-induced hepatic steatosis. In the weanling rat, we investigated the effect of TPN administration on histologic hepatic steatosis, total hepatic lipid, hepatic acetyl-CoA-carboxylase (ACC--the rate limiting enzyme in fatty acid synthesis) specific activity, and total plasma lipids. TPN administration resulted in a threefold increase in hepatic lipid as compared with control and sham animals (TPN 138 +/- 12 mg/g liver versus control 57 +/- 1), an increase in histologic steatosis (TPN 3.7 versus control 1.3), and a decline in total plasma lipid (TPN 2.1 +/- 0.3 g/L versus control 4.1 +/- 0.3). TPN-induced hepatic steatosis in the weanling rat was not associated with an increase in ACC specific activity (TPN 2.10 +/- 0.33 nmol/min/mg protein versus control 2.85 +/- 0.23). Supplementation of the TPN with choline (15 mg/day) did not significantly lessen hepatic steatosis; however, supplementation of TPN with cysteine (2.5 mg/day) or with cysteine and choline did result in a significant lessening of hepatic lipid content and of histologic steatosis and a normalization of total plasma lipid.(ABSTRACT TRUNCATED AT 250 WORDS)

Miller-Dieker syndrome. Detection of a cryptic chromosome translocation using in situ hybridization in a family with multiple affected offspring

OBJECTIVE

To describe a family in whom fluorescence in situ hybridization allowed for accurate diagnosis of Miller-Dieker syndrome in an at-risk pregnancy and determination of parental carrier status.

DESIGN

Retrospective case analysis and application of a new molecular tool to evaluate the family.

SETTING

Health maintenance organization. The family was followed up by the Departments of Medical Genetics, Pediatrics, and Obstetrics and Gynecology, Kaiser Permanente Medical Center, Panorama City, Calif.

PARTICIPANTS

Members of a single family.

INTERVENTIONS

Clinical evaluation and neuroimaging studies of the proband. Prenatal diagnosis via ultrasonography and amniocentesis. Chromosomal evaluation of the couple and their offspring. In situ hybridization studies in both parents and an affected fetus.

MEASUREMENTS/MAIN RESULTS

We describe a family in whom fluorescence in situ hybridization detected a submicroscopic deletion of the Miller-Dieker syndrome critical region 17p13.3 arising from a cryptic translocation in one of the parents. The proband was determined at birth owing to the presence of multiple congenital anomalies, including low birth weight, microcephaly, agenesis of the corpus callosum, lissencephaly, cerebral atrophy, unilateral ptosis, polydactyly, and omphalocele. High-resolution chromosome-banding analysis findings were normal in the parents and proband, who died at age 4 years. There were four subsequent pregnancies: two ended in first-trimester spontaneous abortion, and in the other two, large omphaloceles were detected in fetuses at 15 and 13 weeks' gestation. Both pregnancies were terminated. Fluorescence in situ hybridization probes for 17p13.3 had become available before the most recent pregnancy and were used to study parental and fetal cells. As a result, a balanced cryptic translocation between chromosome 17 and chromosome 19 was identified in the father: 46,XY,t(17;19)(p13.3q13.33). An unbalanced form of the translocation, involving a deletion of 17p13.3, was detected with fluorescence in situ hybridization in the fetus. This finding was in accordance with a clinical diagnosis of Miller-Dieker syndrome.

CONCLUSIONS

Molecular cytogenetic technology should be used in cases of suspected Miller-Dieker syndrome when high-resolution cytogenetic analysis fails to detect del(17) (p13.3). Positive findings should be followed up with parental studies. In addition, omphalocele should be included among the list of malformations that make up the Miller-Dieker syndrome.

Michelin tire baby syndrome: familial constriction bands during infancy and early childhood in four generations

We report on an infant with an unusual pattern of transitory familial constriction bands distributed symmetrically and circumferentially over the neck, forearms, and lower legs. Family history showed the occurrence of similar bands among individuals in 4 generations transmitted as an autosomal dominant trait. Neck and limb distribution in the other affected family members was also symmetrical and circumferential, with spontaneous resolution taking place during childhood. This case represents another example of the Michelin tire baby syndrome, also known as multiple benign circumferential skin creases of the limbs, and further demonstrates its autosomal dominant mode of inheritance.

Cystic fibrosis, intravenous antibiotics, and home therapy

The survival rate of patients with cystic fibrosis has improved considerably in the last 20 years. Although not all of the factors accounting for this change are understood, aggressive nutritional management and treatment of pulmonary exacerbations certainly play a role. Home intravenous (IV) antibiotic delivery for pulmonary exacerbation has proved to be as effective as hospital treatment and offers significant advantages to the patient and family. This article examines the microbiology of pulmonary infections in patients with cystic fibrosis, as well as antimicrobial therapy, methods of IV administration, home IV therapy, and the nurse practitioner's role in this home program in the future.

Underrecognition of morbidity from stings of the red imported fire ant in the southeastern United States

This cross-sectional study was conducted to determine the health-seeking behaviors of a group of patients stung by red imported fire ants (RIFA) and the number of nursing referrals resulting in treatment. The following two research questions were asked: (1) Is there a delay in seeking the care of a board-certified allergist for symptoms of fire ant hypersensitivity? (2) Are nurses referring patients for treatment? The entire population of board-certified allergists in Alabama, Georgia, and South Carolina (n = 98) was sampled. A questionnaire was developed for the office nurses to use to collect information from allergy patients actually receiving fire ant injections (n = 257). Each patient reported on the reaction, when it occurred as well as age, sex, and county of residence. Descriptive statistics revealed that a delay of a month or more in seeking care of an allergist was experienced by 154 (56%) of patients who completed the questionnaire. The average delay was 1.8 years. The main source of referrals was a general practitioner or emergency room personnel. Nursing and other health professionals must recognize the problem and to institute prompt referral for treatment. In areas where RIFA colonies are spreading, they have to be fully informed and trained in effective primary and secondary techniques to prevent serious reaction to the stings of these ants.

Overview of proposed revisions to the superfund hazard ranking system

The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 required the federal government to establish criteria for setting priorities among releases of hazardous substances, pollutants, and contaminants. The U.S. Environmental Protection Agency responded by developing the Hazard Ranking System (HRS), which is a scoring system used to establish the National Priorities List (NPL). The Superfund Amendments and Reauthorization Act of 1986 required EPA to amend the HRS so it will more accurately assess relative risks and take into account certain specific elements of risk. On December 23, 1988, EPA published in the Federal Register the proposed rule to revise the HRS. EPA expects to issue the final rule in 1990 after reviewing public comments. This paper describes the proposed revisions and summarizes major technical findings that support the revisions. As a result of the HRS revisions, there may be some changes in the types of sites that score high enough to be placed on the NPL. A projection of those changes is discussed.

Glycosylated haemoglobin and plasma glycoprotein assays by affinity chromatography

A rapid chromatography method for separating glycosylated protein from non-glycosylated protein, using a boronate-agarose affinity medium which selectively binds the cis-diol groups of glycoproteins, was used to quantitate plasma glycoprotein as well as glycohaemoglobin. The results were found to be independent of: (1) temperature from 16.5 to 29.8 degrees C; (2) haemoglobin variants, and (3) aldimine glycoprotein adducts. Thus several of the common problems occurring in existing haemoglobin A1 assays are eliminated. There was a close correlation between glycohaemoglobin measured by affinity chromatography and haemoglobin A1 by cation-exchange (r = 0.959, n = 215). Specimens from 103 diabetic patients and 112 healthy volunteers were assayed. The following reference ranges were established: glycohaemoglobin 5.5-8.4%; glycosylated total protein 11.5-16.2%; glycoalbumin 11.6-19.5%.

In vivo distraction-coping in the treatment of test anxiety: a 1-year follow-up study

Data obtained from 19 clinically test anxious students supported the efficacy of an 8-week treatment program that combined relaxation skill training, cognitive restructuring, and systematic desensitization for the reduction of test anxiety in a previous study by Thyer , Papsdorf , Himle , McCann , Caldwell, and Wickert (1981). Significant reductions in test, state, and trait anxiety, and increases in the rationality of personal belief systems were observed. Cognitive performance on an anagram solution task and behavioral performance on a test of manual dexterity also were improved posttreatment. In this present study, 12-month follow-up data on 14 (73.6%) of the original Ss are reported. The results indicate a maintenance of the significantly decreased levels of test anxiety and continued reductions in trait anxiety and irrationality . The significance of these findings is discussed.

In vivo distraction-coping in the treatment of test anxiety

Two groups (N = 19) of clinically test anxious college students received a common core treatment program of cognitive behavior therapy, progressive muscular relaxation training, and thermal biofeedback assisted relaxation training. The experimental group received an additional treatment component that consisted of in vivo distraction-coping training designed to facilitate focusing attentional processes onto task relevant variables and away from external distractors and dysfunctional self-statements. The overall efficacy of the program was demonstrated with reductions in test, trait and state anxiety, and increases in the rationality of personal belief systems. Performance on an anagram solution task conducted under highly distracting conditions and evaluative interactions was improved significantly, as was motoric performance on a manual dexterity task. In vivo distraction-coping was not found to result in more efficacious treatment as measured by self-report and performance variables.