The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Team based collaborative care model, facilitated by mHealth enabled and trained nurses, for management of heart failure with reduced ejection fraction in India (TIME-HF): design and rationale of a parallel group, open label, multi-centric cluster randomised controlled trial

Background: Heart failure (HF) is a debilitating condition associated with enormous public health burden. Management of HF is complex as it requires care-coordination with different cadres of health care providers. We propose to develop a team based collaborative care model (CCM), facilitated by trained nurses, for management of HF with the support of mHealth and evaluate its acceptability and effectiveness in Indian setting. Methods: The proposed study will use mixed-methods research. Formative qualitative research will identify barriers and facilitators for implementing CCM for the management of HF. Subsequently, a cluster randomised controlled trial (RCT) involving 22 centres (tertiary-care hospitals) and more than 1500 HF patients will be conducted to assess the efficacy of the CCM in improving the overall survival as well as days alive and out of hospital (DAOH) at two-years (CTRI/2021/11/037797). The DAOH will be calculated by subtracting days in hospital and days from death until end of study follow-up from the total follow-up time. Poisson regression with a robust variance estimate and an offset term to account for clustering will be employed in the analyses of DAOH. A rate ratio and its 95% confidence interval (CI) will be estimated. The scalability of the proposed intervention model will be assessed through economic analyses (cost-effectiveness) and the acceptability of the intervention at both the provider and patient level will be understood through both qualitative and quantitative process evaluation methods. Potential Impact: The TIME-HF trial will provide evidence on whether a CCM with mHealth support is effective in improving the clinical outcomes of HF with reduced ejection fraction in India. The findings may change the practice of management of HF in low and middle-income countries.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Case Report: Occurrence of Severe Thoracic Aortic Aneurysms (Involving the Ascending, Arch, and Descending Segments) as a Result of Fibulin-4 Deficiency: A Rare Pathology With Successful Management

Aortic diseases requiring surgery in childhood are distinctive and rare. Very few reports in the literature account for the occurrence of multiple thoracic aortic aneurysms in the same pediatric patient because of a genetic cause. We report a rare occurrence of severe thoracic aortic aneurysms (involving the ascending, arch and descending aortic segments) with severe aortic insufficiency in a 7-year-old female child secondary to the extremely rare and often lethal genetic disorder, cutis laxa. She was eventually identified as a carrier of a homozygous EFEMP2 (alias FBLN4) mutation. This gene encodes the extracellular matrix protein fibulin-4, and its mutation is associated with autosomal recessive cutis laxa type 1B that leads to severe aortopathy with aneurysm formation and vascular tortuosity. Parents of the child were not known to be consanguineous. Significant symptomatic improvement in the patient could be discerned after timely intervention with the valve-sparing aortic root replacement (David V procedure) and a concomitant aortic arch replacement. This is a unique report with a successful outcome that highlights the occurrence of a rare hereditary aortopathy associated with a high morbidity and mortality, and the importance of an early diagnosis and timely management. It also offers insight to physicians in having a very broad differential and multimodal approach in handling rare pediatric cardio-pathologies with a genetic predisposition.

Single Incision Laparoscopic Surgery for Leiomyoma in the Adolescent Patient: A Case Report

BACKGROUND

Single-incision laparoscopic surgery (SILS) is an exciting new modality in the field of minimal access surgery. This case illustrates the feasibility of single-incision laparoscopic surgery for uterine pathology in the pediatric and adolescent population.

CASE

A 19-year-old girl presented with pelvic pain. Transabdominal pelvic ultrasound and magnetic resonance imaging revealed multiple fibroids with rapid enlargement over a year. In collaboration with the Minimally Invasive Gynecologic Surgery team, single incision laparoscopic myomectomy was performed with satisfactory results.

SUMMARY AND CONCLUSION

Complex uterine pathology can be managed with minimally invasive surgery with excellent clinical outcomes. SILS is a rapidly developing field that may represent the future of laparoscopic surgery and can be used to treat reproductive pathology in the pediatric and adolescent population.

Compliance of Secondary Prevention Strategies in Coronary Artery Disease Patients with and without Diabetes Mellitus - A Cross-Sectional Analytical Survey from Kerala, India

CONTEXT

There is limited data related to compliance of secondary prevention strategies for coronary artery diseases (CAD) among patients with and without diabetes.

OBJECTIVES

The objective was to compare compliance to secondary prevention strategies for CAD including smoking cessation, weight management, blood pressure (BP) control, Low density lipoprotein (LDL) cholesterol control and adequate physical activity between patients with and without diabetes.

SETTINGS AND DESIGN

This is a hospital-based cross-sectional analytical study.

METHODS AND MATERIALS

The study questionnaire was used to collect data through interviews of CAD patients. Compliance to secondary prevention strategies was documented using European Society of Cardiology guidelines.

STATISTICAL ANALYSIS

We used modified Poisson model to estimate adjusted prevalence ratios (Adj. PR) for estimating compliance.

RESULTS

Among 1,206 participants with CAD, 609 (50.5%) had diabetes. The Adj. PR s for three targets - smoking cessation (Adj. PR 1.01, 95% CI 0.97, 1.06, P 0.50), ideal BMI (Adj. PR 0.99, 95% CI 0.92, 1.09, P 0.99) and adequate physical activity (Adj. PR 1.12, 95% CI 0.97, 1.29, P 0.12) showed no significant difference between the groups. There was poor BP control in patients with diabetes compared to those without the same (Adj. PR 0.19, 95% CI 0.15, 0.23, P < 0.0001). LDL cholesterol control was better in patients with diabetes in comparison to those without the same (Adj. PR 1.19, 95% CI 1.08, 1.31, P 0.0005).

CONCLUSION

The compliance for secondary prevention of CAD among patients with diabetes is similar to those without diabetes except for poor control of hypertension and better control of LDL cholesterol.

Health-Related Quality of Life of Coronary Artery Disease Patients under Secondary Prevention: A Cross-Sectional Survey from South India

BACKGROUND

Health-related quality of life (HRQOL) is emerging as an important outcome among patients with documented coronary artery disease (CAD). The primary objective of this study was to report the HRQOL of CAD patients under secondary prevention-related treatment and follow-up using the 36-Item Short Form (SF-36) tool.

METHODS

This was an analytical cross-sectional survey done in a hospital/clinic setting. We recruited CAD patients 30 to 80 years old with 1 to 6 years of follow-up. Patients self-reported HRQOL using SF-36.

RESULTS

We recruited 1206 patients, among whom 879 (72.9%) were male. The mean age of patients was 61.3 (9.6) years. Mean (± standard deviation) scores for physical functioning, role limitations due to physical health, pain, and general health were 66.48 ± 29.41, 78.96 ± 28.01, 80.96 ± 21.15, and 51.49 ± 20.19, respectively. The scores for role limitations due to emotional problems, energy/fatigue, emotional well-being, and social functioning were 76.62 ± 28.0, 66.18 ± 23.92, 76.91 ± 20.47, and 74.49 ± 23.55. In subgroup analysis, age, sex, type of CAD, and treatment showed no significant association with any of the 8 domains of QOL. In addition, hypertension and diabetes showed no significant association with the individual domains of HRQOL.

CONCLUSION

Patients with coronary artery disease under secondary prevention-related treatment have suboptimal HRQOL under both physical and mental domains. The role of demographic factors, comorbidities, disease subtypes, and treatment options in modifying HRQOL among patients with CAD appears to be minimal.

Cost Needed to Treat (CNT) and Number Needed to Treat (NNT) analysis of drugs for treatment of heart failure in India

Background

Only little attention has been paid to treatment strategies of chronic disease conditions that require long term treatment and repeated hospitalizations

Purpose

Our aim was to review cost-effectiveness of guideline directed medical therapy of heart failure in India and identify drugs that can be made available free of cost or at subsidized rates to the patient population.

Methods

Data extracted from ten landmark trials in heart failure was used to compute Number Needed to Treat (NNT) and Cost Needed to Treat (CNT) of drugs used in heart failure, to prevent cardiovascular mortality and heart failure re-hospitalization using HDS Plotter- Incremental Cost Effectiveness Calculator. Since various brands (i.e. trade names) with wide cost range are available in Indian market, the average retail price in Indian Rupees for year 2019 was considered and converted to US dollars and used for the analysis.NNT and CNT of each drug was computed and the cost-effectiveness was analyzed. WHO recommendation of three times per capita GDP was used as the cost effectiveness threshold.

Results

Medications that were labeled as class I for the treatment of heart failure, were included in our analysis. Ivabradine, Valsartan and Angiotensin Receptor Neprilysin inhibitor (ARNi) did not meet the cost effectiveness criteria for preventing cardio-vascular mortality. For prevention of heart failure re-hospitalization, all drugs except ARNi, met the cost effectiveness threshold.

Conclusion

Any future research would need to consider compliance factor along with Willingness to Pay (WTP) to understand the real acceptance of these drugs on the ground in India.

Log prices (in US$) of various HF drugs

Funding Acknowledgement

Type of funding source: None

Compliance to secondary prevention strategies for coronary artery disease: a hospital-based cross-sectional survey from Ernakulam, South India

OBJECTIVES

The primary objective of the study was to report the compliance to secondary prevention strategies for coronary artery disease (CAD), such as smoking cessation, weight management, low-density lipoprotein (LDL) cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy from a resource-limited setting.

DESIGN

Analytical cross-sectional survey with data collection using questionnaire administered by study personnel.

SETTING

Institutional-two tertiary care hospitals and two cardiology clinics.

PARTICIPANTS

Patients in the age group of 30-80 years with documented CAD with a minimum of 1 year and a maximum of 6 years of follow-up after diagnosis.

MAIN OUTCOME MEASURES

The main outcome measures were the prevalence of individual compliance to secondary prevention strategies for CAD such as smoking cessation, weight management, LDL cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy. The secondary outcomes were the association of secondary prevention strategies with age, sex, domicile, socioeconomic status, insurance and type of treatment.

RESULTS

We recruited a total of 1206 patients among whom 879 (72.9%) were males. The median age of patients was 62 (14) years. The compliance to smoking cessation was 93.86% (95% CI 91.66% to 96.06%), ideal body mass index was 63.76% (95% CI 61.05% to 66.47%), blood pressure control was 65.11% (95% CI 62.42% to 67.80%), LDL compliance was 36.50% (95% CI 33.18% to 39.82%), diabetes control was 51.23% (95% CI 46.10% to 56.36%) and adequate physical activity was 39.22% (95% CI 36.46% to 41.98%)respectively. Reported compliance for cardiovascular drugs therapy was 96% for antiplatelets, 89.4% for statins, 68.2% for beta blockers, 37.7% for renin angiotensin aldosterone system blockers, 81.28% for oral hypoglycaemic agents and 22% for insulin therapy.

CONCLUSION

Compliance to secondary prevention strategies for CAD in resource limited settings are moderate. This needs further improvement for better outcomes related to CAD in future.

Isolation of antigenotoxic ursolic acid from <i>Ixora coccinea</i> flowers

Ixora coccinea L. (Rubiaceae) is a common shrub distributed throughout tropical India. The flowers of I. coccinea are extensively used in ayurvedic medicine. The hexane fraction of the flowers showed significant antigenotoxic properties. Chemical investigation of the above fraction has led to the isolation of the triterpenoid, ursolic acid as the active constituent.

Curcuma ecalcarata - new natural source of pinocembrin and piperitenone

Phytochemical analysis of the rhizome extract of Curcuma ecalcarata, a hitherto uninvestigated south Western Ghats endemic species, resulted in the isolation and identification of the diaryl heptanoid trans, trans-1,7-diphenyl-5-hydroxy-4,6-heptadiene-3-one (1), steroid β-sitosterol (2), flavanone pinocembrin (4) and monoterpenoids piperitenone (3) and 8-hydroxy piperitone (5). HPTLC estimation of pinocembrin in the rhizome revealed the plant as a rich source of pinocembrin (0.37% dry wt.). The rhizome essential oil was isolated by hydrodistillation and analysed by GC-FID, GC-MS and (13)C NMR. Among the 30 constituents identified in the oil, monoterpenoids predominated (94.2%) followed by sesquiterpenoids (5.8%). The major compound consisting of 65.2% of the oil was isolated and identified as piperitenone (3). The study highlights the plant as a rich source of the flavanone pinocembrin and the volatile aroma compound piperitenone.

Aortic pulse wave velocity and its relationship with complexity of coronary artery disease based on SYNTAX score

BACKGROUND

Aortic pulse wave velocity (APWV), a marker of arterial stiffness, was found to be a good predictor for the presence of incipient vascular disease and cardiovascular events in observational studies. APWV measured by echo Doppler is a simple and readily available method comparable with other costlier and complex modalities of APWV measurement like MRI, Complior method or applanation tonometry.

AIMS AND OBJECTIVES

No previous studies have demonstrated a relationship between APWV findings and the complexity of coronary artery disease (CAD). Our aim was to examine the relationship between APWV findings and the severity of SYNTAX scores (SX scores).

METHODS

500 patients who had undergone APWV measurements and elective coronary angiography from September 2012 to June 2013 were taken. Pulsed Doppler ultrasound (6.6 MHZ) probe with ECG synchronisation was used to calculate APWV. SYNTAX scoring was performed by observers who were blinded to APWV values.

RESULTS

A significant, nearly linear correlation between APWV and advancing CAD (p<0.0001) was observed. Patients with dual-vessel and triple-vessel disease had significantly higher APWV than patients without CAD. It was also found that mean APWV values were significantly more in patients with high or intermediate SX scores than in patients with low SX scores. The Fischer's linear discriminant analysis showed a cut-off value of APWV for predicting the possibility of having CAD to be >11.5 m/s.

CONCLUSIONS

APWV has predictive value for the SX score. A positive relation exists between aortic stiffening and coronary atherosclerosis and APWV measured by 2D Doppler is a good predictor of advancing CAD.

A study of ECG pattern, cardiac structural abnormalities and familial tendency in patients with early repolarisation syndrome in South India

BACKGROUND

Early repolarisation (ER) on ECG, which was initially believed to be benign, has of late been considered otherwise. Brugada syndrome has recently been thought to be an extension of the ER spectrum, and the familial tendency of the ER pattern is being highlighted. With attention being drawn to ER's association with idiopathic ventricular fibrillation (VF), the prognosis and lineage of patients with an ER pattern are under scrutiny.

AIMS

To analyse ER patterns on ECG, their presence in first-degree relatives and their association with structural heart disease. To classify different types of ER and estimate the prevalence of the high-risk notch/slur pattern in the population studied.

METHODS

We screened all patients presenting to our department from December 2011 to July 2014 for ER patterns. We excluded patients with other causes of ST elevation that mimicked the ER pattern, those aged <18 years, and those not willing to participate in the study. A complete physical examination, 12-lead ECG and echocardiography were performed on all study patients. Willing first-degree relatives were screened with a 12-lead ECG. Of the 963 patients with ER that we initially screened, 843 completed the study. A total of 4116 relatives were screened.

RESULTS

Of the 843 patients who completed the study, 687 (81.5%) were male and 156 (18.5%) were female. The majority were asymptomatic (70.11%), but had been referred for ECG abnormalities. Fifteen patients with chest pain were inadvertently thrombolysed and were later diagnosed to have ER. Their ER pattern was exaggerated during chest pain, which made this error highly likely. Among the 48 patients who had acute coronary syndrome (ACS), ER pattern was noticed in a different lead than those affected by ACS. Of these, 27 (56.25%) had ventricular tachycardia/VF during the acute phase. Six patients had electrical storm without evidence of ACS, and all had a global ER pattern with prominent notching/slurring on baseline ECG. The most common type of ER pattern was type I (lateral leads; 55.87%). Twenty-one patients had a Brugada pattern. Of all the patients with ER, only a third (34.16%) had the possibly high-risk notched/slurred ECG pattern. The majority (82.92%) had a structurally normal heart. We found that mitral valve prolapse (MVP), as assessed by >2 mm leaflet prolapse from the annulus, was more common in patients with ER (11.39%). Of the 4116 relatives screened, 2625 (63.78%) had an ER pattern; a quarter of family members had the inferolateral variety and over 60% of relatives had the lateral variety. We also noticed different ER patterns in the same family.

CONCLUSIONS

We found that exaggeration of the ER pattern during chest pain may lead to inadvertent thrombolysis. A notched/slurred ER pattern is found in only a third of patients, who need to be grouped separately, as they may constitute a high-risk category. Patients with ER had MVP at a higher prevalence (almost double) than the general population, probably explaining the high incidence of sudden cardiac death associated with MVP. A familial tendency to an ER pattern was found in more than half of first-degree relatives, with different ER patterns, even the Brugada pattern, found in the same family. This may be because Brugada and other ER patterns belong to the same spectrum and may share the same prognosis. Thus we conclude that further studies regarding ER, its association with MVP, risk stratification by notched ECG pattern, and familial distribution along with gene analysis are warranted.

Analysis of multiple sweeteners and their degradation products in lassi by HPLC and HPTLC plates

A solid phase extraction method using C18 cartridges was standardized for the isolation of multiple sweeteners (aspartame, acesulfame-K and saccharin) and their degradation products (diketopiperazine, Lphenylalanine, acetoacetamide and 2-sulfobenzoic acid) from lassi. Analytical conditions for HPLC were standardized over C18 column using UV detector for the simultaneous separation and estimation of multiple sweeteners and their degradation products in lassi sample isolates. A simple cartridge free method was developed for the isolation of sucralose from lassi. Method was also standardized for qualitative detection and quantitative estimation of sucralose over amino and silica gel plates of HPTLC.

Chemical composition and antimicrobial activity of essential oil from the rhizomes of Amomum cannicarpum

The essential oil obtained by hydrodistillation of the rhizomes of Amomum cannicarpum was analyzed by GC and GC/MS. Thirty-four compounds were identified, of which the major components were beta-terpineol (13.4%), beta-pinene (9.4%) and alpha-pinene (6.9%). The essential oil showed significant antimicrobial activity.

Single-nucleotide polymorphisms in the C-reactive protein (CRP) gene promoter that affect transcription factor binding, alter transcriptional activity, and associate with differences in baseline serum CRP level

To investigate whether functional polymorphisms exist in the C-reactive protein (CRP) gene, i.e., ones that contribute directly to differences in baseline CRP among individuals, we sequenced a 1,156-nucleotide-long stretch of the CRP gene promoter in 287 ostensibly healthy people. We identified two single-nucleotide polymorphisms (SNPs), a bi-allelic one at nucleotide -409 (G-->A), and a tri-allelic one at -390 (C-->T-->A), both resident within the hexameric core of transcription factor binding E-box elements. Electrophoretic mobility shift assays confirmed that the SNP within the sequence (-412)CACGTG(-407) (E-box 1) modulates transcription factor binding, and that the one within (-394)CACTTG(-389) (E-box 2) supports transcription factor binding only when the -390 T allele is present. The commonest of four E-box 1/E-box 2 haplotypes (-409G/-390T) identified in the population supported highest promoter activity in luciferase reporter assays, and the rarest one (-409A/-390T) supported the least. Importantly, serum CRP in people with these haplotypes reproduced this rank order, i.e., people with the -409G/-390T haplotype had the highest baseline serum CRP (mean +/- SEM 10.9 +/- 2.25 microg/ml) and people with the -409A/-390T haplotype had the lowest (5.01 +/- 1.56 microg/ml). Furthermore, haplotype-associated differences in baseline CRP were not due to differences in age, sex, or race, and were still apparent in people with no history of smoking. At least two other SNPs in the CRP promoter lie within E-box elements (-198 C-->T, E-box 4, and -861 T-->C, E-box 3), indicating that not only is the quality of E-box sites in CRP a major determinant of baseline CRP level, but also that the number of E-boxes may be important. These data confirm that the CRP promoter does encode functional polymorphisms, which should be considered when baseline CRP is being used as an indicator of clinical outcome. Ultimately, development of genetic tests to screen for CRP expression variants could allow categorization of healthy people into groups at high versus low future risk of inflammatory disease.

Antimicrobial activity of Amomum cannicarpum

The petroleum ether and methanol extracts of rhizomes of Amomum cannicarpum exhibited moderate inhibiting activity against both Gram-positive and Gram-negative bacteria. None of the extractives was active against the tested moulds.

Vibrational spectroscopic studies on the natural product, columbianadin

NIR-FT Raman and FT-IR spectra of columbianadin, extracted from seeds and roots of Heracleum candolleaum, were recorded and analyzed. The vibrational frequencies of the compound have been computed using semi-empirical AM1 method and compared with experimental values. The C=O stretching frequencies of the carbonyl groups have been lowered due to conjugation. The CH stretching and bending vibrations of CH3 groups of the ester part indicate the presence of hyperconjugation effect. Characteristic ring vibrations have also been identified.

Comparison of the QTDT analysis for IgE in the CSGA data set

Over the past few years at least 13 transmission/disequilibrium test (TDT)-based tests have been developed for quantitative (Q) traits for the assessment of association or linkage in the presence of the other. A total of six of these QTDT methods were used to analyze log10IgE in the Collaborative Study on the Genetics of Asthma data set. Only moderate agreement was found between the tests. The results of the QTDT analyses were only slightly affected by the use of gender and age as covariates. Results from analysis of IgE and log10IgE were inconsistent. Our conclusion is that there is only modest agreement among the QTDT methods examined, covariates should be used even if they have a small effect, and that data should be normalized before analysis.

Transmission/disequilibrium test analysis of total serum IgE levels in the Hutterite and Collaborative Study on the Genetics of Asthma data sets

The Hutterite and Collaborative Study on the Genetics of Asthma data sets provided by Genetic Analysis Workshop 12 were analyzed using a regression-based transmission/disequilibrium test that assesses linkage between a marker locus and quantitative trait locus when allelic association is present, as proposed by George et al. [Am J Hum Genet 65:236-45, 1999]. Because the same marker set and analytical technique was used, the results from these data sets are amenable for comparison. Statistically significant results common to both data sets were found on chromosomes 1 and 3. A noteworthy result, significant at p < 10(-4), was detected on chromosome 18 in the Hutterites.

Evaluation of micrometastases in sentinel lymph nodes of cutaneous melanoma: higher diagnostic accuracy with Melan-A and MART-1 compared with S-100 protein and HMB-45

Accurate diagnosis of micrometastases in sentinel lymph nodes of cutaneous melanoma is critical for proper clinical management. S-100 protein and HMB-45 are the traditional immunomarkers widely used for this purpose. However, the interpretation of micrometastases by these markers is difficult with significant reduction in the diagnostic accuracy. S-100 protein demonstrates immunoreactivity for other nonmelanoma cells and obscures nuclear details, which are crucial for the interpretation of single cell metastases. We compared the new melanoma markers, Melan-A (clone A103) and MART-1 (clone M2-7C10), with S-100 protein and HMB-45, by examining 77 formalin-fixed paraffin-embedded sections of sentinel lymph nodes from 13 cases of primary cutaneous melanoma. CD68 (PG-M1) and hematoxylin-eosin-stained sections were also studied. Four pathologists interpreted the staining pattern after concealing the identity of each immunomarker. Az values (area under receiver operating characteristic curve) with receiver operating characteristic curve were higher with Melan-A (0.9742) and MART-1 (0.9779) compared with S-100 protein (0.8034) and HMB-45 (0.8651), demonstrating a higher diagnostic accuracy with Melan-A and MART-1 with superior detection of melanoma micrometastases. Melan-A and MART-1 showed sharp cytoplasmic immunoreactivity, almost exclusively restricted to the melanoma cells. Therefore, Melan-A and MART-1 are recommended for the evaluation of micrometastases in sentinel lymph nodes of cutaneous melanoma as a routine alternative to S-100 protein and HMB-45.

Impact of diet on blood pressure and age-related changes in blood pressure in the US population: analysis of NHANES III

BACKGROUND

The impact of diet on blood pressure and the age-related changes in blood pressure have been difficult to detect within one population. We designed this analysis to study the association of major dietary factors with blood pressure and with age-related changes in blood pressure in a representative sample of the US population.

METHODS

Data were obtained on all individuals 20 years or older (n = 17 030) surveyed in the Third National Health and Nutrition Examination Survey (NHANES III), including demographic data, anthropometric data, dietary intake (sodium, potassium, calcium, magnesium, protein, alcohol, and total energy) based on 24-hour recall, and blood pressure. Multivariate models relating diet to blood pressure were constructed using stepwise regression, best subset regression, and multiple regression.

RESULTS

Systolic blood pressure was positively associated with higher sodium, alcohol, and protein intakes (P<.05) and negatively associated with potassium intake (P =.003). Diastolic blood pressure was negatively associated with potassium and alcohol intakes (P<.001). Pulse pressure was positively associated with sodium, protein, and alcohol intakes (P<.001). A higher intake of calcium (P =.01) was associated with a lower rate of rise in systolic blood pressure with age.

CONCLUSION

A diet low in sodium, alcohol, and protein is associated with lower systolic blood and pulse pressure. Potassium intake was associated with lower systolic and diastolic blood pressure, whereas alcohol intake was associated with lower diastolic blood pressure. In addition, the age-related changes in systolic blood pressure were attenuated by higher calcium and protein intakes. Magnesium was not associated with any changes in blood pressure.

Risk factors for pediatric asthma emergency visits. Milwaukee Childhood Asthma Project Team

The purpose of this study was to identify risk factors for pediatric asthma emergency department (ED) visits. A cross-sectional sample of 307 families (24%) responded to a mailed survey. Respondents were similar to the target population of 2487 children with asthma. Thirty-seven percent of respondents had two or more asthma ED visits in the past year. Asthma ED use was associated with persistent asthma symptoms, parents without high school diplomas, age under 4 years, African-American race/ethnicity, use of written care plans, and use of spacers at school. The latter two variables were associated with severe asthma. High-risk children can be targeted for office-based medical care.

The role of participation in the women's health trial: feasibility study in minority populations

BACKGROUND

This paper examines participation rates and the association between participation and study outcomes (% energy from fat) among participants in the Women's Health Trial: Feasibility Study in Minority Populations, a randomized clinical trial to determine if ethnically and socioeconomically diverse women could be recruited and make significant dietary changes.

METHODS

Women (n = 2,208) were recruited from three clinical centers and randomized to either an intervention group or a control group. Multiple measures were collected at 6 months.

RESULTS

Participation rates for follow-up data collection activities were high (average participation 79%). Hispanics and lower educational groups participated significantly less (59% for Hispanics vs 86% for blacks and whites; 78% for lowest educational group vs 84% for highest educational group). Intervention participation significantly predicted change in percentage energy from fat (P < 0.001), accounting for an additional 8% of variance after background variables were controlled for.

CONCLUSIONS

These data suggest that intervention participation is positively related to dietary change, but they cannot rule out the possibility that other factors may influence both of these factors.

Monoterpenoids from the seeds of Heracleum candolleanum

The isolation and NMR spectra of 2-exo,3-endo-camphanediol (1) and 2-pinene-4,10-diol (2) from the seeds of Heracleum candolleanum are reported.

Intraoperative scrape cytology: comparison with frozen sections, using receiver operating characteristic (ROC) curve

The diagnostic role of intraoperative cytology (IC) has been demonstrated by many comparative studies. These studies have used sensitivity and specificity as statistical tools, based on binary principles. Statistical methods based on binary principles appear to be inappropriate for comparing anatomic pathology studies which involve significant human judgment with a range of subjective nonbinary result patterns. In this study, we applied the receiver operating characteristic (ROC) curve, which is based on probabilistic principles for the comparison of diagnostic accuracy with IC and frozen sections (FS). Seven observers studied a variable number of IC alone, FS alone, and IC/FS together from a pool of 446 specimens. The results were analyzed by ROC curve, using the MEDCALC software program (MedCalc Software, Mariakerke, Belgium). The accuracy with IC alone and FS alone was comparable. IC alone was diagnostic for many lesions, offering the choice of not freezing the tissue, and thus avoiding the introduction of artifacts. This strongly favors the routine practice of preparing IC during intraoperative consultation.

Genetic determinants of hypertension: identification of candidate phenotypes

Our long-term objective is to identify genes whose expression results in hypertension and in phenotypic changes that may contribute to hypertension. The purpose of the present study was to describe evidence for the heritability of hypertension-related phenotypes in hypertensive, hyperlipidemic black sib pairs. Outpatient anthropomorphic measurements were obtained in >200 affected sib pairs. In addition, 68 of these sib pairs were studied under controlled, standardized conditions at an inpatient clinical research center while off both antihypertensive and lipid-lowering medications. Heritability was estimated on the basis of sib-sib correlations and with an association model. Higher heritability estimates for blood pressure were observed with multiple measurements averaged over 24 hours than with measurements at a single time point, and heritability estimates for nighttime blood pressures were higher than those for daytime blood pressures. Heritability estimates for several of the phenotypes were augmented by obtaining measurements in response to a standardized stimulus, including (1) blood pressure responses to the assumption of upright posture, standardized psychological stress, and norepinephrine infusion; (2) plasma renin, aldosterone, epinephrine, and cAMP and cGMP responses to the assumption of upright posture; (3) para-aminohippurate and inulin clearances in response to norepinephrine infusion; and (4) plasma arginine vasopressin in response to NaCl infusion. High heritability estimates were also observed for various measures of body size and body fat, left ventricular size, cardiac index, stroke volume, total peripheral resistance, and serum concentrations of LDL and HDL cholesterol and leptin. These heritability estimates identify the hypertension-related phenotypes that may facilitate the identification of specific genetic determinants of hypertension in blacks with hyperlipidemia.

Spontaneous fungal peritonitis in patients with hepatitis B virus-related liver disease

Spontaneous bacterial peritoneal infections is recognized as a very common complication of cirrhotic ascites, but isolation of fungus in pure culture from ascitic fluid is relatively rare, even more so in the human immunodeficiency virus (HIV)-negative or nonimmunocompromised hosts. We describe two patients of spontaneous fungal peritonitis where the isolate was Cryptococcus neoformans. Both cases suffered from hepatitis B virus (HBV) infection. The clinical and laboratory profiles of both patients were similar to those of conventional spontaneous bacterial peritonitis. We suggest that it would be prudent to heighten clinical suspicion for fungal peritonitis in such cases.

Analysis of 'natural' and vaccine-induced haemophilus influenzae type B capsular polysaccharide serum antibodies for 3H1, a V3-23-associated idiotope

The variable (V-) region repertoire of antibodies (Abs) to Haemophilus influenzae capsular polysaccharide (Hib PS) has been extensively studied in individuals vaccinated against the microbe, but to a lesser extent in subjects who generated such Abs in response to a 'natural' encounter with this microbe or its antigenic mimics. To gain an insight into the repertoire of Hib PS-reactive Abs in vaccinated and non-vaccinated individuals, we used a monoclonal Ab, 3H1, which detects an idiotypic marker associated with an Ab V-region gene, V3-23. We show here that Hib PS-reactive Abs with detectable 3H1 idiotope can be quantified by an indirect inimunoezymatic assay in serum samples of non-vaccinated healthy adults as well as of recently vaccinated healthy infants. The percentage of Abs that was simultaneously Hib PS-reactive and 3H1-positive ranged widely (from 0 to 68%) among individual serum samples from both groups of subjects. No dramatic differences in the expression of 3H1 idiotope on Hib PS-reactive Abs were found between vaccinated and non-vaccinated individuals. Our results are consistent with the hypothesis that the utilization of V-region genes in Hib PS-reactive Abs that individuals generate after a 'natural' encounter with Hib PS or its mimics is similar to that in these Abs elicited by Hib PS conjugate vaccines.

Asthma severity among children hospitalized in 1990 and 1995

BACKGROUND

During the past decade, the number of children with asthma increased; however, the number of asthma hospitalizations for children decreased.

OBJECTIVE

To assess the proportion of high-severity cases among children hospitalized with asthma and the association of high-severity asthma with patient and hospital characteristics.

DESIGN

The data set used was the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Records were selected of patients 18 years and younger who had the principal diagnosis of asthma. Records were analyzed of 29077 patients at 746 hospitals in 1990 and 33 443 patients at 811 hospitals in 1995. Asthma severity was classified by All Patient Refined-Diagnosis-Related Groups. Cross-sectional logistic regression analysis was performed using survey data analysis software.

RESULTS

The most common diagnoses associated with high-severity asthma were respiratory distress and respiratory failure. The proportion of high-severity asthma cases did not change significantly between 1990 (4.2%) and 1995 (4.6%) (P = .08). Adolescents and boys were more likely to have high-severity asthma than children aged 5 to 12 years and girls. Western, southern, and north-central hospitals and urban teaching hospitals had a higher proportion of high-severity asthma cases than northeastern hospitals and nonteaching hospitals.

CONCLUSIONS

Between 1990 and 1995, the proportion of high-severity cases among children hospitalized with asthma did not change significantly. However, patient age, sex, region of the country, and hospital teaching status were associated with variations in the proportion of high-severity asthma cases.

The use of esmolol, nicardipine, or their combination to blunt hemodynamic changes after laryngoscopy and tracheal intubation

Laryngoscopy and tracheal intubation (LTI) often provoke an undesirable increase in blood pressure (BP) and/or heart rate (HR). We tested the premise that nicardipine (NIC) and esmolol (ESM) in combination (COMB) would oppose both. Adult surgical patients received pretreatment (randomized) with IV bolus NIC 30 microg/kg (n = 31), ESM 1.0 mg/kg (n = 34), or COMB (one-half dose each, n = 32). Peak BP and HR after LTI were compared with controls (CONT; n = 35) with no pretreatment. Anesthetic induction was standardized: IV thiopental (5-7 mg/kg), fentanyl (1-2 microg/kg), and succinylcholine (1.5 mg/kg). Systolic (S), diastolic (D), and mean (M) BP and HR awake before pretreatment (baseline) were similar in all test groups. No patient was treated for hypotension, bradycardia, or tachycardia after pretreatment or anesthetic induction. Peak HR after LTI was increased versus baseline in CONT and all test groups, but did not differ from CONT among the test groups. Peak SBP and DBP increased versus baseline in CONT, and with ESM and NIC, but not COMB. Peak SBP, DBP, and MBP were increased with ESM versus COMB, and peak DBP with ESM versus NIC. Compared with no pretreatment before the IV induction of general anesthesia, the peak increase in BP after LTI is best blunted by the combination of nicardipine and ESM, compared with either drug alone. No single drug or combination in the doses tested opposed increased HR.

IMPLICATIONS

Compared with no pretreatment before the IV induction of general anesthesia, the peak increase in blood pressure after laryngoscopy and tracheal intubation is best blunted by the combination of nicardipine and esmolol, compared with either drug alone. No single drug or combination in the doses tested opposed increased heart rate.

Linkage and association analyses of alcoholism using a regression-based transmission/disequilibrium test

Recently, George et al. proposed a regression-based transmission/disequilibrium test for linkage using information on the parent-to-offspring transmission status of an allele at a marker locus. We extended this test by simultaneously testing for any population association by incorporating the presence/absence status of the associated allele as a covariate in the model. We used this method to analyze markers on chromosomes 1 through 21 of the Collaborative Study on the Genetics of Alcoholism data on alcoholism for possible association and linkage. We found nominal significance (at the 0.02 level) at eight different regions for linkage, though statistical significance may not be concluded due to multiple testing. The strongest evidence of linkage was observed for markers D4S2639 and D12S397 with p-values less than 0.005. We also found strong association between the trait and alleles 149 of D7S691 and 131 of D21S1437.

Association and linkage analysis of ICD-10 diagnosis for alcoholism

We analyzed the GAW11 data on alcoholism provided by the Collaborative Study on the Genetics of Alcoholism (COGA) using an extension of a new test of linkage and association for quantitative traits developed by George et al. [1999]. This method determines linkage between marker loci and quantitative traits, when allelic association is present between the trait and marker loci, by regressing the disease trait on the parental transmission of the allele of interest. We found no strong evidence of linkage to any markers. However, we found several markers suggestive of possible linkage that may deserve further investigation.

Prostate-specific antigen expression and lipochrome pigment granules in the differential diagnosis of prostatic adenocarcinoma versus seminal vesicle-ejaculatory duct epithelium

BACKGROUND

Lipochrome pigment granules (LPGs) and prostate-specific antigen (PSA) localization have been cited as helpful adjuncts in differentiating atypical histologic patterns of seminal vesicle-ejaculatory duct (SVED) from prostatic adenocarcinoma. However, LPGs have been described in both benign and neoplastic prostatic acini, and PSA expression within the intraprostatic SVED has not been fully explored.

DESIGN

Fifty radical prostatectomy specimens were studied for LPGs and 9 cases for PSA expression.

RESULTS

Two morphologic types of LPGs (type 1 and type 2) were observed. The reproducibility in classifying LPGs was evaluated by kappa statistics, which demonstrated a strong agreement between 4 observers. Type 1 was restricted to SVED in all 50 specimens. Type 2 was subclassified into 2A and 2B. Type 2 LPGs were observed in prostatic acini of different zones, high-grade prostatic intraepithelial neoplasia, prostatic adenocarcinoma, and occasionally with type 1 LPG in SVED. Focal reactivity for PSA in the distal portion of SVED near urethra was noted in 1 of 9 cases.

CONCLUSION

Awareness about morphologic differences between the 2 types of LPGs could help to avoid a potential diagnostic pitfall of misinterpreting SVED epithelium for adenocarcinoma. Caution is recommended in interpreting PSA expression, since rare focal PSA reactivity was observed in the distal SVED.

Acinetobacter meningitis following head trauma

A case of acinetobacter meningitis following head injury in a patient who developed cerebrospinal fluid otorrhea, and did not have any neurosurgical procedure, is presented. Previously reported cases are cited, with a review of the literature. Pefloxacin monotherapy is associated with a poor clinical response.

Recurrent and de novo glomerular disease after renal transplantation: a report from Renal Allograft Disease Registry (RADR)

INTRODUCTION

Short-term and long-term results of renal transplantation have improved over the past 15 years. However, there has been no change in the prevalence of recurrent and de novo diseases. A retrospective study was initiated through the Renal Allograft Disease Registry, to evaluate the prevalence and impact of recurrent and de novo diseases after transplantation.

MATERIALS AND METHODS

From October 1987 to December 1996, a total of 4913 renal transplants were performed on adults at the Medical College of Wisconsin, University of Cincinnati, University of California at San Francisco, University of Louisville, University of Washington, Seattle, and Washington University School of Medicine. The patients were followed for a minimum of 1 year. A total of 167 (3.4%) cases of recurrent and de novo disease were diagnosed by renal biopsy. These patients were compared with other patients who did not have recurrent and de novo disease (n=4746). There were more men (67.7% vs. 59.8%, P<0.035) and a higher number of re-transplants (17% vs. 11.5%, P<0.005) in the recurrent and de novo disease group. There was no difference in the rate of recurrent and de novo disease according to the transplant type (living related donor vs. cadaver, P=NS). Other demographic findings were not significantly different. Common forms of glomerulonephritis seen were focal segmental glomerulosclerosis (FSGS), 57; immunoglobulin A nephritis, 22; membranoproliferative glomerulonephritis (GN), 18; and membranous nephropathy, 16. Other diagnoses include: diabetic nephropathy, 19; immune complex GN, 12; crescentic GN (vasculitis), 6; hemolytic uremic syndrome-thrombotic thrombocytopenic purpura (HUS/TTP), 8; systemic lupus erythematosus, 3; Anti-glomerular basement membrane disease, 2; oxalosis, 2; and miscellaneous, 2. The diagnosis of recurrent and de novo disease was made after a mean period of 678 days after the transplant. During the follow-up period, there were significantly more graft failures in the recurrent disease group, 55% vs. 25%, P<0.001. The actuarial 1-, 2-, 3-, 4, and 5-year kidney survival rates for patients with recurrent and de novo disease was 86.5%, 78.5%, 65%, 47.7%, and 39.8%. The corresponding survival rates for patients without recurrent and de novo disease were 85.2%, 81.2%, 76.5%, 72%, and 67.6%, respectively (Log-rank test, P<0.0001). The median kidney survival rate for patients with and without recurrent and de novo disease was 1360 vs. 3382 days (P<0.0001). Multivariate analysis using the Cox proportional hazard model for graft failure was performed to identify various risk factors. Cadaveric transplants, prolonged cold ischemia time, elevated panel reactive antibody, and recurrent disease were identified as risk factors for allograft failure. The relative risk (95% confidence interval) for graft failure because of recurrent and de novo disease was 1.9 (1.57-2.40), P<0.0001. The relative risk for graft failure because of posttransplant FSGS was 2.25 (1.6-3.1), P<0.0001, for membranoprolifera. tive glomerulonephritis was 2.37 (1.3-4.2), P<0.003, and for HUS/TTP was 5.36 (2.2-12.9), P<0.0002. There was higher graft failure (64.9%) and shorter half-life (1244 days) in patients with recurrent FSGS.

CONCLUSION

In conclusion, recurrent and de novo disease are associated with poorer long-term survival, and the relative risk of allograft loss is double. Significant impact on graft survival was seen with recurrent and de novo FSGS, membranoproliferative glomerulonephritis, and HUS/TTP.

A test of transmission/disequilibrium for quantitative traits in pedigree data, by multiple regression

The transmission/disequilibrium (TD) test (TDT), proposed, by Spielman et al., for binary traits is a powerful method for detection of linkage between a marker locus and a disease locus, in the presence of allelic association. As a test for linkage disequilibrium, the TDT makes the assumption that any allelic association present is due to linkage. Allison proposed a series of TD-type tests for quantitative traits and calculated their power, assuming that the marker locus is the disease locus. All these tests assume that the observations are independent, and therefore they are applicable, as a test for linkage, only for nuclear-family data. In this report, we propose a regression-based TD-type test for linkage between a marker locus and a quantitative trait locus, using information on the parent-to-offspring transmission status of the associated allele at the marker locus. This method does not require independence of observations, thus allowing for analysis of pedigree data as well, and allows adjustment for covariates. We investigate the statistical power and validity of the test by simulating markers at various recombination fractions from the disease locus.

The Women's Health Trial Feasibility Study in Minority Populations: changes in dietary intakes

This randomized clinical trial examined the feasibility of low-fat dietary interventions among postmenopausal women of diverse backgrounds. During 1992-1994, 2,208 women aged 50-79 years, 28% of whom were black and 16% Hispanic, enrolled at clinics in Atlanta, Georgia, Birmingham, Alabama, and Miami, Florida. Intervention/support groups met periodically with a nutritionist to reduce fat intake to 20% of energy and to make other diet modifications. At 6 months postrandomization, the intervention group reduced fat intake from 39.7% of energy at baseline to 26.4%, a reduction of 13.3% of energy, compared with 2.3% among controls. Saturated fatty acid and cholesterol intakes were reduced, but intakes of fruits and vegetables, but not grain products, increased. Similar effects were observed at 12 and 18 months. Black and non-Hispanic white women had similar levels of reduction in fat, but the decrease in Hispanic women was less. Changes did not vary significantly by education. While bias in self-reported intakes may have resulted in somewhat overestimated changes in fat intake, the reported reduction was similar to the approximately 10% of energy decrease found in most trials and suggests that large changes in fat consumption can be attained in diverse study populations and in many subgroups.