Specialist and Patient Perspectives on Strategies to Improve Cardiovascular Disease Prevention Among Persons Living with Psoriatic Disease

Background

Psoriasis is an immune-mediated disease associated with excess risk for cardiovascular disease (CVD). Guidelines recognize psoriasis as a CVD risk enhancer; however, psoriasis patients often do not have CVD risk factors identified nor managed.

Objective

This study examines strategies to improve CVD prevention care from the perspective of dermatologists and patients with psoriasis.

Methods

Qualitative interviews were conducted using the Consolidated Framework for Implementation Research to examine the perspectives of physicians (N = 16) and patients with psoriatic disease (N = 16) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity using NVivo software.

Results

We found three major themes suggesting areas to target for the future: (1) Appropriateness: perceptions of whether CVD care should be deployed in this setting by both clinicians and patients, (2) Feasibility: whether CVD prevention care could be integrated into the current structure of specialist practice, and (3) Care Coordination: an interest by all parties to better integrate a team approach in CVD preventative care to reduce duplicative efforts, work practically in an already existing system rather than reinventing the wheel, and progress with the patients' best interests in mind.

Conclusions

These findings will inform the design of a clinical trial comparing the effectiveness of specialist clinician implementation of CVD guideline-based prevention care in patients with psoriasis. Ultimately, this study aims to increase the lifespan and health of patients living with psoriatic disease by decreasing barriers to their receiving appropriate CVD prevention care.

Definitions of Remission in Psoriasis: A Systematic Literature Review from the National Psoriasis Foundation

Psoriasis studies increasingly employ outcomes that indicate complete disease resolution, yet remission and cure are poorly defined for psoriasis. We conducted a systematic literature review to identify definitions of psoriasis remission and cure reported in the literature. Medline, EMBASE, and The Cochrane Central Register of Controlled Trials databases were searched on July 22, 2020 for full-text studies providing definitions for psoriasis remission/cure. Definitions were analyzed descriptively for endpoint, time-frame, on/off treatment, patient-reported outcomes, and disease domains. We identified 106 studies that provided 41 unique remission definitions. Most definitions included endpoints based on Psoriasis Area and Severity Index (PASI), such as PASI75 (n=16 studies), PASI90 (n=10), PASI100 (n=10), and PASI of 0 (n=3), and descriptive endpoints related to 'skin clearance' (n=18). Few definitions specified time-frame, on/off treatment or other psoriasis-related disease domains. One small consensus-initiative defined drug-free remission for plaque psoriasis by BSA of 0 without any therapy for at least 12 months. While there is no cure for psoriasis, seven studies defined psoriasis cure using similar endpoints to those used to define remission. We identified a variety of definitions of psoriasis remission. These results will inform the development of consensus-based definitions for psoriasis remission to support efforts to improve research and clinical outcomes.

Five-year maintenance of clinical response and health-related quality of life improvements in patients with moderate-to-severe psoriasis treated with guselkumab: results from VOYAGE 1 and VOYAGE 2

BACKGROUND

Psoriasis is a chronic disease requiring long-term therapy.

OBJECTIVES

Physician- and patient-reported outcomes were evaluated through week 252 in VOYAGE 1 and VOYAGE 2.

METHODS

In total, 1829 patients were randomized at baseline to receive guselkumab 100 mg every 8 weeks, placebo or adalimumab. Patients receiving placebo crossed over to guselkumab at week 16. Patients receiving adalimumab crossed over to guselkumab at week 52 in VOYAGE 1, and randomized withdrawal and retreatment occurred at weeks 28-76 in VOYAGE 2; all patients then received open-label guselkumab through week 252. Efficacy and health-related quality of life (HRQoL) endpoints were analysed through week 252. Safety was monitored through week 264.

RESULTS

The proportions of patients in the guselkumab group who achieved clinical responses at week 252 in VOYAGE 1 and VOYAGE 2, respectively, were 84·1% and 82·0% [≥ 90% improvement in Psoriasis Area and Severity Index (PASI)]; 82·4% and 85·0% [Investigator's Global Assessment (IGA) 0 or 1]; 52·7% and 53·0% (100% improvement in PASI) and 54·7% and 55·5% (IGA 0). HRQoL endpoints were achieved as follows: 72·7% and 71·1% of patients (Dermatology Life Quality Index 0 or 1: no effect on patient's life); 42·4% and 42·0% [Psoriasis Symptoms and Signs Diary (PSSD) symptom score = 0] and 33·0% and 31·0% (PSSD sign score = 0). As measured in VOYAGE 2 only, approximately 45% of patients achieved ≥ 5-point reduction in Short Form-36 physical and mental component scores, and 80% reported no anxiety or depression (Hospital Anxiety and Depression Scale scores < 8). Similar findings were reported for adalimumab crossovers. These effects were maintained from week 52 in VOYAGE 1 and week 100 in VOYAGE 2. No new safety signals were identified.

CONCLUSIONS

Guselkumab maintains high levels of clinical response and improvement in patient-reported outcomes through 5 years in patients with moderate-to-severe psoriasis.

Hepatitis B seroprevalence in the U.S. military and its impact on potential screening strategies

INTRODUCTION

Knowledge of the contemporary epidemiology of hepatitis B virus (HBV) infection among military personnel can inform potential Department of Defense (DoD) screening policy and infection and disease control strategies.

MATERIALS AND METHODS

HBV infection status at accession and following deployment was determined by evaluating reposed serum from 10,000 service members recently deployed to combat operations in Iraq and Afghanistan in the period from 2007 to 2010. A cost model was developed from the perspective of the Department of Defense for a program to integrate HBV infection screening of applicants for military service into the existing screening program of screening new accessions for vaccine-preventable infections.

RESULTS

The prevalence of chronic HBV infection at accession was 2.3/1,000 (95% CI: 1.4, 3.2); most cases (16/21, 76%) identified after deployment were present at accession. There were 110 military service-related HBV infections identified. Screening accessions who are identified as HBV susceptible with HBV surface antigen followed by HBV surface antigen neutralization for confirmation offered no cost advantage over not screening and resulted in a net annual increase in cost of $5.78 million. However, screening would exclude as many as 514 HBV cases each year from accession.

CONCLUSIONS

Screening for HBV infection at service entry would potentially reduce chronic HBV infection in the force, decrease the threat of transfusion-transmitted HBV infection in the battlefield blood supply, and lead to earlier diagnosis and linkage to care; however, applicant screening is not cost saving. Service-related incident infections indicate a durable threat, the need for improved laboratory-based surveillance tools, and mandate review of immunization policy and practice.

An Outbreak of Covid-19 on an Aircraft Carrier

BACKGROUND

An outbreak of coronavirus disease 2019 (Covid-19) occurred on the U.S.S. Theodore Roosevelt, a nuclear-powered aircraft carrier with a crew of 4779 personnel.

METHODS

We obtained clinical and demographic data for all crew members, including results of testing by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). All crew members were followed up for a minimum of 10 weeks, regardless of test results or the absence of symptoms.

RESULTS

The crew was predominantly young (mean age, 27 years) and was in general good health, meeting U.S. Navy standards for sea duty. Over the course of the outbreak, 1271 crew members (26.6% of the crew) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by rRT-PCR testing, and more than 1000 infections were identified within 5 weeks after the first laboratory-confirmed infection. An additional 60 crew members had suspected Covid-19 (i.e., illness that met Council of State and Territorial Epidemiologists clinical criteria for Covid-19 without a positive test result). Among the crew members with laboratory-confirmed infection, 76.9% (978 of 1271) had no symptoms at the time that they tested positive and 55.0% had symptoms develop at any time during the clinical course. Among the 1331 crew members with suspected or confirmed Covid-19, 23 (1.7%) were hospitalized, 4 (0.3%) received intensive care, and 1 died. Crew members who worked in confined spaces appeared more likely to become infected.

CONCLUSIONS

SARS-CoV-2 spread quickly among the crew of the U.S.S. Theodore Roosevelt. Transmission was facilitated by close-quarters conditions and by asymptomatic and presymptomatic infected crew members. Nearly half of those who tested positive for the virus never had symptoms.

Safety of guselkumab in patients with moderate-to-severe psoriasis treated through 100 weeks: a pooled analysis from the randomized VOYAGE 1 and VOYAGE 2 studies

BACKGROUND

Long-term evaluation is required to confirm the safety profile of newer biologic agents.

OBJECTIVES

To report on pooled safety data from the ongoing VOYAGE 1 (NCT02207231) and VOYAGE 2 (NCT02207244) trials through 100 weeks of follow-up.

METHODS

Patients were randomized to either guselkumab 100 mg at weeks 0 and 4 and every 8 weeks thereafter; placebo at weeks 0, 4, 12 followed by guselkumab 100 mg at weeks 16 and 20 and every 8 weeks thereafter; or adalimumab 80 mg at week 0, 40 mg at week 1, and 40 mg every 2 weeks thereafter. Patients who received adalimumab crossed over to guselkumab at week 52 (VOYAGE 1) and at/after week 28 based on clinical response (VOYAGE 2). Open-label extensions, in which all patients received guselkumab, started at week 52 (VOYAGE 1) and week 76 (VOYAGE 2). Rates of adverse events (AEs) per 100 patient-years (PYs) are presented through 100 weeks of follow-up.

RESULTS

Through week 52, observed rates for guselkumab- and adalimumab-treated patients, respectively, were 262·45 per 100 PYs and 328·28 per 100 PYs for AEs, 6·20 per 100 PYs and 7·77 per 100 PYs for serious AEs (SAEs), 1·22 per 100 PYs and 1·79 per 100 PYs for serious infections (SIs), 0·28 per 100 PYs and 0·40 per 100 PYs for malignancies other than nonmelanoma skin cancers (NMSCs), 0·56 per 100 PYs and 0·40 per 100 PYs for NMSCs, and 0·47 per 100 PYs and 0·40 per 100 PYs for major adverse cardiovascular events (MACEs). Rates among patients treated with guselkumab through week 52 and week 100, respectively, were 262·45 per 100 PYs and 210·41 per 100 PYs for AEs, 6·20 and 6·29 per 100 PYs, for SAEs, 1·22 per 100 PYs and 1·06 per 100 PYs for SIs, 0·28 per 100 PYs and 0·38 per 100 PYs for malignancies, 0·56 per 100 PYs and 0·39 per 100 PYs for NMSCs, and 0·47 per 100 PYs and 0·38 per 100 PYs for MACEs. Among patients treated with adalimumab, rates of AEs, SAEs, SIs, malignancies, NMSCs, and MACEs showed some variability before and after crossover to guselkumab, although no new safety signals were noted after crossover.

CONCLUSIONS

The safety profile for guselkumab remains favourable through 100 weeks of treatment in patients with moderate-to-severe psoriasis.

Work/study productivity gain and associated indirect cost savings with guselkumab compared with adalimumab in moderate-to-severe psoriasis: results from the VOYAGE 1 study

Background: Work productivity loss (WPL) is a major contributor to the indirect costs of psoriasis. Newer biologic therapies are effective at reducing disease symptoms and improving quality of life, but their impact on WPL and associated indirect cost savings compared to previously approved biologic therapies is largely unknown.Objectives: To compare the effects of guselkumab and adalimumab on WPL and associated indirect cost savings in patients with moderate-to-severe psoriasis.Methods: Using data from the VOYAGE 1 (NCT02207231) trial, improvements from baseline in Dermatology Life Quality Index (DLQI) work/study domain scores were compared for patients receiving guselkumab or adalimumab at 24 and 48 weeks of treatment. Improvements in WPL and associated cost savings were calculated using a previously established DLQI-WPL algorithm.Results: Among patients who could not work/study at baseline (DLQI work/study domain score = 3), a significantly greater proportion of guselkumab-treated patients could work/study without problems (DLQI work/study domain score = 0) than adalimumab-treated patients at Weeks 24 and 48. Improvements from baseline in WPL and associated cost savings were greater with guselkumab than with adalimumab at Week 48.Conclusions: Guselkumab was superior to adalimumab for improvement in WPL and associated indirect cost savings, and its use may reduce the economic burden of psoriasis.

Adalimumab medium-term dosing strategy in moderate-to-severe hidradenitis suppurativa: integrated results from the phase III randomized placebo-controlled PIONEER trials

Background

Weekly adalimumab (Humira^®) is approved for the treatment of hidradenitis suppurativa (HS) based on the 12‐week placebo‐controlled periods of the two phase III PIONEER trials.

Objectives

Using PIONEER integrated trial results, we aimed to evaluate the optimal medium‐term adalimumab maintenance dosing strategy for moderate‐to‐severe HS.

Methods

Each trial had two double‐blind periods; 12‐week Period A and 24‐week Period B. Patients randomized to adalimumab 40 mg every week (ADAew) (Period A), were rerandomized in Period B to ADAew (ADAew/ew), ADA every other week (ADAew/eow), or placebo (ADAew/pbo). Placebo‐randomized patients were reassigned in Period B to ADAew (PIONEER I) or placebo (PIONEER II). The primary outcome was HS Clinical Response (HiSCR). Patients who lost response during Period B were discontinued from the study and offered an option to enter the open‐label extension (OLE) to receive ADAew. Results are reported across the two study periods, and data were combined from the two study periods and the OLE.

Results

For week‐12 HiSCR achievers, the HiSCR week‐36 rate was 48·1% (ADAew/ew) vs. 46·2% (ADAew/eow) and 32·1% (ADAew/pbo). Combining (post hoc) these patients with week‐12 partial responders further differentiated outcomes in Period B (ADAew/ew 55·7% vs. ADAew/eow 40·0% and ADAew/pbo 30·1%). Period‐B adverse‐event rates were ADAew/ew 59·6% vs. ADAew/eow 57·4% and ADAew/pbo 65·0%. One patient (ADAew/ew) reported a serious infection.

Conclusions

Weekly adalimumab treatment, effective throughout 36 weeks, was the optimal maintenance medium‐term dosing regimen for this population. At least partial response after 12 weeks with continued weekly dosing had better outcomes than dose reduction or interruption. Patients who do not show at least a partial response to weekly adalimumab by week 12 are unlikely to benefit from continued therapy. No new safety risks were identified.

What's already known about this topic?

Hidradenitis suppurativa (HS) is a chronic inflammatory disease, commonly misinterpreted as an infection and treated with long‐term antibiotic regimens or surgical incisions.

Based on the chronicity of HS and the lack of evidence for efficacious and safe long‐term HS treatments, it is important to evaluate medium‐ to long‐term therapies for HS.

Weekly adalimumab (Humira^®) is approved for the treatment of moderate‐to‐severe HS based on the two phase III PIONEER trials.

What does this study add?

This study pooled data from the two PIONEER trials, providing a more robust assessment of outcomes.

After at least partial treatment success with weekly adalimumab short‐term therapy (12 weeks), continuing weekly dosing during the subsequent 24 weeks had better outcomes than dose reduction or treatment interruption.

Patients who do not show at least a partial response to weekly adalimumab by week 12 are unlikely to benefit from continued therapy.

Linked Comment: https://doi.org/10.1111/bjd.18437.

https://www.bjdonline.com/article/adalimumab-medium-term-dosing-strategy-in-moderate-to-severe-hidradenitis-suppurativa-integrated-results-from-the-phase-iii-randomized-placebo-controlled-pioneer-t/

Next-generation sequencing of HIV-1 single genome amplicons

The analysis of HIV-1 sequences has helped understand the viral molecular epidemiology, monitor the development of antiretroviral drug resistance, and design candidate vaccines. The introduction of single genome amplification (SGA) has been a major advancement in the field, allowing for the characterization of multiple sequences per patient while preserving linkage among polymorphisms in the same viral genome copy. Sequencing of SGA amplicons is performed by capillary Sanger sequencing, which presents low throughput, requires a high amount of template, and is highly sensitive to template/primer mismatching. In order to meet the increasing demand for HIV-1 SGA amplicon sequencing, we have developed a platform based on benchtop next-generation sequencing (NGS) (IonTorrent) accompanied by a bioinformatics pipeline capable of running on computer resources commonly available at research laboratories. During assay validation, the NGS-based sequencing of 10 HIV-1 env SGA amplicons was fully concordant with Sanger sequencing. The field test was conducted on plasma samples from 10 US Navy and Marine service members with recent HIV-1 infection (sampling interval: 2005–2010; plasma viral load: 5,884–194,984 copies/ml). The NGS analysis of 101 SGA amplicons (median: 10 amplicons/individual) showed within-individual viral sequence profiles expected in individuals at this disease stage, including individuals with highly homogeneous quasispecies, individuals with two highly homogeneous viral lineages, and individuals with heterogeneous viral populations. In a scalability assessment using the Ion Chef automated system, 41/43 tested env SGA amplicons (95%) multiplexed on a single Ion 318 chip showed consistent gene-wide coverage >50×. With lower sample requirements and higher throughput, this approach is suitable to support the increasing demand for high-quality and cost-effective HIV-1 sequences in fields such as molecular epidemiology, and development of preventive and therapeutic strategies.

Efficacy and safety of brodalumab in patients with psoriasis who had inadequate responses to ustekinumab: subgroup analysis of two randomized phase III trials

BACKGROUND

Brodalumab, a fully human anti-interleukin-17 receptor A monoclonal antibody, has demonstrated superior efficacy and safety over ustekinumab as induction therapy for moderate-to-severe psoriasis.

OBJECTIVES

To evaluate the efficacy and safety of brodalumab through week 52 in patients who had inadequate responses to ustekinumab.

METHODS

A subgroup analysis of the phase III AMAGINE-2/-3 double-blind randomized controlled trials was performed. Participants were aged 18-75 years and had a Psoriasis Area and Severity Index (PASI) ≥ 12, static Physician's Global Assessment score ≥ 3 and involvement of ≥ 10% body surface area. The studies were registered at ClinicalTrials.gov: AMAGINE-2, NCT01708603; AMAGINE-3, NCT01708629.

RESULTS

At baseline, patients with or without prior biologic experience who had an adequate response at week 16 on ustekinumab or brodalumab had lower rates of involved body surface area, PASI, prior biologic use, psoriatic arthritis and body mass index than patients who experienced inadequate response at or after week 16. Among patients who experienced inadequate response to ustekinumab, those rescued with brodalumab had PASI ≥ 75%, ≥ 90% and 100% improvement response rates of 72·6%, 58·1% and 36·3%, respectively, at week 52 compared with 61·7%, 25·5% and 5·4%, respectively, in patients who continued ustekinumab. Exposure-adjusted rates of treatment-emergent adverse events were similar among patients rescued with brodalumab (377·3 adverse events per 100 patient-years) and those who remained on ustekinumab (389·9 adverse events per 100 patient-years).

CONCLUSIONS

Among patients who experienced inadequate responses to ustekinumab, rescue with brodalumab improved skin clearance outcomes compared with continuing ustekinumab.

Anxiety and depression in patients with moderate-to-severe psoriasis and comparison of change from baseline after treatment with guselkumab vs. adalimumab: results from the Phase 3 VOYAGE 2 study

BACKGROUND

Anxiety and depression are clinically significant comorbidities associated with psoriasis. Improvements in psoriasis are known to decrease anxiety and depression. Guselkumab, an anti-interleukin-23 monoclonal antibody, has demonstrated efficacy and safety for the treatment of moderate-to-severe psoriasis.

OBJECTIVE

Assess improvements in anxiety and depression with guselkumab vs. placebo and adalimumab using the Hospital Anxiety and Depression Scale (HADS).

METHODS

In VOYAGE 2, a Phase 3, randomized, double-blind, placebo- and adalimumab-controlled study, patients received placebo (through week 16 followed by crossover to guselkumab), guselkumab, or adalimumab through week 24. HADS consists of two subscales measuring anxiety (HADS-A) and depression (HADS-D), with scores ranging from 0 to 21 and higher scores indicating more severe symptoms. Scores ≥8 indicate instrument-defined anxiety or depression. Severity of psoriasis was assessed using the Psoriasis Area and Severity Index (PASI).

RESULTS

Among 989 patients randomized (with baseline HADS measurements), mean HADS-A and HADS-D scores were 6.8 ± 4.2 and 5.3 ± 4.2, respectively; 38.6% of patients reported HADS-A ≥8 and 27.7% HADS-D ≥8 at baseline. At week 16, a significantly greater proportion of guselkumab patients with baseline HADS-A or HADS-D ≥8 reported HADS-A <8 (51.4% vs. 25.9%; P < 0.001) or HADS-D <8 (59.2% vs. 27.0%; P < 0.001) vs. placebo patients. At week 24, a greater proportion of guselkumab patients with baseline HADS-A or HADS-D ≥8 reported HADS-A <8 (58.4% vs. 42.9%; P = 0.028) or HADS-D <8 (59.8% vs. 46.4%; P = 0.079) vs. adalimumab patients. PASI improvements correlated with improvement in anxiety (r = 0.27; P < 0.0001) and depression (r = 0.25; P < 0.0001) scores in patients with baseline HADS-A or HADS-D ≥8. Greater improvements in HADS were also observed at week 16 in guselkumab-treated patients vs. placebo using a more stringent cut-off of HADS ≥11.

CONCLUSION

Guselkumab treatment was associated with greater improvements in symptoms of anxiety and depression scores in patients with psoriasis compared with placebo and adalimumab.

Costs and consequences: Hepatitis C seroprevalence in the military and its impact on potential screening strategies

Knowledge of the contemporary epidemiology of hepatitis C viral (HCV) infection among military personnel can inform potential Department of Defense screening policy. HCV infection status at the time of accession and following deployment was determined by evaluating reposed serum from 10,000 service members recently deployed to combat operations in Iraq and Afghanistan in the period 2007-2010. A cost model was developed from the perspective of the Department of Defense for a military applicant screening program. Return on investment was based on comparison between screening program costs and potential treatment costs avoided. The prevalence of HCV antibody-positive and chronic HCV infection at accession among younger recently deployed military personnel born after 1965 was 0.98/1000 (95% confidence interval 0.45-1.85) and 0.43/1000 (95% confidence interval 0.12-1.11), respectively. Among these, service-related incidence was low; 64% of infections were present at the time of accession. With no screening, the cost to the Department of Defense of treating the estimated 93 cases of chronic HCV cases from a single year's accession cohort was $9.3 million. Screening with the HCV antibody test followed by the nucleic acid test for confirmation yielded a net annual savings and a $3.1 million dollar advantage over not screening.

CONCLUSIONS

Applicant screening will reduce chronic HCV infection in the force, result in a small system costs savings, and decrease the threat of transfusion-transmitted HCV infection in the battlefield blood supply and may lead to earlier diagnosis and linkage to care; initiation of an applicant screening program will require ongoing evaluation that considers changes in the treatment cost and practice landscape, screening options, and the epidemiology of HCV in the applicant/accession and overall force populations.

Perceived risk of watery diarrhea and dysentery and intended compliance with chemoprophylaxis among a deployed military population

Background

Infectious diseases are a leading cause of morbidity among travelers to resource-limited regions and primary prevention is a cornerstone to risk reduction. Chemoprophylaxis has been successfully utilized for specific diseases.

Methods

We assessed self-reported compliance to daily chemoprophylaxis among deployed US military personnel. A 21 item self-completed questionnaire was completed by military personnel during mid-deployment.

Results

The perception of high disease risk was associated with an increased likelihood of compliance with daily chemoprophylaxis. However, 60 % of respondents stated they would not comply with a daily regimen.

Conclusions

These data highlight the complexity of perceived risk and the difficulties with prophylactic interventions.

Prebiotics and probiotics: the prevention and reduction in severity of atopic dermatitis in children

The purpose of this review was to identify whether supplementation with prebiotics and/or probiotics help prevent the development or reduce the severity of atopic dermatitis in children less than three years of age. Since 1997, immunostimulatory supplements, such as prebiotics and probiotics, have been investigated. Various supplementations include probiotics (single strain or mix), probiotics with formula, probiotics mix with prebiotics, and prebiotics. In this narrative review, we examined 13 key articles on prebiotics and/or probiotics, and their effects on infant atopic dermatitis. Among the selected studies, a total of 3,023 participants received supplements or placebo. Eight out of the 13 (61.5%) studies reported a significant effect on the prevention of atopic dermatitis after supplementation with probiotics and/or prebiotics. Five out of the 13 (38.5%) studies indicated significant reduction in the severity of atopic dermatitis after supplementation. Based on the available studies, supplementation with certain probiotics (Lactobacillus rhamnosus GG) appears to be an effective approach for the prevention and reduction in severity of atopic dermatitis. A mix of specific probiotic strains prevented atopic dermatitis among infants. Based on studies with prebiotics, there was a long-term reduction in the incidence of atopic dermatitis. Supplementation with prebiotics and probiotics appears useful for the reduction in the severity of atopic dermatitis. Additional interventional studies exploring prebiotics and probiotics are imperative before recommendations can be made.

Psoriasis and smoking: a systematic review and meta-analysis

Psoriasis is an inflammatory skin disease associated with increased cardiovascular comorbidity. Smoking is associated with an increased risk of cardiovascular disease, and prior studies have suggested that patients with psoriasis are more likely to be active smokers. Smoking may also be a risk factor in the development of psoriasis. We conducted a systematic review and meta-analysis to assess the prevalence of smoking among patients with psoriasis, and we reviewed the contribution of smoking to the incidence of psoriasis. A total of 25 prevalence and three incidence studies were identified. The meta-analysis of prevalence studies included a total of 146 934 patients with psoriasis and 529 111 patients without psoriasis. Random effects meta-analysis found an association between psoriasis and current smoking [pooled odds ratio (OR) 1·78, 95% confidence interval (CI) 1·52-2·06], as well as between psoriasis and former smoking (pooled OR 1·62, 95% CI 1·33-1·99). Meta-regression analysis did not reveal any sources of study heterogeneity, but a funnel plot suggested possible publication bias. A subset of studies also examined the association between moderate-to-severe psoriasis and smoking, with a pooled OR of 1·72 (95% CI 1·33-2·22) for prevalent smoking. The three incidence studies found an association between smoking and incidence of psoriasis, with a possible dose-effect of smoking intensity and duration on psoriasis incidence. These findings suggest that smoking is an independent risk factor for the development of psoriasis, and that patients with established psoriasis continue to smoke more than patients without psoriasis.

Willingness to receive a hypothetical avian influenza vaccine among US military personnel in mid-deployment

Though no avian influenza vaccine currently exists, development efforts have increased. Given recent reports of suboptimal vaccination rates among US military personnel, we sought to assess factors associated with a willingness to receive a hypothetical avian influenza vaccine. A self-administered questionnaire was completed by US military personnel during mid-deployment to Iraq, Afghanistan, and surrounding regions. Respondents were predominately male (86.2%), Army (72.1%), and enlisted (86.3%) with a mean age of 29.6 y. The majority (77.1%) agreed to receive an avian influenza vaccine if available. Exploratory factor analysis (EFA) identified two factors, vaccine importance and disease risk, that best described the individual perceptions and both were associated with an increased willingness to receive the hypothetical vaccine (OR: 8.2 and 1.6, respectively). Importantly, after controlling for these factors differences in the willingness to receive this hypothetical vaccine were observed across gender and branch of service. These results indicated that targeted education on vaccine safety and efficacy as well as disease risk may modify vaccination patterns in this population.

Psoriasis and dyslipidemia: a population-based study analyzing the National Health and Nutrition Examination Survey (NHANES)

BACKGROUND

Psoriasis has been linked to an increased incidence of coronary artery disease, stroke, myocardial infarctions and cardiovascular deaths. Dyslipidemia, a well-established risk factor for cardiovascular disease, involves inflammatory pathways that are also implicated in psoriasis. An understanding of the relationship between psoriasis and dyslipidemia may have a substantial clinical impact.

OBJECTIVE

This study aimed to examine the association between psoriasis and multiple measurements of dyslipidemia, which include levels of triglycerides, apolipoprotein B, LDL-cholesterol, HDL-cholesterol, HDL/LDL ratio and total cholesterol.

METHODS

We conducted a population-based, cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) 2003-2006 and 2009-2010. NHANES is a national research survey programme conducted biennially to evaluate the health and nutritional status of the U.S. population. The survey uses a multistage, stratified design. NHANES data were collected from questionnaires, physical examination and laboratory values.

RESULTS

The sample population consisted of 13 418 adults who provided responses to their psoriasis status. A total of 353 (2.63%) participants reported a health care provider-given diagnosis of psoriasis. The multivariate analysis showed that psoriasis was not significantly associated with certain measures of dyslipidemia from this population. Specifically, in psoriasis patients, the weighted odds ratio (OR) of total cholesterol >200 mg/dL was 0.96 (95% CI 0.74-1.24); weighted OR of HDL-cholesterol <40 mg/dL was 0.92 (95% CI 0.65-1.30); weighted OR of LDL-cholesterol >130 mg/dL was 0.67 (95% CI 0.43-1.03); weighted OR of triglycerides >150 mg/dL was 1.20 (95% CI 0.89-1.63); weighted OR of apolipoprotein B >130 mg/dL was 1.29 (95% CI 0.69-2.41); weighted OR of HDL/LDL <0.4 was 1.20 (95% CI 0.8-1.79).

CONCLUSION

Based on the NHANES data 2003-2006 and 2009-2010, psoriasis is not significantly associated with alterations in certain lipid levels. Larger sample sizes may be necessary to detect appreciable differences in the lipid levels between patients with and without psoriasis.

Genotypic characterization of Egypt enterotoxigenic Escherichia coli isolates expressing coli surface antigen 6

Introduction: One approach to control enterotoxigenic Escherichia coli (ETEC) infections has been to develop vaccines focused on inducing protective immunity against surface expressed antigenic factors. One such factor is coli surface antigen 6 (CS6); ETEC isolates expressing CS6 may also simultaneously co-express surface antigens CS4 or CS5. However, there is little information regarding the inter-relationships of isolates expressing the CS6 antigen alone or in combination with CS4 or CS5. Methodology: A total of 62 CS6-associated ETEC isolates were evaluated for their antimicrobial susceptibility, mechanisms of resistance, toxin genes, colonization factor expression, and XbaI-pulsed-field gel electrophoretic profiles. Results: We observed 46 XbaI profiles; 31 were exclusive to ETEC expressing CS6 alone and 15 among the ETEC co-expressing CS4 or CS5. Nearly half (47%) of these isolates were resistant to ampicillin, a third (37%) of the isolates were resistant to trimethoprim-sulfamethoxazole, and 24% of the isolates were tetracycline-resistant. A blaTEM gene was detected in 24 (83%) ampicillin-resistant isolates. Trimethoprim-sulfamethoxazole-resistant isolates (n = 23) carried either sulI (n = 1, 4%), sulII (n = 8, 35%) or both genes (n = 10, 43%); 4 had no detectable sul gene. Conclusions: Our results show a lack of clonality among Egypt CS6 E. coli isolates and supports the use and the further research on vaccines targeting this cell surface antigen.

Association between psoriasis and viral infections in the United States: focusing on hepatitis B, hepatitis C and human immunodeficiency virus

BACKGROUND

No published data in the U.S. population regarding an association between viral infections and psoriasis are currently available. Assessment of infection and immunosuppression risk is critical in managing psoriasis patients.

OBJECTIVES

To examine the association between psoriasis and viral infections including hepatitis B, hepatitis C and human immunodeficiency viral infections in the general U.S. population.

METHODS

Population data representative of the U.S. cohort were analysed from the National Health and Nutrition Examination Survey (NHANES), 2003-2006. Hepatitis B, hepatitis C, and human immunodeficiency antibodies status were ascertained from laboratory evaluations. Univariate and multivariate analyses were performed to assess the associations between psoriasis and these viral infections.

RESULTS

Among 6532 participants aged 20-59 years who provided responses to their psoriasis status, 162 patients reported having psoriasis. Based on multivariate regression analyses, psoriasis was not significantly associated with positive serology for hepatitis B core [odds ratio (OR), 0.83; 95% confidence interval (CI), 0.32-2.17; P = 0.7060], hepatitis B surface [OR, 7.89; CI, 0.52-119; P = 0.1355], hepatitis C [OR, 0.24; CI, 0.03-2.01; P = 0.1915], or human immunodeficiency virus [OR, 0.73; CI, 0.09-5.93; P = 0.7646] antibodies, after adjusting for age, gender, race and smoking status.

CONCLUSIONS

From the limited sample of the NHANES database on psoriasis and viral infections, psoriasis does not appear to be associated with an increased risk of hepatitis B, hepatitis C, or HIV infection in the U.S. population. Epidemiology of these viral infections in psoriasis needs to be continually studied and updated given their importance in management considerations.

Specific IgA antibodies in the diagnosis of acute brucellosis

An Egyptian female with night sweats, headache, and back pain was diagnosed with acute brucellosis one week after returning from a North African country. Humoral immune responses to specific immunogenic proteins were investigated before and after treatment. ELISA was performed to detect levels of specific antibody (Ab) titers. Immunoblot analysis of Ab recognizing specific Brucella antigenic bands was also performed. IgA was detected on the day of disease onset. Specific agglutination titer was 1:160; it doubled three days later and treatment was implemented. Blood culture yielded Gram-negative coccobacilli after one month, confirmed as B. melitensis by AMOS-PCR. Immunoblotting revealed IgM Abs against two protein bands of 112 and 130-kDa observed only during the acute stage. On the other hand, the intensity of IgG Abs against 21 and 21.5-kDa protein bands positively correlated with the time of convalescence. Based on our observations we conclude that specific IgA levels may be used as an early diagnostic marker for Brucella and high molecular weight protein bands may be useful in the differentiation between acute and chronic brucellosis.

Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic mechanisms

Recent studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Smoking initiates formation of free radicals that stimulate cell signalling pathways active in psoriasis including mitogen-activated protein kinase (MAPK), nuclear factor-κB (NF-κB) and Janus kinase/signal transducers and activators of transcription (JAK-STAT). Smoking damages the skin by increasing formation of reactive oxygen species and decreasing the gene expression of antioxidants. Nicotine also stimulates innate immune cells integral to the pathogenesis of psoriasis including dendritic cells, macrophages and keratinocytes. These cells release cytokines that activate T lymphocytes and perpetuate a cycle of chronic inflammation. Smoking also enhances expression of genes known to confer an increased risk of psoriasis, including HLA-Cw6, HLA-DQA1*0201 and CYP1A1. Improved understanding of the possible link between smoking and psoriasis pathogenesis may provide further insight into mechanisms underlying smoking, psoriasis and risk of subsequent cardiovascular disease.

Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic mechanisms

Recent studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Smoking initiates formation of free radicals that stimulate cell signalling pathways active in psoriasis including mitogen-activated protein kinase (MAPK), nuclear factor-κB (NF-κB) and Janus kinase/signal transducers and activators of transcription (JAK-STAT). Smoking damages the skin by increasing formation of reactive oxygen species and decreasing the gene expression of antioxidants. Nicotine also stimulates innate immune cells integral to the pathogenesis of psoriasis including dendritic cells, macrophages and keratinocytes. These cells release cytokines that activate T lymphocytes and perpetuate a cycle of chronic inflammation. Smoking also enhances expression of genes known to confer an increased risk of psoriasis, including HLA-Cw6, HLA-DQA1*0201 and CYP1A1. Improved understanding of the possible link between smoking and psoriasis pathogenesis may provide further insight into mechanisms underlying smoking, psoriasis and risk of subsequent cardiovascular disease.

Knowledge, attitudes, and practice of travelers' diarrhea management among frontline providers

BACKGROUND

Many studies have found acute gastrointestinal infections to be among the most likely reason for clinic visits among forward deployed soldiers and are considered a significant contributor to morbidity in this population. This occurs despite the controlled food and water distribution systems under which military populations operate. Furthermore, recent studies have indicated that providers often fail to appropriately identify and treat the typical causes of these infections. To adequately address this issue, an assessment of gaps in knowledge, practice, and management of acute diarrhea in deployed troops was conducted.

METHODS

A multiple-choice survey was developed by clinical researchers with expertise in travelers' diarrhea (TD) and provided to a convenience sample of clinical providers with a broad range of training and operational experience. The survey evaluated provider's knowledge of TD along with their ability to identify etiologies of various syndromic categories of acute gastrointestinal infections. Providers were also queried on selection of treatment approaches to a variety of clinical-based scenarios.

RESULTS

A total of 117 respondents completed the survey. Most were aware of the standard definition of TD (77%); however, their knowledge about the epidemiology was lower, with less than 24% correctly answering questions on etiology of diarrhea, and 31% believing that a viral pathogen was the primary cause of watery diarrhea during deployment. Evaluation of scenario-based responses showed that 64% of providers chose not to use antibiotics to treat moderate TD. Furthermore, 19% of providers felt that severe inflammatory diarrhea was best treated with hydration only while 25% felt hydration was the therapy of choice for dysentery. Across all provider types, three practitioner characteristics appeared to be related to better scores on responses to the nine management scenarios: having a Doctor of Medicine or Doctor of Osteopathy degree, greater knowledge of TD epidemiology, and favorable attitudes toward antimotility or antibiotic therapy.

CONCLUSION

Results from this survey support the need for improving knowledge and management of TD among deploying providers. The information from this study should be considered to support the establishment and dissemination of military diarrhea-management guidelines to assist in improving the health of military personnel.

Technologies in dermatology: teledermatology review

Many rural and underserved communities face a shortage of dermatologists and long patient wait times. Teledermatology systems have the potential to accommodate increasing demands for dermatologists. With the current shortage of dermatologists in many communities, teledermatology complements conventional face-to-face dermatologic care where access to specialty care is limited. Teledermatology involves the use of communications technology to remotely provide skin care, and it is an extensively investigated branch of telemedicine. The overall goal of this review is to discuss the current literature on: 1) teledermatology technology; 2) accuracy and reliability of teledermatology; 3) healthcare delivery models, clinical outcomes, and satisfaction data; 4) economic considerations; and 5) future research considerations and implications of teledermatology.

A randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of rifaximin for the prevention of travelers' diarrhea in US military personnel deployed to Incirlik Air Base, Incirlik, Turkey

BACKGROUND

Infectious diarrhea is an important problem among travelers and deployed US military overseas causing substantial morbidity due to acute illness and may result in burdensome postinfectious sequelae.

METHODS

The nonsystemic antibiotic rifaximin was evaluated for prevention of travelers' diarrhea (TD) in a US military and civilian adult beneficiary population in a randomized, double-blind, placebo-controlled clinical trial. In all, 100 volunteers deployed to Incirlik Air Base, Turkey, received rifaximin 1,100 mg once daily or placebo for 2 weeks, and participants were followed daily for 2 weeks.

RESULTS

In an intention to treat analysis (n = 95), TD (based on subjects meeting case definition or early treatment) developed in 6.3% (3 of 48) of the rifaximin group compared with 19.2% (9 of 47) in the placebo group (Fisher's exact test p = 0.07). Rifaximin provided 67% (95% confidence interval, -13% to 91%, p = 0.07) protection against TD. Rifaximin 1,100 mg once daily was well tolerated with no observed differences in adverse events, whether solicited or unsolicited among the two treatment groups.

CONCLUSIONS

Rifaximin may represent an option among military personnel on deployment for prevention of TD with supportive future studies that consider deployment length, settings, and operational situations where widespread use of chemoprophylaxis may increase force health protection without undue risk during critical deployments.

Design and validation of a multiplex polymerase chain reaction for the identification of enterotoxigenic Escherichia coli and associated colonization factor antigens

Development of a genetic tool for the detection of genes encoding enterotoxins and colonization factors would greatly enhance enterotoxigenic Escherichia coli (ETEC) surveillance. Oligonucleotide primers were designed to amplify genes encoding human ST, porcine ST, LT and the structural genes of colonization factor antigen (CFA)/I, CS1 to CS8, CS12 to CS15, CS17 to CS22, and PCFO71. Screening 89 ETEC isolates phenotypically expressing a known CFA showed that, without exception, the multiplex polymerase chain reaction (mPCR) detected the structural gene of the expressed CFA, in addition to CS21 in 22.5% of isolates. Silent genes such as cssB (CS6) were also detected in 9.0%. Additionally, we screened 71 CFA phenotypically negative isolates and detected a CFA in more than 50% of tested isolates. In conclusion, we have designed a simple 4-step mPCR for the rapid detection of ETEC virulence factors. The assay is rapid, reproducible, relatively inexpensive, and has the potential to be field applicable.

Factors associated with the use of protective measures against vector-borne diseases among troops deployed to Iraq and Afghanistan

BACKGROUND AND METHODS

Vector-borne diseases are known threats to deployed troops. We performed a cross-sectional study of troops deployed to Southwest Asia between January 2005 and February 2007 to evaluate practices of personal protective measures and their relationship to self-report of Old World cutaneous leishmaniasis (CL), a marker of vector-borne disease threat.

RESULTS

Regular or always N, N-diethyl-m-toluamide (DEET) use was low (2-5%). Associations for DEET use were command emphasis, branch of service, uniform treatment with permethrin, and duty station. Uniform treatment with permethrin was associated with branch of service, command emphasis, and use of DEET. We identified 22 cases of CL (incidence density of 1.8-3.7 per 100 person-years) with increased risk among Reserve/National Guard components, Air Force and Marine personnel.

CONCLUSIONS

Commanders can influence the use of the military insect repellent system. Unit-based treatment of uniforms improves prevalence. CL incidence may be higher than previously reported.

Past trends and current status of self-reported incidence and impact of disease and nonbattle injury in military operations in Southwest Asia and the Middle East

OBJECTIVES

To evaluate the evolutional changes in disease and nonbattle injury in a long-term deployment setting, we investigated trends of selected disease and nonbattle injury (NBI) incidence among US military personnel deployed in ongoing military operations in Southwest Asia and the Middle East.

METHODS

Participants completed an anonymous questionnaire concerning diarrhea, acute respiratory illness (ARI), and NBIs. We compared incidence, morbidity, and risk associations of disease and NBI incidence with historical data. We analyzed a clinic screening form to describe trends in diarrhea incidence over a 3-year period.

RESULTS

Between April 2006 and March 2007, 3374 troops completed deployment questionnaires. Incidence of diarrhea was higher than that of ARI and NBI (12.1, 7.1, and 2.5 episodes per 100 person-months, respectively), but ARI and NBI resulted in more-frequent health system utilization (both P < .001) and decreased work performance (P < .001 and P = .05, respectively) than did diarrhea. Compared with historical disease and NBI incidence rates, diarrhea and NBI incidence declined over a 4-year period, whereas ARI remained relatively constant.

CONCLUSIONS

Diarrhea, ARI, and NBI are important health concerns among deployed military personnel. Public health and preventive measures are needed to mitigate this burden.

Attitudes toward predeployment and experimental vaccinations among troops deployed to Operation Iraqi Freedom and Operation Enduring Freedom

BACKGROUND

The Department of Defense is actively engaged in the research and development of vaccine(s) to mitigate the burden of disease associated with diarrhea among deployed troops. Soldiers' attitudes and beliefs toward predeployment vaccines and participation in experimental research with vaccines are unknown.

METHODS

To assess these attitudes, a survey was distributed among soldiers who had been and were currently deployed to Operations Iraqi and Enduring Freedom.

RESULTS

Sixty-one percent of soldiers believe that predeployment vaccines are important, and 21% are hesitant to receive these vaccinations. Fifteen percent of soldiers stated that they would be willing to enroll in a study evaluating experimental vaccines, and 14% stated that they would participate in military research for vaccine development. Both male and female soldiers agreed that predeployment vaccines were important (86 and 92%, respectively); however, compared to their male counterparts, females were more hesitant to receive routine vaccinations (45% vs 37%) and less likely to volunteer for an experimental vaccine study (12% vs 20%). Officers and Air Force personnel were less hesitant to receive routine vaccinations compared to enlisted and other service personnel, respectively. Furthermore, if a soldier experienced three or more episodes of diarrhea, he or she was more likely to try an experimental vaccine to prevent diarrhea (23% vs 13%, p < 0.0001).

CONCLUSIONS

A disconnect exists between the belief that immunizations are important and the hesitancy to receive them. Future studies should be directed to understand this gap and emphasize the critical importance of vaccines for health of US personnel in garrison and on deployment.

Acute gastrointestinal infection, respiratory illness, and noncombat injury among US military personnel during Operation Bright Star 2005, in Northern Egypt

BACKGROUND

In the fall 2005, approximately 7,500 US military personnel participated in an exercise in the Egyptian desert. The epidemiology of disease and noncombat injury among deployed troops is important in the context of assessing current mitigation strategies and the development of future ones.

METHODS

To assess the prevalence and impact of diarrhea and enteropathogen distribution, we conducted a case series study. To assess the relative impact of diarrhea compared to respiratory infection and injury, we conducted a post-deployment survey and compared these data to clinic-based syndromic surveillance data.

RESULTS

We enrolled 43 patients with acute diarrhea, 21 (49%) having one or more pathogens isolated. Enterotoxigenic Escherichia coli (n= 16), enteroaggregative E coli (n= 3), and Shigella spp. (n= 3) were the most common pathogens identified. Respiratory illness had the highest incidence (73 episodes/100 person-months) compared to diarrhea (35 episodes/100 person-months) and noncombat injury (17 episodes/100 person-months), though noncombat injury more frequently resulted in lost duty days and health-care utilization.

CONCLUSIONS

Noncombat injuries and illnesses have had a significant impact on military missions and continue to result in force health protection challenges today. Future studies are needed to test and evaluate countermeasures to mitigate these illnesses and injuries to increase the health of the individuals and optimize mission readiness.

Effectiveness of highly-active antiretroviral therapy by race/ethnicity

OBJECTIVE

To determine the effectiveness of HAART by race/ethnicity.

DESIGN

Prospective multicenter cohort study.

METHODS

We studied 991 African-Americans and 911 European-Americans enrolled in the United States Military's Tri-Service AIDS Clinical Consortium Natural History Study who had dates of HIV seroconversion known within 5 years and followed between 1990 and 2002. We determined the rate of disease progression to AIDS and death for subjects in this cohort. Multivariable models evaluated race, pre-HAART (1990-1995) and HAART (1996-2002) eras, age, gender and military service.

RESULTS

In the pre-HAART era, African-Americans had a statistically nonsignificant trend towards better outcomes: the relative hazards (RH) of AIDS and death for African-Americans compared to European-Americans were 0.85 [95% confidence interval (CI), 0.68-1.05] and 0.77 (95% CI, 0.55-1.08), respectively. In the HAART era, outcomes were similar by race: 1.17 (95% CI, 0.86-1.61) for AIDS and 1.11 (95% CI, 0.81-1.53) for death with overlapping Kaplan-Meier curves. Relative to the pre-HAART era, the adjusted RH of AIDS in the HAART era was 0.41 (95% CI, 0.31-0.54) and 0.30 (95% CI, 0.22-0.40) for African-American and European-American participants, respectively. Analogous RH for death were 0.55 (95% CI, 0.38-0.80) and 0.38 (95% CI, 0.27-0.54). The precipitous declines in AIDS and death in the HAART era were not statistically different by race.

CONCLUSIONS

: In a large multi-racial cohort with equal access to health care, HIV treatment outcomes by race/ethnicity were similar.

Comparisons of causes of death and mortality rates among HIV-infected persons: analysis of the pre-, early, and late HAART (highly active antiretroviral therapy) eras

METHODS

Comparisons of death-related variables during the 3 eras were performed.

RESULTS

The number of deaths declined over the study period, with 987 deaths in the pre-HAART era, 159 deaths in the early HAART era (1997-1999), and 78 deaths in the late HAART era (2000-2003) (P < 0.01). The annual death rate peaked in 1995 (10.3 per 100 patients) and then declined to <2 deaths per 100 persons in the late HAART era (P < 0.01). The proportion of deaths attributable to infection decreased, but infection remained the leading cause of death in our cohort, followed by cancer. Of those who died, there was an increasing proportion of non-HIV-related deaths (32% vs. 9%; P < 0.01), including cardiac disease (22% vs. 8%; P < 0.01) and trauma (8% vs. 2%; P = 0.01) in the post-HAART versus pre-HAART era. Despite the absence of intravenous drug use and the low prevalence of hepatitis C coinfection in our cohort, an increasing proportion of deaths in the HAART era were attributable to liver disease, although the numbers are small.

CONCLUSIONS

Despite increasing concerns regarding antiretroviral resistance, the death rate among HIV-infected persons in our cohort continues to decline. Our data show a lower death rate than that reported among many other US HIV-infected populations; this may be the result of open access to health care. A shift in the causes of death toward non-HIV-related causes suggests that a more comprehensive health care approach may be needed for optimal life expectancy; this may include enhanced screening for malignancy and heart disease as well as preventive measures for liver disease and accidents.

Environmental tobacco smoke and lung cancer risk in nonsmoking women

BACKGROUND

Exposure to environmental tobacco smoke (passive smoking) has been suggested to be a cause of lung cancer, although early epidemiologic studies have produced inconsistent results.

PURPOSE

We conducted an epidemiologic case-control study to assess the relationship between exposure to environmental tobacco smoke and lung cancer risk among women who have never smoked (i.e., having smoked for a total of less than 6 months or having smoked less than 100 cigarettes in their lifetimes).

METHODS

Case patients (n = 210) were women with histologically confirmed primary carcinomas of the lung who were lifetime nonsmokers. They were identified through hospital tumor registries and the Florida Cancer Data System of the Statewide Cancer Registry. Community-based control women (n = 301) were also lifetime nonsmokers and were identified through random-digit dialing. Details on childhood and adulthood exposures to environmental tobacco smoke were ascertained through interviews with the study participants themselves or with surrogate respondents. Risks were calculated in terms of smoke-years, defined as the sum of the reported years of exposure to cigarette smoke from each smoker in the household.

RESULTS

The risk of lung cancer more than doubled for women who reported 40 or more smoke-years of household exposure during adulthood (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.1-5.3) or 22 or more smoke-years of exposure during childhood and adolescence (OR = 2.4; 95% CI = 1.1-5.4). Risks were highest for non-adenocarcinoma lung cancers, although modest elevations in risk were also observed for adenocarcinomas. When a surrogate respondent other than the patient's husband provided information on exposure, the risk estimates were considerably lower.

CONCLUSION

These findings suggest that long-term exposure to environmental tobacco smoke increases the risk of lung cancer in women who have never smoked.

Dietary intake and risk of lung cancer in women who never smoked

A case-control study was conducted to examine the influence of dietary factors on the risk of developing lung cancer among women who have never smoked cigarettes. This study included 124 cases of histologically confirmed carcinoma of the lung and 263 community-based controls. Dietary data were collected utilizing the reduced version of the National Cancer Institute (Block) food frequency questionnaire. The results of this analysis, adjusted for age, education, and total calories, indicated a strong protective effect associated with total vegetable consumption and intake of carotene. Individuals in the highest quartile of vegetable consumption experienced the greatest decreased risk with an odds ratio (OR) of 0.2, [confidence interval (CI) 0.1-0.5]. The effect of all vegetables combined was greater than that of green and yellow vegetables alone (highest quartile OR 0.4, CI 0.2-0.7). Similarly, the protective effect of total carotene (highest quartile OR 0.3, CI 0.1-0.6) was somewhat greater than that of beta-carotene alone (highest quartile OR 0.4, CI 0.2-0.8). Retinol intake was not associated with a decreased risk of lung cancer in our population. There was an inverse association between lung cancer risk and vitamin C intake, which was not significant, although a statistically significant trend was noted.

Histopathology of lung cancers among smokers and nonsmokers in Florida

A study was undertaken of the relationship between lung cancer cell type and age, race, sex and smoking characteristics. The study population consisted of 35 183 cases of microscopically confirmed carcinoma of the lung, first diagnosed between 1981 and 1985, among residents of the state of Florida. The data suggested that the histological types of lung cancer observed varied by age, sex and the use of cigarettes. The number of cigarettes smoked per day did not appear to influence the cell types observed. The study indicated that adenocarcinomas occurred more frequently in lung cancer cases diagnosed at earlier ages, among both men and women. Among women who smoked, there was an increased proportion of small cell carcinomas compared to nonsmoking women, while in male smokers, the increase appeared primarily in squamous cell carcinomas.