Predictive Value of Genomic Classifier Scores and Transcriptomic Data for Prostate Cancer Distant Metastasis Risk: A Multicenter Retrospective Study

PURPOSE/OBJECTIVE(S)

Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) has a greater specificity and sensitivity for detection of extraprostatic prostate cancer than conventional imaging. The Decipher genomic classifier is an established prognostic biomarker being evaluated for its ability to predict systemic treatment intensification. The relationship between Decipher scores and PSMA-based spread remains unknown, as do differences in transcriptomic patterns of PSMA PET-based spread in the de novo vs. recurrent setting.

MATERIALS/METHODS

We retrospectively identified patients who (a) had undergone staging with a PSMA PET prior to treatment or for evaluation of recurrence post-radical prostatectomy (RP) at two institutions and (b) had transcriptomic data available from the Genomics Resource for Intelligent Discovery (GRID) database from either biopsy or RP specimens. We classified the PSMA PET pattern of spread using molecular imaging (mi) staging as localized (miT+N0M0), node-positive (miN1M0), distant metastasis (miM1a-c), or negative/non-diagnostic. We used logistic regression to calculate the odds ratios (OR) with 95% confidence intervals (CI) for distant metastasis risk based on Decipher score both pre-treatment and post-RP. As an exploratory analysis, we compared each of the staging groups for differences in important transcriptomic signatures. Kruskal-Wallis and Pearson chi-squared tests were used for continuous and categorical variables, respectively.

RESULTS

A total of 315 patients were included in this analysis (n = 164 pre-treatment, n = 151 post-RP). Eighty PSMA PET scans were negative, while 147 were miT+N0M0, 45 were miN1M0, and 43 were miM1a-c. A higher Decipher score was associated with distant metastasis (miM1a-c) on PSMA PET both pre-treatment (OR 1.3 [95% CI: 1.0-1.7] per 0.1 increase in Decipher score, P = 0.05) and post-RP (OR 1.2 [1.0-1.4] per 0.1 increase in Decipher score, P = 0.04). There were higher TP53 mutation (P = 0.01) and cell cycle progression (P = 0.04) signature scores in miM1a-c patients compared to miN1M0 or miT+N0M0 patients. Basal subtype was more prevalent per PAM50 in miM1a-c or miN1M0 patients (36%) than miT+N0M0 patients (19%, P=0.01). Patients with de novo miN1M0 or miM1a disease (n = 19) had higher Decipher scores (0.85 vs 0.57, P = 0.10) and IFNa response (P = 0.08) than patients with recurrent miN1M0 or miM1a disease (n = 35).

CONCLUSION

Higher Decipher scores were associated with distant metastasis on PSMA PET in both the de novo and recurrent setting. Transcriptomic differences in pathways related to proliferation, p53 status, and PAM50 classification were seen when comparing localized, node-positive, and distant metastatic disease. Patients with de novo miN1M0 or miM1a disease may harbor more aggressive disease than those with miN1M0 or miM1a disease at recurrence.

Sexual and reproductive health information and referrals for resettled refugee women: A survey of resettlement agencies in the United States

BACKGROUND

Refugee resettlement offices are the first point of contact for newly arrived refugees and play a significant role in helping refugees acclimate and settle into life in the United States. Available literature suggests that refugee women are vulnerable to poor sexual and reproductive health (SRH) outcomes, including sexually transmitted infections and HIV infections as well as adverse pregnancy outcomes, but little is known about the role that refugee resettlement offices play in supporting refugee women's SRH. This study examines the capacity and interest of resettlement offices in providing SRH information and referrals to newly arrived refugees.

METHODS AND FINDINGS

The research team conducted an online survey of staff members at refugee resettlement offices throughout the US in 2018 to determine (1) available SRH resources and workshops; (2) referrals to and assistance with making appointments for SRH and primary care appointments; (3) barriers to addressing SRH needs of clients; and (4) interest in building the capacity of office staff to address SRH issues. The survey was created for this study and had not been previously used or validated. Survey data underwent descriptive analysis. A total of 236 resettlement offices were contacted, with responses from 100 offices, for a total response rate of 42%. Fifteen percent (N = 15) of refugee resettlement agencies (RRAs) who responded to the survey provide materials about SRH to clients, and 49% (N = 49) incorporate sexual health into the classes they provide to newly arrived refugee clients. Moreover, 12% (N = 12) of responding RRAs screen clients for pregnancy intention, and 20% (N = 20) directly refer to contraceptive care and services. This study is limited by the response rate of the survey; no conclusions can be drawn about those offices that did not respond. In addition, the survey instrument was not validated against any other sources of information about the practices of refugee resettlement offices.

CONCLUSIONS

In this study, we observed that many resettlement offices do not routinely provide information or referrals for SRH needs. Responding offices cite lack of time and competing priorities as major barriers to providing SRH education and referrals to clients.

4119Predictors of progression of preclinical left ventricular diastolic dysfunction to clinical heart failure in patients with malignancy

Background

Preclinical diastolic dysfunction PDD is a well-known but poorly understood risk factor for clinical heart failure CHF. Preclinical diastolic dysfunction and predictors of progression of PDD to CHF in patients with malignancy has never been studied.

Purpose

The purpose of our study was to determine the incidence of CHF in cancer patients who have preexisting preclinical diastolic dysfunction, with a particular focus on identifying the risk factors contributing to progression of PDD to CHF.

Study design

We retrospectively sought all the patients who underwent echocardiography from 2003 to 2008 and were found to have preclinical diastolic dysfunction at our institution. PDD was defined as presence of grade I diastolic dysfunction, LVEF ≥50%, and free of clinical diagnosis of heart failure. Of these, only the patients who had a confirmed histopathological diagnosis of malignancy were included in the study. The end point was incidence of clinical heart failure, HFrEF and HFpEF. Multivariable adjusted Cox proportional hazards regression were performed to study the predictors of CHF.

Results

Out of 1086 patients with PDD and a histopathological diagnosis of malignancy, 208 patients were diagnosed with new onset CHF during the 10 years follow-up. Incidence of CHF, HFpEF and HFrEF was found to be 32.1 per 1,000 person-year, 13.9 per 1,000 person-year and 2.93 per 1,000 person-year respectively. Patients who developed clinical heart failure were found to have more hypertension, diabetes, myocardial infarction, peripheral vascular disease, pulmonary disease, renal disease, hematological malignancies and metastatic disease when compared to patients who did not develop heart failure. In multivariable adjusted Cox regression analysis, age at index date (HR 1.02, 95% CI 1.01–1.04, p=0.001), diabetes (HR 1.74, 95% CI 1.28–2.35, p<0.001), myocardial infarction (HR 2.19, 95% CI 1.49–3.20, p<0.001), lung disease (HR 1.53, 95% CI 1.14–2.06, p=0.004) and renal disease (HR 2.03, 95% CI 1.45–2.84, p<0.001) were independent predictors of CHF in patients with PDD and malignancy. Among chemotherapy agents, Vincristine, Ifosfamide, transtuzumab and Bortezomib were found to be associated with CHF.

Conclusion

This is the first study ever to report the incidence of CHF, HFrEF and HFpEF and identify a distinct set of predictors of heart failure in patients with PDD and malignancy. We estimated a much higher incidence of CHF (19%) in our study population, when compared to the general population with malignancy. Our study also depicted a significantly high incidence of HFpEF compared to HFrEF (8.3% vs 1.75%). Our study shows that patients with malignancy are at a significantly higher risk of developing heart failure if they have preexisting diastolic dysfunction. This emphasizes the importance of identifying patients with diastolic dysfunction and a more rigorous cardiovascular surveillance to prevent them from potential heart failure.

Acknowledgement/Funding

None

Corticosteroid signaling at the brain-immune interface impedes coping with severe psychological stress

The immune system supports brain plasticity and homeostasis, yet it is prone to changes following psychological stress. Thus, it remains unclear whether and how stress-induced immune alterations contribute to the development of mental pathologies. Here, we show that following severe stress in mice, leukocyte trafficking through the choroid plexus (CP), a compartment that mediates physiological immune-brain communication, is impaired. Blocking glucocorticoid receptor signaling, either systemically or locally through its genetic knockdown at the CP, facilitated the recruitment of Gata3- and Foxp3-expressing T cells to the brain and attenuated post-traumatic behavioral deficits. These findings functionally link post-traumatic stress behavior with elevated stress-related corticosteroid signaling at the brain-immune interface and suggest a novel therapeutic target to attenuate the consequences of severe psychological stress.

Broadband, high spectral resolution 2-D wavelength-parallel polarimeter for Dense WDM systems

A broadband wavelength-parallel polarimeter has been designed or polarization measurements of multiple Dense WDM channels in parallel, which is based on a 2-D spectral disperser via a diffraction grating and a virtually-imaged phased-array (VIPA). At a hyperfine 2.8 GHz sub-channel spacing, we have demonstrated spectral polarization measurements of ~1500 sub-channels (~32 nm spectral range), with a potential total measurement time of less than 5 ms.

A programmable Fresnel transform pulse shaper

We demonstrate the first reprogrammable Fresnel transform pulse shaper based on a modified direct space-to-time pulse shaping apparatus. In our approach, the pulse shaping lens and mask are implemented by a dual-layer liquid crystal spatial light modulator. The input mask subsequently undergoes a free-space Fresnel transform which causes quadratic dispersion of the output temporal waveform. When used as a spectrometer, we demonstrate that the passband function of the apparatus (determined by the Fourier transform of the input spatial mask) may be chosen to exhibit a user-defined scale. Here we present the theory of operation, as well as experimental verification in both the time- and frequency-domains.

Engineering of the passband function of a generalized spectrometer

To our knowledge, we demonstrate a new scheme for passband engineering of a grating spectrometer. Through spatial masking of the input beam and translation of the optical components we present shaping, shifting, and scaling of the passband in optical frequency. Specifically, we demonstrate the relationship between the applied spatial masking function and the spectrometer passband may be tuned from an exact Fourier transform to a direct scaling through longitudinal displacement of the spectrometer lens and sampling slit and that this operation is independent of the choice of spectrometer center frequency.

Programmable polarization-independent spectral phase compensation and pulse shaping

We report the first use of a double-layer liquid crystal modulator array for spectral phase pulse shaping that operates independent of polarization. Such insensitivity to polarization is crucial for fiber applications, e.g., dispersion compensation.

Evaluation of travoprost as adjunctive therapy in patients with uncontrolled intraocular pressure while using timolol 0.5%

PURPOSE

To evaluate the intraocular pressure-lowering efficacy and safety of travoprost 0.0015% and 0.004%, dosed daily in the evening compared with vehicle, in patients with open-angle glaucoma or ocular hypertension, whose intraocular pressure was not adequately controlled on timolol 0.5% twice daily (twice daily).

METHODS

Subjects who qualified at screening began a run-in period dosing timolol twice daily for 3 weeks. If the subjects had an intraocular pressure of 24 to 36 mm Hg at 8 AM and 21 to 36 mm Hg at 10 AM and 4 pm in at least one eye on timolol, they were randomized to one of two concentrations of travoprost (0.0015% or 0.004%) or vehicle solution every day and were followed for 6 months. Four hundred twenty-six subjects were randomized. The mean intraocular pressure at 8 AM, 10 AM, and 4 PM in the patient's eye with the higher intraocular pressure was used for the analysis.

RESULTS

Mean baseline values (25 mm Hg) for subjects at eligibility (while maintained on timolol) were not significantly different (P <.0001) among the treatment groups. The intraocular pressure was lowered an additional -5.7 to -7.2 mm Hg and -5.1 to -6.7 mm Hg in the travoprost 0.004% and 0.0015% concentrations, respectively. These changes were significantly (P < or =.0001) different from the vehicle group (-1.3 to -2.8 mm Hg). The intraocular pressure range on treatment at all visit times over the 6-month treatment period ranged from 17.9 to 19.2 mm Hg for travoprost 0.004% and 18.3 to 20.1 mm Hg for travoprost 0.0015% compared with 22.4 to 24.1 mm Hg for vehicle. Average hyperemia scores ranged from trace to mild (mean 0.5 on a scale of 0 = none/trace; 1= mild; 2 = moderate; 3 = severe) for all treatment groups. No iris pigmentation changes were observed in any patient during this study. There were no clinically or statistically significant changes from baseline in visual acuity, ocular cells and flare, fundus parameter, cup-to-disk ratio and visual field between the treatment groups. There were no serious adverse events reported for any treatment group.

CONCLUSIONS

Travoprost produced clinically relevant and statistically significant additional intraocular pressure reductions from baseline when used adjunctively with timolol in subjects with open-angle glaucoma or ocular hypertension.

Travoprost compared with latanoprost and timolol in patients with open-angle glaucoma or ocular hypertension

PURPOSE

This study evaluated the safety and intraocular pressure-lowering efficacy of two concentrations of travoprost (0.0015% and 0.004%) compared with latanoprost 0.005% and timolol 0.5% in patients with open-angle glaucoma or ocular hypertension.

METHODS

Eight hundred one patients with open-angle glaucoma or ocular hypertension were randomly assigned to travoprost 0.0015%, travoprost 0.004%, latanoprost 0.005%, or timolol 0.5%. The efficacy and safety of travoprost (0.0015% and 0.004%) daily was compared with latanoprost daily and timolol twice daily for a period of 12 months.

RESULTS

Travoprost was equal or superior to latanoprost and superior to timolol with mean intraocular pressure over visits and time of day ranging from 17.9 to 19.1 mm Hg (travoprost 0.0015%), 17.7 to 19.1 mm Hg (travoprost 0.004%), 18.5 to 19.2 mm Hg (latanoprost), and 19.4 to 20.3 mm Hg (timolol). For all visits pooled, the mean intraocular pressure at 4 PM for travoprost was 0.7 mm Hg (0.0015%, P =.0502) and 0.8 mm Hg (0.004%, P =.0191) lower than for latanoprost. Travoprost 0.004% was more effective than latanoprost and timolol in reducing intraocular pressure in black patients by up to 2.4 mm Hg (versus latanoprost) and 4.6 mm Hg (versus timolol). Based on a criterion of 30% or greater intraocular pressure reduction from diurnal baseline or intraocular pressure 17 mm Hg or less, travoprost 0.0015% and 0.004% had an overall response to treatment of 49.3% and 54.7%, respectively, compared with 49.6% for latanoprost and 39.0% for timolol. Iris pigmentation change was observed in 10 of 201 of patients (5.0%) receiving travoprost 0.0015%, six of 196 of patients (3.1%) receiving travoprost 0.004%, 10 of 194 of patients (5.2%) receiving latanoprost, and none of the patients receiving timolol (0 of 196). The average ocular hyperemia score was less than 1 on a scale of 0 to 3, indicating that on average patients experienced between none/trace and mild for all treatment groups. There were no serious, unexpected, related adverse events reported for any therapy.

CONCLUSIONS

Travoprost (0.0015% and 0.004%), a highly selective, potent prostaglandin F (FP) receptor agonist, is equal or superior to latanoprost and superior to timolol in lowering intraocular pressure in patients with open-angle glaucoma or ocular hypertension. In addition, travoprost 0.004% is significantly better than either latanoprost or timolol in lowering intraocular pressure in black patients. Travoprost is safe and generally well tolerated in the studied patient population.

The Minnesota Senior Health Options program: an early effort at integrating care for the dually eligible

BACKGROUND

Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program.

METHODS

A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes.

RESULTS

The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care.

CONCLUSIONS

Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care.

The matrix model of outpatient stimulant abuse treatment: history and description

The Matrix model was originally developed in response to the cocaine epidemic of the 1980s. The program consists of relapse prevention groups, education groups, social support groups, individual counseling, and urine and breath testing delivered in a structured manner over a 16-week period. The treatment is a directive, nonconfrontational approach which focuses on current issues and behavior change. Several evaluations of the model have supported its usefulness and efficacy with methamphetamine (MA) users. Methamphetamine users appear to respond to treatment similarly to cocaine users and many continue to show improvements at follow-up.

Confidentiality of social work records in the computer age

Computers have brought social, cultural, and economic benefits. They also are challenging social workers to preserve a basic tenet of the profession--confidentiality. Electronic record systems and rapid changes in communication over the Internet are outpacing the profession's ability to ensure privacy. This article discusses ideas of information protection and makes recommendations to minimize violations of privacy.

Foveal dysfunction and central visual field loss in glaucoma

OBJECTIVE

To determine whether foveal function distal to the ganglion cell layer is an independent predictor of central visual field function in glaucoma.

SETTING

University affiliated hospital and private practice.

PARTICIPANTS

Twenty-seven eyes (27 patients) with normal-pressure glaucoma, 10 eyes (10 patients) with primary open-angle glaucoma, and 47 eyes of 47 matched normal volunteers.

INTERVENTION AND MAIN OUTCOME MEASURES

Foveal cone electroretinogram (ERG) amplitude, relative optic cup to disc area and their relations to Humphrey full-threshold 30-2 visual field central 4-point mean total deviation (C4MTD) and pattern deviation (C4MPD).

RESULTS

Foveal cone ERG amplitude was subnormal in 14 (37.8%) of the 37 glaucomatous eyes and lower in the glaucoma group compared with normal eyes (P<.01). The C4MTD and C4MPD were lower in glaucomatous eyes with subnormal amplitudes compared with those with normal amplitudes (P<.01 and P<.05, respectively). Amplitude was directly correlated with C4MTD (P<.01) and C4MPD (P<.01). Relative optic cup to disc area was inversely correlated with C4MTD (P<.001) and C4MPD (P<.001). Partial correlation analysis revealed that amplitude and relative optic cup to disc area were independent predictors of C4MTD and C4MPD.

CONCLUSION

Foveal function distal to the ganglion cell layer and optic disc cupping independently predict central visual field function in glaucoma.

Foveal outer retinal function in eyes with unexplained visual symptoms or acuity loss

OBJECTIVE

To determine whether foveal outer retinal dysfunction is common in eyes with unexplained visual symptoms or acuity loss.

DESIGN

Prospective study.

PARTICIPANTS

Seventy-three eyes of 44 consecutive patients with unexplained visual symptoms or acuity loss, 39 eyes of 39 control subjects, and 12 eyes of 7 patients with known maculopathy.

INTERVENTION

Foveal cone electroretinography (ERG) and letter recognition perimetry.

MAIN OUTCOME MEASURES

Foveal cone ERG data.

RESULTS

Abnormal foveal cone ERG data were recorded in 35 (48%) of 73 eyes (23 [52%] of 44 patients). Among these 35 eyes, amplitude was lower than in normal controls (P<.001) and was correlated with visual acuity and the number of letter recognition perimetry errors (P<.05 for both). The latter was higher in eyes with abnormal retinal responses than in symptomatic eyes with normal responses (P<.01). However, initial symptoms, visual acuity, and macular appearance did not differentiate between these 2 groups. Foveal cone ERG test vs retest data showed consistent results.

CONCLUSION

Foveal outer retinal dysfunction is a common underlying mechanism of previously unexplained visual symptoms or acuity loss. Foveal cone ERG testing should be considered early in the evaluation of eyes with this presentation.

High-risk characteristics of fellow eyes of patients with unilateral neovascular age-related macular degeneration

OBJECTIVE

This study aimed to determine whether clinical tests of ocular function and macular appearance independently can help to predict which patients with unilateral neovascular age-related macular degeneration (AMD) will have a choroidal neovascular membrane (CNVM) develop in their fellow eye.

DESIGN

The study design was a prospective cohort study.

PARTICIPANTS

One hundred twenty-seven patients with unilateral neovascular AMD observed for up to 4.5 years participated.

INTERVENTION

Functional measurements included visual acuity, macular visual field, glare recovery time, and foveal electroretinogram amplitude and implicit time.

MAIN OUTCOME MEASURE

The age-adjusted proportion of patients having a CNVM develop over follow-up assessed by the Cox proportional hazards model with stepwise selection was measured.

RESULTS

On average, 8.8% of patients had a CNVM develop each year. Independent risk factors for the fellow eye were its glare recovery time in minutes (relative risk = 1.30, confidence interval = 1.10-1.54, P = 0.003) and its extent of visible macular abnormalities on a four-point scale (relative risk = 1.62, confidence interval = 1.06-2.59, P = 0.03). Of the fellow eyes that converted, the interval to have a CNVM develop was inversely related to the foveal electroretinogram implicit time.

CONCLUSIONS

A slower recovery from glare and more extensive funduscopic changes appear to be independent risk factors for the development of a CNVM in the fellow eyes of patients with unilateral neovascular AMD. A slower foveal electroretinogram implicit time may be a sign of early stage CNVM development, perhaps because of outer retinal ischemia. These results have clinical management implications, particularly for those patients at high risk of having a potentially treatable form of AMD develop.

Foveal cone function in nonproliferative diabetic retinopathy and macular edema

PURPOSE

To study results of foveal cone electroretinography (ERG) in patients with nonproliferative diabetic retinopathy (NPDR), with and without clinically significant macular edema (CSME).

METHODS

Electroretinograms of foveal cones were elicited, with a dual-beam stimulator-ophthalmoscope, from 18 consecutive patients with bilateral NPDR and unilateral CSME.

RESULTS

Analysis of resulting data revealed that mean amplitude was significantly lower in eyes with CSME and in eyes without CSME., compared with that in normal eyes. Mean implicit time was significantly longer in eyes with CSME compared with that in normal eyes, but in eyes of diabetic patients without CSME., mean implicit time was the same as that in normal eyes. Amplitudes were directly correlated and implicit times were inversely correlated with best-corrected Snellen visual acuity in eyes with and without CSME. Eyes with CSME had significantly lower amplitudes and longer implicit times than their fellow eyes without CSME. In addition, eyes with NPDR, with or without CSME, did not exhibit the normal rise in amplitude with increasing duration of light exposure.

CONCLUSIONS

Electroretinographic findings showed abnormalities in foveal cone responses in eyes with NPDR, particularly in the presence of CSME. These results may support a functional role for outer retinal dysfunction in patients with diabetic retinopathy and loss of central vision.

The child's conception of psychiatric cure

Twenty-two sequentially hospitalized children on a preadolescent psychiatric unit were videotaped with a semi-structured Piagetian-type interview that focused on assessing their understanding of why they were in the hospital, how they conceptualized their problems and how they thought they would get better or cured. We found six categories of "cure": 1) there was no cure for their problems; 2) cure meant reversal of some behaviors; 3) cure involved some internal change; 4) cure was equivalent to being discharged; 5) cure meant changing other people; and 6) idiosyncratic answers. Our findings suggest that it is useful to clarify a child's understanding of treatment and cure in order to target more understandable and effective treatment.

Understanding the social needs of streetwalking prostitutes

The social dynamics of prostitution render prostitutes unable at times to meet basic human needs, vulnerable to violence, and at risk for sexually transmitted disease. Since April 1989 a mobile van from a private foundation has been contacting prostitutes throughout the five boroughs of New York City to provide HIV testing and counseling and to distribute condoms, bleach kits for cleaning needles, and HIV prevention information. Data collected from 1,963 female prostitutes are discussed in this article. Information is provided on demographics, family and living arrangements, sex and drug practices, HIV status and risk reduction practices, and health history. Methods are discussed for social workers to develop creative ways to provide outreach and develop relationships with a vulnerable population that invests much effort in remaining concealed.

Persistent hepatitis C virus infection in a chimpanzee is associated with emergence of a cytotoxic T lymphocyte escape variant

Hepatitis C virus (HCV) establishes a persistent infection in humans and chimpanzees despite the presence of virus-specific, class I major histocompatibility complex-restricted CD8+ cytotoxic T lymphocytes (CTLs) in the liver. The data presented here demonstrate that CTLs directed against a conserved epitope in the HCV nonstructural 3 protein persist in the liver of a chronically infected chimpanzee for at least 2 years after infection. However, these CTLs did not recognize the HCV quasi-species present in the plasma of this animal at week 16 postinfection or at later time points. Escape from the CTL response was facilitated by an aspartic acid to glutamic acid (D-->E) substitution at amino acid position 1449 in all HCV genomes that were sequenced. The results of this study strongly support the concept that CTL responses can select for variant viruses with an enhanced ability to persist in a host and have important implications for the design of vaccines against HCV.

Video home training (the Orion project): a short-term preventive and treatment intervention for families with young children

Developed in Holland and based on short-term, home-centered, filmed video feedback of family interactions, an experimental Orion project was conducted in Israel to determine whether it could be provided through local welfare departments as a routine treatment alternative. This article summarizes an evaluation of 52 families (with problems in parent-child interaction) and 64 control families that participated in the Orion Video Home-Training Project. Only the Orion families showed significant gains in all the eight areas of positive parent-child communication that are the focus of the program, which is based on reinforcing potential family strengths. These gains were generally sustained 6 months after program completion. There were several background variables, such as family status, income, health, education, and employment, that influenced the extent of family gains.

Iris pigmentation and extent of disease in patients with neovascular age-related macular degeneration

PURPOSE

To determine whether the extent of disease in age-related macular degeneration (AMD) varies with iris pigmentation.

METHODS

The authors assessed visual function and macular appearance in the fellow eye or both eyes of 132 white patients with unilateral neovascular AMD. All patients had a visual acuity of 20/60 or better in the fellow eye. Eighty-nine of the patients were coded as having light irides (blue, green, or hazel) and 43 were coded as having dark irides (brown); the two groups of patients had comparable mean ages.

RESULTS

By the Mann-Whitney test for differences in mean rank, fellow eyes with light irides showed a marginally worse visual acuity (P = .156) but significantly more visual field impairment by letter recognition perimetry (P = .011) and the macular threshold test of the Humphrey Field Analyzer (P = .043), and more retinal pigment epithelial atrophy (P = .017) and focal areas of hyperpigmentation (P = .002) than fellow eyes with dark irides. For eyes with a choroidal neovascular membrane (CNVM), those with light irides had significantly lower visual acuities (P = .006) and larger scars (P = .006) than eyes with dark irides. In addition, extent of disease in the eye with a CNVM was positively correlated with extent of disease in the fellow eye for most comparisons.

CONCLUSIONS

These observations suggest that light iris pigmentation is associated with more extensive retinal disease in patients with unilateral neovascular AMD. Furthermore, in such patients, those with worse disease in the eye with a CNVM may tend to have more extensive atrophic disease in the fellow eye.

Vaccination of chimpanzees against infection by the hepatitis C virus

A high incidence of community-acquired hepatitis C virus infection that can lead to the progressive development of chronic active hepatitis, liver cirrhosis, and primary hepatocellular carcinoma occurs throughout the world. A vaccine to control the spread of this agent that represents a major cause of chronic liver disease is therefore needed. Seven chimpanzees (Pan troglodytes) have been immunized with both putative envelope glycoproteins [E1 (gp33) and E2 (gp72)] that were copurified from HeLa cells infected with a recombinant vaccinia virus expression vector. Despite the induction of a weak humoral immune response to these viral glycoproteins in experimentally infected chimpanzees, a strong humoral immune response was obtained in all vaccines. The five highest responders showed complete protection against an i.v. challenge with homologous hepatitis C virus 1. The remaining two vaccines became infected, but both infection and disease may have been ameliorated in comparison with four similarly challenged control chimpanzees, all of which developed acute hepatitis and chronic infections. These results provide considerable encouragement for the eventual control of hepatitis C virus infection by vaccination.

Hepatitis C virus (HCV) circulates as a population of different but closely related genomes: quasispecies nature of HCV genome distribution

Sequencing of multiple recombinant clones generated from polymerase chain reaction-amplified products demonstrated that the degree of heterogeneity of two well-conserved regions of the hepatitis C virus (HCV) genome within individual plasma samples from a single patient was consistent with a quasispecies structure of HCV genomic RNA. About half of circulating RNA molecules were identical, while the remaining consisted of a spectrum of mutants differing from each other in one to four nucleotides. Mutant sequence diversity ranged from silent mutations to appearance of in-frame stop codons and included both conservative and nonconservative amino acid substitutions. From the relative proportion of essentially defective sequences, we estimated that most circulating particles should contain defective genomes. These observations might have important implications in the physiopathology of HCV infection and underline the need for a population-based approach when one is analyzing HCV genomes.

Hydroxychloroquine retinopathy

We analyzed ocular findings from two patients (aged 49 and 60 years) with hydroxychloroquine (Plaquenil, Winthrop Pharmaceuticals, Division of Sterling Drug, Inc., New York, New York) retinopathy. Both patients were treated for systemic lupus erythematosus; one patient was treated with 400 to 800 mg of hydroxychloroquine per day (6.1 to 12.2 mg/kg of body weight/day) over a ten-year period. Cumulative doses were 1,788 and 2,920 g, respectively. Neither patient had ever been treated with chloroquine. One patient complained of glare and difficulty in adjusting to changes in illumination, whereas the other was asymptomatic. Both had bilateral visual acuities of 20/25, pericentral scotomata, and increased final dark-adapted rod thresholds in the two retinal areas that were tested. Fullfield electroretinograms were reduced and delayed, and focal cone electroretinography showed abnormal foveal responses as well. Ophthalmoscopy and fluorescein angiography showed a bull's-eye maculopathy in both eyes of one patient and perifoveal depigmentation in both eyes of the other patient. Retinal function remained stable at follow-up examinations 18 to 24 months after the cessation of hydroxychloroquine treatment. These two cases demonstrate that peripheral retinopathy, as well as maculopathy, can develop in patients who are treated with hydroxychloroquine for systemic lupus erythematosus, and that retinal function may remain stable after discontinuation of hydroxychloroquine treatment.

Normal change in the foveal cone ERG with increasing duration of light exposure

Foveal cone electroretinograms (ERG) were elicited with a stimulator-ophthalmoscope from 24 normal subjects with a 4 degrees stimulus flickering at 42 Hz and centered within a 12 degrees steady surround. The stimulus and surround were presented at retinal illuminances of 4.8 log td and 5.5 log td, respectively, to facilitate visualization of the fundus. Several consecutive averaged responses were evaluated to determine whether increasing duration of light exposure causes an increase in amplitude, as previously found for the full-field cone ERG. On average, amplitude increased by 27% over time, and the linear regression of amplitude on recording number accounted, on average, for 42% of the amplitude variability between consecutive responses. Two subjects had amplitudes that were initially subnormal, based on previously published norms, but that value increased to within the normal range in subsequent recordings. These findings show that a significant change in the cone ERG occurs in the fovea with increasing duration of light exposure at these retinal illuminances, and suggest that, when the stimulator-ophthalmoscope is used, consecutive foveal cone ERGs should be obtained from patients with suspected macular disease to avoid a false diagnosis of retinal malfunction.

Clinical patterns and associated conditions in chronic uveitis

We determined the relative frequencies of the different types of chronic uveitis, and the possible associated conditions, among 400 consecutive patients with chronic uveitis examined during the years 1982 through 1988. Of the 400 patients, 183 (45.75%) had anterior uveitis, 98 (24.5%) ahd panuveitis, 61 (15.3%) had intermediate uveitis, and 58 (14.5%) had isolated posterior uveitis. Only four of the 98 patients with panuveitis (4.1%) were considered idiopathic after a comprehensive examination, whereas 94 of the 183 patients with anterior uveitis (51.4%) were similarly classified. We found an associated condition in 242 of the 400 patients of the study group (60.5%). Of these 242 patients, 61 had Behçet's disease, which constituted the most frequently encountered associated condition in this study. Of the 61 patients with Behçet's disease, 58 had panuveitis and constituted 59.2% of the panuveitis group. Of the 61 patients with intermediate uveitis, 17 (27.9%) had a concurrent disease. An associated condition was found in 95% and 96.2% of patients with unilateral and bilateral panuveitis, respectively, but in none of the patients with unilateral intermediate uveitis. Environmental, cultural, or genetic factors may be accountable for the differences discovered between our findings and those of previously published studies from the United States and England with respect to relative frequencies of some of the associated diseases in patients with chronic uveitis.

Analysis of genomic variability of hepatitis C virus

The anti-C100-enzyme-linked immunosorbent assay, the new four-antigen antibody recombinant immunoblot assay, and detection of viral RNA sequences by copy DNA-polymerase chain reaction were used to establish the course of hepatitis C virus (HCV) infection in recipients of HCV-infected blood products. Different patterns of infection were observed: (1) persistent HCV infection with and without chronic hepatitis, and with acute resolved hepatitis; and (2) acute resolved hepatitis with clearance of HCV. In order to determine whether different infection- and anti-HCV recognition patterns are correlated to differences in viral nucleotide sequences, we compared sequences in the NS3 region between isolates from recipient(s) and their infective donors. Based on these comparisons we conclude that in The Netherlands two types of molecular variants circulate; one resembling the Japanese prototype isolate JH1, and the other the HCV-1 isolate from the U.S.A. The difference in sequence homology between the two types is approximately 24%. Comparison of sequences of donors and involved recipients determined in isolates prepared from blood samples four years after transfusion revealed that viral RNA sequences are strongly conserved (greater than 96.8%) in the NS3 region. These data indicate that the observed differences in anti-HCV immune response patterns between recipients are more a reflection of their immune reactivity than of divergence of viral strains.

Impacts associated with special care units in long-term care facilities

This study is a comprehensive, longitudinal assessment of the characteristics of special care patients. Demented patients in special care units (SCUs) within four nursing homes were compared with their demented counterparts in the same facilities who were not placed in SCUs. Results of this preliminary study suggest that the two groups differ in level of cognitive impairment, in behavior, and in functional and physical status. No deleterious or beneficial effects were associated with SCU residence during a 6-month period.

Psychopathology and plasma cortisol responses to dexamethasone in prepubertal psychiatric inpatients

This study of 51 prepubertal psychiatric inpatients evaluates plasma cortisol measurements at 8 AM, 4 PM, and 11 PM before and after dexamethasone was administered in counterbalanced order at doses of 0.5 mg and 1.0 mg. Approximately 76.5% of the children had an affective disorder. Major depressive disorder was associated with higher plasma cortisol levels than other disorders. Pre- and postdexamethasone plasma cortisol levels using 0.5 mg dexamethasone exhibited a circadian variation. The optimal criterion for cortisol nonsuppression was 5 micrograms/dl measured at 8 AM after administration of 0.5 mg dexamethasone.

Children's conceptualization of their own psychiatric illness and hospitalization

Conscious understanding of their psychiatric hospitalization and illness was examined in 22 preadolescent children. Semistructured interviews evaluated their understanding of why they were hospitalized and its relationship to their problems. Their concepts of hospitalization fell into five categories: moralistic/punitive, adultomorphic, medical/physical, doesn't know, and due to misunderstanding. Most children described personal problems, yet believed that these were unrelated to and did not justify hospitalization.

Clinicopathologic report of spontaneous expulsive hemorrhage

A 78-year-old woman who was known to suffer from bilateral absolute glaucoma underwent enucleation of her left eye because of corneal perforation with spontaneous bleeding. The clinical and pathologic findings were compatible with spontaneous expulsive hemorrhage. A possible cause of the hemorrhage in this case was inflamed necrotic choroidal vascular walls that bled after corneal perforation with decompression in the glaucomatous eye.

An in vivo and in vitro investigation of the phototoxic potential of tenoxicam, a new non-steroidal anti-inflammatory agent

The phototoxic potential of tenoxicam, a new non-steroidal anti-inflammatory drug (NSAID), was investigated following oral and intradermal administration of the drug. No hypersensitivity responses to ultraviolet radiation (UVR) were observed for either orally or intradermally administered tenoxicam. In a parallel in vitro study, human polymorphonuclear leucocytes (PMNL) and mononuclear leucocytes (MNL) were exposed to UVR in the presence and absence of the NSAIDs tenoxicam, piroxicam and benoxaprofen (10-40 micrograms/ml). The generation of reactive oxidants by control and UVR-treated human PMNL and MNL in the presence and absence of the NSAIDs was measured according to the extent of luminol-enhanced chemiluminescence. Only benoxaprofen activated reactive oxidant generation by PMNL and MNL. The results of these in vitro and in vivo studies show that phototoxicity is unlikely to complicate chemotherapy with tenoxicam.

Psychiatric inpatient treatment of childhood schizoaffective disorder

Psychiatric inpatient treatment of a child with multiple life-threatening symptoms, including suicidal behavior and food refusal, is described. Changes in symptomatology were monitored by applying research scales and research interview methods during the course of intervention. The process that led to the diagnosis of childhood schizoaffective disorder is discussed.