Clinical Outcomes of Patients with Brain Metastases from Colorectal Cancer Treated with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Prior studies have demonstrated that brain metastases from gastrointestinal (GI) primary cancers have a poorer response to stereotactic radiosurgery (SRS) when compared to patients with other primary sites, with reported local control of 62-74%. We report our institutional outcomes for patients with colorectal primary cancer who were treated with SRS for brain metastases.

MATERIALS/METHODS

Patients with colorectal primary cancer who underwent SRS for brain metastases between 1989 and 2021 were retrospectively reviewed from a single institutional IRB-approved database. The primary endpoint was local failure (LF) and secondary endpoint was overall survival (OS). LF was estimated using the Cumulative Incidence Function with death as a competing risk. Survival analysis was performed using the Kaplan-Meier Method. Predictors of cumulative incidence of LF were assessed using competing risk regression.

RESULTS

The study population comprised of 109 patients with primary colorectal adenocarcinoma with 207 brain metastases. The median follow-up was 5.2 months (range: 0.4-124 months) and median OS was 5.8 months (range: 0.5-71.2 months). Fifty-two patients (48%) were male and median Karnofsky Performance Status at the time of treatment was 80 (range: 40-100). The median tumor diameter was 1.55 cm (range: 0.17-5.48 cm). The median prescription dose and number of fractions were 24 Gy (range: 11-36 Gy) and 1 fraction (range: 1-3 fractions), respectively. The cumulative incidence of LF at 3, 6, and 12 months was 9.7% (95% CI: 6.1-14%), 22% (95% CI: 16-28%), and 25% (95% CI: 20-31%), respectively. Overall survival at 3, 6, and 12 months was 81% (95% CI: 76-87%), 49% (95% CI: 42-56%) and 24% (95% CI: 18-31%), respectively. On univariate analysis, age was a significant predictor (HR = 0.96, 95% CI: 0.94-0.98), p < 0.001) of LF. Tumor size (HR = 0.80, p = 0.13) and prescription dose (HR = 1.02, p = 0.54) did not predict for LF.

CONCLUSION

To our knowledge, this is the largest series of patients with brain metastases from colorectal primary cancer treated with SRS. Compared to historical data, LF and OS in our cohort of patients was favorable. Our data confirms relatively higher rates of LF when compared to brain metastases from other primary disease sites. Further studies are warranted to identify factors that predict for LF following SRS and to develop models that predict which patients with colorectal brain metastases may be at higher risk of failure.

Addition of Orange Pomace Attenuates the Acute Glycemic Response to Orange Juice in Healthy Adults

BACKGROUND

Fiber is an important part of a healthy diet and is known to attenuate postprandial glycemia. Orange pomace (OP) is a by-product of orange juice (OJ) production and is a rich source of fiber.

OBJECTIVE

Two separate studies determined the impact of added OP to 100% OJ on postprandial glycemic response compared with sugar-matched OJ or whole orange fruit (WOF).

METHODS

Study 1 included 17 adults [65% female, age 39.3 ± 3.1 y, and BMI (in kg/m2) 24.6 ± 0.7], and study 2 included 45 different adults (47% female, age 25.1 ± 4.3 y, and BMI 22.5 ± 1.6). Studies were conducted at separate locations using a randomized, 3-arm, crossover design to test the glycemic response to sugar-matched OJ, OJ with 5 g fiber from OP (OPF), or WOF. The primary outcomes were 2-h glucose incremental area under the curve (iAUC) in study 1, analyzed by repeated measures ANOVA, and maximum glucose concentration (Cmax) in study 2, analyzed using PROC MIXED (ANCOVA). Glucose and insulin concentrations were measured at fasting and multiple time points over 2 h after test product consumption (study 1, serum; study 2, plasma).

RESULTS

In study 1, glucose iAUC was not significantly lower in OPF compared to the OJ or WOF (825 ± 132 compared with 920 ± 132 and 760 ± 132 mg · min · dL-1, respectively, P = 0.57 for both). In study 2, glucose iAUC was significantly lower in WOF compared with OPF and OJ (689 ± 70.7 compared with 892 ± 70.7 and 974 ± 70.7 mg · min · dL-1, P = 0.02 and 0.001, respectively). Data from both studies indicated OPF reduced Cmax compared with OJ and that the reductions were comparable to WOF (study 1: OPF, 115 ± 4.06 compared with OJ, 124 ± 4.06 and WOF, 114 ± 4.06 mg · dL-¹, P = 0.002 and 0.75, respectively; study 2: OPF, 128 ± 1.92 compared with OJ, 136 ± 1.92 and WOF, 125 ± 1.92 mg · dL-¹, P = 0.001 and 0.28, respectively).

CONCLUSION

Data from both studies demonstrated no significant effect of OPF on postprandial iAUC compared with OJ. However, adding OP into OJ attenuates the postprandial glucose Cmax, and the responses were comparable to WOF in healthy adults.

Rehabilitation and physical activity for COVID-19 patients in the post infection period

The first cases of COVID-19 were initially recorded in December 2019 in Wuhan, the capital of China's Hubei Province. The situation quickly escalated and turned into a global pandemic. COVID-19 is a highly infectious respiratory disease that leads to decreased respiratory, physical, and psychological function of affected patients (2). Patients' symptoms widely vary; from asymptomatic course to severe symptoms. Decrease in physical function, and, in some cases, a persistence of symptoms may be observed in patients, who overcame the infection period. Rehabilitation represents a potential treatment option for COVID-19 patients in post-infection period. Rehabilitation therapies may help to restore physical function in patients and to reduce the long-term effects of COVID19 infection (Ref. 37). Text in PDF www.elis.sk Keywords: COVID19, rehabilitation, post-infection syndrome.

Perspective: US Documentation and Regulation of Human Nutrition Randomized Controlled Trials

Training to ensure good documentation practices and adherence to regulatory requirements in human nutrition randomized controlled trials has not been given sufficient attention. Furthermore, it is difficult to find this information conveniently organized or in a form relevant to nutrition protocols. Current gaps in training and research surveillance exist in clinical nutrition research because training modules emphasize drugs and devices, promote reliance on monitoring boards, and lack nutrition expertise on human nutrition research teams. Additionally, because eating is essential, ongoing, and highly individualized, it is difficult to distinguish risks associated with interventions from eating under free-living conditions. Controlled-feeding trials provide an option to gain more experimental control over food consumed, but at a price of less external validity, and may pose human behavior issues that are unrelated to the intervention. This paper covers many of the expected practices for documentation and regulation that may be encountered in planning and conducting nutrition intervention trials with examples and references that should be useful to clinical nutrition researchers, funders of research, and research institutions. Included are definitions and guidance on clinical nutrition research oversight (institutional review boards, data safety and monitoring boards, US FDA); participant safety; standard operating procedures; training of investigators, staff, and students; and local culture and reporting requirements relevant to diet-related clinical research conduct and documentation.

A Randomized, Double-Blind, Crossover Study to Determine the Available Energy from Soluble Fiber

OBJECTIVE

Determining the available energy (caloric value) of dietary non-digestible fibers that are fermented to varying degrees by intestinal microbes and metabolized to short chain fatty acids is important for provision of accurate information to food and beverage manufacturers for reformulation and labeling purposes. The objective of this human study was to determine the available energy of soluble fiber products by measuring post consumption breath hydrogen, with inulin as a control.

METHODS

PROMITOR^® Soluble Corn Fiber 70 (SCF70) and PROMITOR^® Soluble Corn Fiber 85B (SCF85B) are Tate & Lyle dietary fiber products with 70% and 85% fiber, respectively. The fiber portion of these products is structurally representative of the fiber portion of all PROMITOR^® SCF products. The study conducted was a randomized, double-blind, crossover design. Breath hydrogen was quantified following consumption of beverages consisting of 8 oz. of water and: inulin (control), SCF70, or SCF85B at 5, 10, or 15 g (total ingredient weight, "as is"). Subjects were generally healthy men and women (N = 19), age 18 to 34 years, with body mass index (BMI) 19.3 to 24.8 kg/m². The primary outcome was incremental area under the curve over 10 h (iAUC0-10 h) for inulin, SCF70, and SCF85B at each dose. The available energy (kcal/g ingredient and kcal/g fiber) from SCF70 and SCF85B at each dose was then calculated using inulin as the reference.

RESULTS

Results demonstrated that breath hydrogen production was significantly lower following consumption of SCF70 and SCF85B compared to inulin at all consumption amounts. There were no significant differences in breath hydrogen production following consumption of SCF70 compared to SCF85B.

CONCLUSION

The available energy per gram of fiber was not significantly different between the SCF70 and SCF85B PROMITOR^® products. The available energy of the fiber portion of PROMITOR^® SCF products was determined to be 0.2 kcal/gram.

Small bowel adenocarcinoma in Crohn's disease: a rare but devastating complication

BACKGROUND

Small bowel adenocarcinoma (SBA) remains a rare entity but occurs at increased frequency in the setting of chronic Crohn's disease (CD). Our aim was to study the presentation, diagnosis and prognosis of SBA in patients undergoing surgery for CD at a single institution.

METHODS

We reviewed the medical records of all patients with CD complicated by adenocarcinoma of the small bowel from 2000 to 2017. Descriptive statistics and Kaplan-Meier overall survival estimates were calculated.

RESULTS

In total, 22 patients (14 males) with CD (median duration of Crohn's diagnosis 32 years) were diagnosed with SBA and underwent surgical resection (8 isolated small bowel resections, 12 ileocolic resections, and 2 total proctocolectomies). The median patient age at the time of diagnosis was 54 years (range 22-82 years). A total of 17 patients (77%) underwent cross-sectional CT imaging within 3 months of surgery, a cancer diagnosis was suggested in only one patient. In one other patient, SBA was diagnosed preoperatively on endoscopic biopsy of the terminal ileum. The remaining patients were operated on for obstruction (n = 17), abscess or fistulizing disease (n = 2), and sigmoid cancer (n = 1). For these 20 (90%) patients not suspected to have SBA on preoperative assessment, 5 (25%) were diagnosed intraoperatively on frozen section and 15 (75%) were unexpectedly diagnosed postoperatively on final pathology. T staging was characterized by more advanced tumors (T4: 59%, T3: 27%, T2: 9%, and T1: 5%). Nine patients (41%) had nodal involvement and five patients (23%) had hepatic and/or peritoneal carcinomatosis. The 1-, 3-, and 5-year survival estimates for our cohort were 84%, 30%, and 10%, respectively. Median survival was 30.5 months with median follow-up of 23 months (range 6-84 months).

CONCLUSIONS

SBA in the setting of CD is most commonly found incidentally after surgical resection for benign indications. As such, any suspicious finding at the time of surgery in a patient with chronic CD should warrant careful investigation with frozen section and/or resection. Prognosis for CD complicated by SBA remains poor even in the modern era.

100% Fruit Juice and Dental Health: A Systematic Review of the Literature

Background: The objective of this systematic review was to assess the scope and breadth of publicly available prospective cohort and randomized controlled trial (RCT) literature on 100% fruit juice and dental caries or tooth erosion in humans.

Methods: We performed a systematic search in MEDLINE/PubMed, EMBASE, and Web of Science for studies published from inception through May 2018, and the Cochrane Library databases for reports published through January 2018. Prospective cohort studies or RCTs conducted on dental health and 100% fruit juice, and published in English were selected. No restrictions were set for age, sex, geographic location, or socioeconomic status.

Results: Eight publications representing five independent prospective cohort studies and nine publications on nine RCTs were included. All prospective cohort studies were in children or adolescents, and all RCTs were in adults. Prospective cohort studies on tooth erosion found no association between juice intake and tooth erosion, while those on dental caries incidence reported either no association or an inverse association between 100% fruit juice intakes and dental caries incidence. RCTs on tooth erosion showed decreased microhardness, increased surface enamel loss, increased erosion depth, greater enamel softening, and/or increased pellicle layer with 100% fruit juice, and those on dental caries showed increased demineralization of enamel slabs with 100% fruit juice.

Conclusions: The existing evidence on 100% fruit juice intake and caries and tooth erosion are not conclusive. Overall, prospective cohort studies in children and adolescents found no association between 100% fruit juice intake and tooth erosion or dental caries, but, RCT data in adults suggests that 100% fruit juice could contribute to tooth erosion and dental caries. The RCT data, however, were from small, short-term studies that utilized intra-oral devices generally devoid of normal plaque or saliva action, and generally employed conditions that are not reflective of normal juice consumption.

Effect of Egg Consumption on Cardiometabolic Health Outcomes: An Overview of Systematic Reviews and Meta-Analyses (P08-043-19)

Objectives

The relationship of egg consumption and cardiometabolic disease risk is controversial. This report provides an overview on the consistencies and gaps in the evidence base on eggs and cardiometabolic health.

Methods

PubMed database was screened for evidence-based reviews published in English that assessed human studies on egg consumption and cardiometabolic outcomes, augmented by searches in Web of Science and Google.

Results

Seven qualitative and 15 quantitative reviews were identified, with >70% having published since 2015. Overall, the systematic reviews were of low quality, while meta-analyses were of moderate to high quality. No association of increased egg intake and risks of heart disease or stroke in the general population were found in the meta-analyses. Increased risk of heart failure was noted in two meta-analyses that analyzed the same three cohort studies. Five recent meta-analyses reported no increased risk of type 2 diabetes mellitus (T2DM) in the general population, although increased risk in US-based populations only was reported. Older (2013) meta-analyses reported increased risk of cardiovascular disease (CVD) or heart disease in T2DM populations and no recent evidence-based reviews were identified. Finally, only one meta-analysis reported intervention studies specifically on eggs and biomarkers (i.e., lipids), and the results contradicted those from observation studies.

Conclusions

Recent evidence-based reviews conclude that increased egg consumption is not associated with CVD in the general population. More research is needed on the positive associations between heart failure and T2DM risk with egg consumption, as well as CVD risk in diabetics, before firm Conclusions can be made.

Funding Sources

Partial support from Egg Nutrition Council.

Effect of Cranberry on Urinary Tract Infection Risk: A Meta-Analyses (P06-116-19)

Objectives

Cranberry (Vaccinium spp.) has been advocated for maintaining healthy urinary tract function in women; however, the effect in other populations is controversial. The aim of this meta-analysis was to evaluate cranberry intake and the risk of uncomplicated urinary tract infection (UTI) and some categories of complicated UTI in otherwise healthy populations.

Methods

MEDLINE, EMBASE, Cochrane, and Web of Science were systematically searched, and studies screened and extracted using a predefined strategy by two independent investigators. Discrepancies were resolved by discussion with a third investigator. Meta-analysis was performed using RevMan (version 5.3.5, Cochrane, UK). Heterogeneity was assessed with both I2 and the chi-square tests. A low to moderate (I2 < 50%) heterogeneity was found; thus, fixed-effect model using the Mantel-Haenszel method were used to estimate the risk ratio (RR).

Results

A total of 16 studies were included in the quantitative analysis. Pooled RR estimates for the seven studies on healthy, non-pregnant women (RR = 0.76 [95% CI: 0.63–0.91]) suggest that cranberry may reduce the risk for UTI recurrence in this population, consistent with previous meta-analyses. Meta-analysis also suggests lower UTI risk with cranberries in children based on four studies (RR = 0.58 [95% CI: 0.41–0.83]). Only two studies in pregnant women were identified and these were both performed by the same research group. RR estimates obtained for healthy, pregnant women (RR = 0.87 [95% CI: 0.37–2.04]) were not significant. The RR estimate for elderly/institutionalized adults was also not significant (RR = 0.81 [95% CI: 0.48–1.35]), but the three studies in this evaluation included data combined from heterogeneous populations having immune, neurological, and/or physical dysfunction with data from healthy people. Therefore, these findings do not reflect data in the generally healthy elderly population.

Conclusions

Meta-analysis of studies investigating cranberry and UTI risk suggests that cranberries may be useful in reducing the risk of uncomplicated UTI recurrence in healthy, non-pregnant women and children. More research is needed on the effect of cranberry on UTI risk in pregnant women and generally healthy elderly/institutionalized adults before firm conclusions can be made.

Funding Sources

Ocean Spray.

The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma

AIM

The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes.

METHOD

We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables.

RESULTS

Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05).

CONCLUSION

Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.

Narrative Review of Hydration and Selected Health Outcomes in the General Population

Although adequate hydration is essential for health, little attention has been paid to the effects of hydration among the generally healthy population. This narrative review presents the state of the science on the role of hydration in health in the general population, specifically in skin health, neurological function (i.e., cognition, mood, and headache), gastrointestinal and renal functions, and body weight and composition. There is a growing body of evidence that supports the importance of adequate hydration in maintaining proper health, especially with regard to cognition, kidney stone risk, and weight management. However, the evidence is largely associative and lacks consistency, and the number of randomized trials is limited. Additionally, there are major gaps in knowledge related to health outcomes due to small variations in hydration status, the influence of sex and sex hormones, and age, especially in older adults and children.

Substitution of Corn Starch with Resistant Starch Type 4 in a Breakfast Bar Decreases Postprandial Glucose and Insulin Responses: A Randomized, Controlled, Crossover Study

BACKGROUND

Resistant starches type 4 (RS4) are chemically modified starches that are resistant to digestion by human enzymes.

OBJECTIVE

We aimed to test our hypothesis that replacement of standard starch with RS4 in a baked breakfast bar would decrease postprandial glycemic and insulinemic responses in healthy adults.

METHODS

In this double-blind, randomized crossover study, 21 healthy adults [10 men; 20-45 y old; BMI (kg/m2): 19.3-27.0] consumed a baked breakfast bar containing tapioca-based RS4 (Actistar 75330; Cargill, Inc.) or a macronutrient-matched control bar, delivering 32 g and 4 g of dietary fiber, respectively. Primary outcome was the incremental area under the curve (iAUC0-120 min) for postprandial capillary glucose. Other outcomes included postprandial serum insulin iAUC0-120 min, glucose and insulin maximum concentration (Cmax), and time to Cmax (Tmax).

RESULTS

Median glucose iAUC0-120 min was 22% lower (P < 0.05) and median insulin iAUC0-120 min was 37% lower (P < 0.05) after consumption of the RS4 food compared with the control food. Glucose and insulin Cmax and Tmax were not significantly different (P > 0.05) between foods.

CONCLUSION

The results suggest that replacement of standard starch with tapioca-based RS4 is a practical approach for reducing available carbohydrate in products and achieving postprandial blood glucose management. This trial was registered at clinicaltrials.gov as NCT03239288.

Cranberry Reduces the Risk of Urinary Tract Infection Recurrence in Otherwise Healthy Women: A Systematic Review and Meta-Analysis

Background: Cranberry (Vaccinium spp.) has been advocated for treatment of urinary tract infection (UTI); however, its efficacy is controversial. Women have a 50% risk of UTI over their lifetime, and ∼20-30% experience a subsequent UTI recurrence.Objective: We conducted this meta-analysis to assess the effect of cranberry on the risk of UTI recurrence in otherwise healthy women.Methods: Literature published before January 2011 was obtained from 2 published systematic reviews, and we conducted updated searches in EMBASE and MEDLINE (through July 2017). We included randomized controlled trials that were conducted in generally healthy nonpregnant women aged ≥18 y with a history of UTI, compared cranberry intervention to a placebo or control, and reported the outcome as the number of participants experiencing a UTI. Two researchers conducted abstract and full-text screenings, data extractions, and risk of bias assessments independently, and discrepancies were resolved by group consensus. Meta-analyses were performed by using Stata SE software (version 13). We employed a fixed-effect model using the Mantel-Haenszel method to estimate the summary risk if the heterogeneity was low to moderate (I² < 50%). Otherwise, we applied a random-effects model using the DerSimonian-Laird method.Results: We identified 7 randomized controlled trials conducted in healthy women at risk of UTI (n = 1498 participants). Results of the meta-analysis showed that cranberry reduced the risk of UTI by 26% (pooled risk ratio: 0.74; 95% CI: 0.55, 0.98; I² = 54%). Risk of bias indicated that 2 studies had high loss to follow-up or selective outcome reporting. Overall, the studies were relatively small, with only 2 having >300 participants.Conclusion: These results suggest that cranberry may be effective in preventing UTI recurrence in generally healthy women; however, larger high-quality studies are needed to confirm these findings. This trial was registered at crd.york.ac.uk/prospero as CRD42015024439.

Single-incision pediatric endosurgical epigastric hernia repair

PURPOSE

Epigastric hernias represent about 4 % of all abdominal hernias in children and require surgical repair. Traditionally, these hernias are repaired by an open surgical technique. More recently, laparoscopic epigastric hernia repairs have been described using two trocars in the upper abdomen. In this paper, we describe a novel single-incision pediatric endosurgical (SIPES) technique.

METHODS

Patients with symptomatic epigastric hernias that were deemed to be too far superior to be repaired with an open technique through an umbilical incision were selected for SIPES repair. Two trocars (5 and 3 mm) were introduced through a single umbilical incision and the hernia repair was performed using looped 4-0 polypropylene sutures introduced through a 17-gage spinal needle in a lasso technique.

RESULTS

Five girls (age 4.4-12.6, median 6.4 years) underwent single-incision endosurgical epigastric hernia repair. The mean operative time was 25 ± 6 min, and there were no intraoperative complications. All patients were discharged home from the recovery room on the day of surgery. All patients were followed up 2-3 weeks after the operation, with no recurrence and excellent cosmetic results.

CONCLUSIONS

The described SIPES technique offers a virtually scarless, quick, and simple option for the repair of symptomatic epigastric hernias that can be performed with standard laparoscopic equipment.

Optimal surgical treatment of locally advanced low rectal cancer

Colorectal adenocarcinoma is the second leading cause of cancer deaths in Western countries. Rectal cancer comprises approximately 25% of the malignancies arising in the large bowel. However, the past two decades have seen many major advances in the diagnosis and treatment of this disease. While surgery is still the cornerstone of curative therapy, a multidisciplinary approach including neoadjuvant chemoradiotherapy has resulted in significantly improved outcomes. Information concerning the T, N, M stage and the exact location of tumor in relation to the anal verge are of crucial importance when planning a curative rectal cancer resection. Preoperative staging, utilizing a combination of diagnostic modalities, must be undertaken to determine whether or not neoadjuvant therapy is indicated. In radical resection of locally advanced low rectal cancer, several unique surgical management issues should be considered: 1) total mesorectal excision (TME); 2) longitudinal and circumferential resection margins; 3) autonomic nerve preservation (ANP); 4) sphincter preservation versus abdominoperineal resection (APR); 5) restoration of bowel continuity; and 6) laparoscopic versus open resection. The surgeon must first strive to achieve an oncologic cure, but whenever possible this should be undertaken with the goal of maintaining the patient's quality of life. The purpose of this review is to outline the critical surgical issues involved in management of locally advanced low rectal cancer.

Clinical effects of a proprietary combination isoflavone nutritional supplement in menopausal women: a pilot trial

BACKGROUND

As they reach menopause, a majority of women living in Westernized countries experience climacteric symptoms. Hormone replacement therapy (HRT) has been used to remediate these symptoms. Recent studies, however, have suggested that HRT may increase the risk of developing breast cancer and cardiovascular disease (CVD). Therefore, many women are looking for alternative treatment options.

PURPOSE

This trial was a pilot study to assess the effect of a nutritional supplement containing isoflavones from kudzu and red clover, along with other targeted nutrients on menopausal symptoms and markers of breast cancer and CVD risk. Twenty-five menopausal women suffering from severe hot flushes and night sweats completed a 12-week intervention using this combination isoflavone nutritional supplement.

RESULTS

We observed a 46% decrease in reported hot flushes, from an average of 9.7 to 5.2 per day. Quality of life, as assessed by the standardized Greene Questionnaire, showed similar improvement. Two markers of CVD risk, the ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol and homocysteine, showed modest improvement. A proposed marker of breast cancer risk, the ratio of 2-hydroxyestrone to 16 alpha-hydroxyestrone, also showed a statistically significant improvement.

CONCLUSIONS

The results of this pilot trial suggests that this combination isoflavone nutritional supplement may significantly relieve the most troubling symptoms of menopause, as well as confer some chemopreventive and cardioprotective benefits.

A Pilot trial evaluating meta050, a proprietary combination of reduced iso-alpha acids, rosemary extract and oleanolic acid in patients with arthritis and fibromyalgia

The aim of this open-label, 8-week observational trial was to investigate the efficacy of Meta050 (a proprietary, standardized combination of reduced iso-alpha-acids from hops, rosemary extract and oleanolic acid) on pain in patients with rheumatic disease. Osteoarthritis, rheumatoid arthritis and fibromyalgia patients were given 440 mg Meta050 three times a day for 4 weeks, which was changed to 880 mg twice a day for the subsequent 4 weeks in the majority of patients. Pain and condition-specific symptoms were assessed using a standard visual analog scale (VAS), an abridged arthritis impact measurement scale (AIMS2) and the fibromyalgia impact questionnaire. Fifty-four subjects with rheumatic disease completed the trial. Following treatment, a statistically significant decrease in pain of 50% and 40% was observed in arthritis subjects using the VAS (p < 0.0001; Wilcoxon-ranked sums) and AIMS2 (p < 0.0001), respectively. Fibromyalgia subject scores did not significantly improve. A decreasing trend of C-reactive protein, a marker for inflammation, was also observed in those subjects who presented with elevated C-reactive protein. No serious side effects were observed. These observations suggest that Meta050 at a dosage of 440 mg three times a day has a beneficial effect on pain in arthritis subjects.

Changing state and federal payment policies for Medicaid disproportionate-share hospitals

The Medicaid disproportionate-share hospital (DSH) program has been the subject of considerable policy debate throughout the 1990s, prompting Congress to revise the program three times since 1991. Using Medicaid administrative data and information obtained from twelve state case studies, we examined how the study states dealt with the federal reforms. We found a variety of state responses, ranging from not spending their full DSH allotments to seeking new, "DSH-like" federal money to help support safety-net providers.

The impact of HLA mismatches on the survival of first cadaveric kidney transplants

BACKGROUND

The benefits of HLA-A, B, and DR matching of cadaveric kidney grafts and recipients remain controversial when viewed from the perspective of social equity and graft survival.

METHODS

We estimated graft survival using proportional-hazards techniques, adjusting for patient and donor characteristics, for a series of 30,564 Medicare patients receiving a first cadaveric kidney transplant between 1984 and 1990. The effects of minimal achievable HLA mismatches and maximal matching on graft survival were estimated by simulated allocation of a sample of organs to a sample of 20,000 candidates for transplantation.

RESULTS

The adjusted one-year graft survival was 84.3 percent for grafts with no mismatches and 77.0 percent for grafts with four mismatches. National rationing of donor organs to achieve minimal mismatching and maximal matching could potentially decrease the average number of HLA mismatches from 3.6 to 1.2, with a corresponding increase in the number of matches. As a consequence, projected five-year graft survival could potentially increase from 58.5 percent to 62.9 percent. This would be associated with a decrease in the proportion of kidneys allocated to black recipients from 22.2 to 15.0 percent.

CONCLUSIONS

Under ideal circumstances, a policy of maximal matching of cadaveric renal transplants would increase five-year graft survival by a comparatively small 4.4 percentage points, but the actual benefit is likely to be smaller.

Nuclear factor binding to an AP-1 site is associated with the activation of pro-alpha 1(I)-collagen gene in dedifferentiating chondrocytes

Isolated chondrocytes grown on plastic gradually lose their differentiated phenotype upon subculturing. This dedifferentiation is manifested by an altered production of extracellular-matrix molecules (ECM): e.g., the cartilage specific type II collagen is replaced by types I and III. We have studied the regulation of ECM gene expression in dedifferentiating human and murine fetal chondrocytes. Nuclear extracts from dedifferentiated cells, human fetal fibroblasts and 3T3 cells contained a protein that bound in an electrophoretic mobility shift assay to an AP-1 site in the first intron of the human alpha 1(I) collagen gene. This binding activity was not present in freshly isolated human or murine chondrocytes, which produced type II, but not type I, collagen mRNA in culture. Thus the binding activity was induced simultaneously with alpha 1(I)-collagen-gene expression during dedifferentiation. The specific interaction was sensitive to dephosphorylation of the nuclear extract and to chemical modification of reduced cysteine residues. The AP-1 site we studied had previously been shown to be a positive transcriptional contributor in the first intron to the expression of the alpha 1(I) collagen gene. In transient transfections into dedifferentiating chondrocytes, an alpha 1(I) collagen expression plasmid carrying a mutated AP-1 site in the first intron resulted in three-times-lower reporter gene RNA levels than a plasmid carrying the respective functional AP-1 site. These data suggest that the AP-1 sequence and its respective trans-acting factors may play a role in the transcriptional regulation of the alpha 1(I) collagen gene during dedifferentiation of chondrocytes.