Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination

Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychosocial and Economic Impacts of the COVID-19 Pandemic on the Mental Health of Veteran Men and Women

Purpose: The psychosocial impacts of the coronavirus disease-2019 (COVID-19) pandemic on women Veterans' mental health compared to men are understudied, with few studies examining the differential impact of COVID-19 stressors on depression and post-traumatic stress disorder (PTSD). Furthermore, little is known about whether social support may buffer against adverse pandemic-related outcomes for this population. In the present study, we examined (1) gender differences in the impact of the COVID-19 pandemic on numerous life domains, including economic, work, home, social, and health; (2) how pandemic impacts in these domains were associated with depression and PTSD symptoms; and (3) whether social support buffered against worse mental health outcomes. Materials and Methods: Data from 1530 Veterans enrolled in the Longitudinal Investigation of Gender, Health, and Trauma (LIGHT) study were analyzed using descriptive statistics and multiple groups' path analyses. Results: Women reported higher pandemic impact scores across life domains. For both men and women, higher health impacts were associated with increased PTSD symptoms; differential findings emerged for depressive symptoms. Home and economic impacts were associated with increased depression for both men and women, social and health impacts were associated with depression for women, and work impacts were associated with depression for men. Higher social support was associated with decreased depressive symptoms for both men and women; however, social support moderated the relationship between pandemic impacts and both PTSD and depressive symptoms for women only. Conclusions: Findings highlight the value of social support in mitigating effects of pandemic-related stress, particularly for women Veterans.

Psychiatric Issues in Women Veterans

Women veterans have unique life experiences and mental health needs, perhaps in part related to their high rates of exposure to traumatic events including military sexual trauma, combat trauma, and intimate partner violence. We review mental health difficulties among women veterans and describe related functional impairment. Evidence-based treatments are available, but barriers to care remain, including providers' lack of awareness of the unique needs of women veterans. Efforts are needed to increase access to evidence-based interventions, remove barriers to care, and improve provider competency working with this population to maximize clinical outcomes.

Examining emotional processing theory and predictors of outcome in prolonged exposure for PTSD

Prolonged exposure (PE) is an empirically supported treatment for posttraumatic stress disorder (PTSD). The current study examined multiple facilitators and indicators of emotional processing to identify key predictors of outcome in PE using observational coding methods. Participants were 42 adults with PTSD who received PE. Video recordings of sessions were coded to capture negative emotion activation, negative and positive trauma-related cognitions, and cognitive rigidity. Two variables emerged as predictors of PTSD symptom improvement assessed via self-report, but not clinical interview: a greater decrease in negative trauma-related cognitions and lower average cognitive rigidity. Peak emotion activation, reductions in negative emotions, and increases in positive cognitions did not predict PTSD improvement (self-report or clinical interview). Findings contribute to growing evidence highlighting the importance of cognitive change as part of emotional processing and as a key ingredient of PE, beyond activation and reduction in negative emotions. Implications for evaluating emotional processing theory and for clinical practice are discussed.

A systematic review of literature examining mediators and mechanisms of change in empirically supported treatments for posttraumatic stress disorder

Despite the availability of empirically supported treatments (ESTs) for posttraumatic stress disorder (PTSD), relatively little is known regarding these treatments' mechanisms of change. This systematic review moves beyond previous reviews by summarizing the findings and reviewing the methodological quality of literature that specifically examined mediators/mechanisms of change in ESTs for PTSD. Studies were included if they were written in English, empirical, peer-reviewed, claimed to study mediators/mechanisms of a recommended PTSD treatment, measured the mediator/mechanism during or before and after treatment, and included a posttreatment PTSD or global outcome (e.g., functioning). PsycINFO and PubMed were searched on October 7, 2022. Two coders screened and coded studies. Sixty-two eligible studies were identified. The most consistent mediator/mechanism was reduction in negative posttraumatic cognitions, followed by between-session extinction and decreased depression. Only 47% of studies measured the mediator/mechanism before the outcome and measured the mediator/mechanism and outcome at least three times, and 32% also used growth curve modeling to establish temporal precedence of change in the mediator/mechanism and outcome. Many of the mediators/mechanisms examined had weak or no empirical support. Results highlight the need for improved methodological rigor in treatment mediator and mechanism research. Implications for clinical care and research are discussed. PROSPERO ID: 248088.

The Relative Impact of Different Types of Military Sexual Trauma on Long-Term PTSD, Depression, and Suicidality

Sexual assault and harassment in the U.S. military are very common. Military sexual trauma (MST) is defined as sexual assault or harassment experienced during military service; yet, the relative impact of sexual assault, harassment, and their combination is not well understood. Given the extent and potential severity of the long-term outcomes of MST, it is critical to evaluate the relative impacts of these types of MST on long-term mental health outcomes. Veterans (n = 2,590; 55% female) completed self-report measures of experiences of sexual assault and harassment perpetrated by coworkers during military service, posttraumatic stress disorder (PTSD), depression, and suicidality. Controlling for combat exposure, all types of MST experiences (Harassment Only, Assault Only, or Both) compared to No MST predicted greater severity of PTSD, depression, and suicidality after military service. Compared to Veterans with No MST, those who experienced Both Assault and Harassment reported significantly more severe PTSD, depression, and suicidality followed by Harassment Only, and then Assault Only. Data suggest that different types of MST experiences have an impact on long-term mental health outcomes, and the combination of Both sexual Assault and Harassment is particularly deleterious.

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants' written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.

Paycheck Protection Program (PPP) COVID-19 relief funding for veteran-, minority-, and women- owned dental businesses: A cross-sectional study

Background

The Covid-19 pandemic exacerbated dental staffing shortages, which impact care delivery and ultimately oral health equity. Federal funding efforts like the Paycheck Protection Program (PPP) sought to aid traditionally underserved businesses including those owned by veterans, minority racial and ethnic groups, and women.

Objectives

(1) To examine differences in PPP funding between veteran- and nonveteran-owned dental care delivery businesses and organizations and (2) to analyze other relevant factors associated with variation in PPP funding levels for dental businesses.

Methods

Using publicly available PPP data, we ran unadjusted bivariable and adjusted multivariable linear regression models to estimate associations between loan approval amount and forgiveness amount, veteran status, and relevant covariates.

Results

Minority racial and ethnic groups and women received less PPP funding and less loan forgiveness, on average, compared with non-minority groups. In the adjusted model with no missing self-reported demographic observations at p < 0.10, veterans received more PPP funding and loan forgiveness, on average, compared to non-veterans.

Conclusion

To our knowledge, this is the first comprehensive analysis of all dental recipients of PPP funding throughout the United States. Despite PPP program intentions and strategies, traditionally underserved dental businesses did not receive increased funding to support employment.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Dental caries and anthropometrics of children living in an informal floating Amazonian community: a cross-sectional pilot study

Aims: Increasing evidence supports a relationship between poor oral health and growth in children. Our objective was to assess the association between the presence of dental caries and anthropometric measurements of children residing in Claverito, a floating slum community in the Peruvian Amazon. Methods: For this cross-sectional study, presence of caries was assessed using dmft/DMFT (decayed, missing, filled teeth) scores and the SiC Index (mean dmft/DMFT of one-third of the study group with the highest caries score). Anthropometric categories for age-sex-specific z-scores for height and weight were calculated based on WHO standardized procedures and definitions. The association between SiC (measured by dmft/DMFT) and anthropometric measures was estimated using unadjusted and adjusted multivariable linear regression models. Critical value was established at 5%. Results: Our study population consisted of 67 children between the ages of 1 and 18 years old. Mean age was 9.5 years old (SD: 4.5), and the majority were female (52.2%). Almost all had dental caries (97.0%) and the mean dmft/DMFT score was 7.2 (SD: 4.7). The SiC Index of this population was 9.0. After adjusting for confounding variables, participants who had permanent dentition with the highest dmft/DMFT levels had statistically significant decreased height-for-age z-scores (HAZ) (p=0.04). Conclusions: We found an inverse linear association between SiC Index and height-for-age z-scores (HAZ) among children living in poverty in a floating Amazonian community in Peru. Children from under-resourced communities, like floating slums, are at high risk for oral disease possibly negatively impacting their growth and development.

Processes of Change in Trauma-Focused Cognitive Behavioral Therapy for Youth: An Emotional Processing Theory Informed Approach

This study examines processes of change in trauma-focused cognitive behavioral therapy (TF-CBT) delivered to a community sample of 81 youth. Emotional processing theory (EPT) is used as an organizational framework. EPT highlights activating and changing pathological trauma-related responses and increasing adaptive responses across cognitive, emotional, behavioral, and physiological domains. We coded sessions during the trauma processing phase of TF-CBT to examine the extent to which pathological and adaptive trauma-related responses were activated across domains. Higher scores indicate that more domains (0-4) were activated at a threshold of moderate to high intensity. Curvilinear change (inverted U, increase then decrease) in multimodal negative response scores across sessions predicted improvement in internalizing and PTSD symptoms at posttreatment. Linear increases in multimodal positive responses predicted improvement in externalizing symptoms. Findings suggest value in activating and changing both pathological and adaptive trauma responses across multiple domains and examining nonlinear patterns of change.

Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content

Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.

Constructive and Unproductive Processing of Traumatic Experiences in Trauma-Focused Cognitive-Behavioral Therapy for Youth

Although there is substantial evidence to support the efficacy of cognitive-behavioral treatments (CBT) for posttraumatic stress disorder (PTSD), there is some debate about how these treatments have their effects. Modern learning theory and cognitive and emotional processing theories highlight the importance of reducing avoidance, facilitating the constructive processing of feared experiences, and strengthening new inhibitory learning. We examined variables thought to be associated with unproductive and constructive processing of traumatic experiences in a sample of 81 youth with elevated PTSD symptoms, who received Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for abuse or traumatic interpersonal loss. Sessions during the trauma narrative phase of TF-CBT were coded for indicators of unproductive processing (overgeneralization, rumination, avoidance) and constructive processing (decentering, accommodation of corrective information), as well as levels of negative emotion. In previous analyses of this trial (Ready et al., 2015), more overgeneralization during the narrative phase predicted less improvement in internalizing symptoms at posttreatment and a worsening of externalizing symptoms over the 12-month follow-up. In contrast, more accommodation predicted improvement in internalizing symptoms and also moderated the negative effects of overgeneralization on internalizing and externalizing symptoms. The current study examined correlates of overgeneralization and accommodation. Overgeneralization was associated with more rumination, less decentering, and more negative emotion, suggesting immersion in trauma-related material. Accommodation was associated with less avoidance and more decentering, suggesting a healthy distance from trauma-related material that might allow for processing and cognitive change. Decentering also predicted improvement in externalizing symptoms at posttreatment. Rumination and avoidance showed important associations with overgeneralization and accommodation, respectively, but did not predict treatment outcomes. This study identifies correlates of overgeneralization and accommodation that might shed light on how these variables relate to unproductive and constructive processing of traumatic experiences.

The effect of treatment on quality of life and functioning in OCD

BACKGROUND

Given that obsessive compulsive disorder (OCD) is associated with impaired quality of life (QoL) and functioning, it is important examine whether therapeutic recovery from OCD leads to improvements on these important secondary outcomes. Only a few studies have examined how measures of OCD symptom severity relate to QoL and functioning among patients receiving treatment for OCD.

METHODS

OCD severity was measured with the Obsessive-Compulsive Inventory-Revised (OCI-R), a self-report scale of OCD, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), an interview measure of OCD. Participants were 100 adults with a primary diagnosis of OCD on serotonin reuptake inhibitors (SRIs) enrolled in a randomized clinical trial comparing SRI augmentation with either exposure and response prevention (EX/RP) therapy, risperidone, or pill placebo. At baseline, mid-treatment, and post-treatment, patients completed assessments for OCD symptoms and QoL/functioning measures. Multilevel modeling was used to assess changes in QoL/functioning over the course of treatment and to compare such changes across treatment conditions.

RESULTS

Improvements in QoL/functioning were significantly greater among those receiving EX/RP compared to those receiving risperidone. Compared to pill placebo, EX/RP performed better on measures of functioning but not QoL. Greater improvement in individual OCI-R scores was associated with greater improvements in QoL/functioning, regardless of condition. In addition, Y-BOCS scores appeared to moderate improvements in QoL over the course of all treatment conditions, such that those with higher Y-BOCS scores showed the greatest improvements in QoL over time.

CONCLUSIONS

Improvements in QoL/functioning were associated with reduction in OCD symptom severity. The implications on OCD treatment and clinical research are discussed.

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

OBJECTIVE

The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model).

METHOD

Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout.

RESULTS

Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE.

CONCLUSIONS

The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.

The impact of treatment condition and the lagged effects of PTSD symptom severity and alcohol use on changes in alcohol craving

Given the high rates of comorbidity between posttraumatic stress disorder (PTSD) and substance use disorder (SUD), we investigated an integrated treatment for these disorders. Individuals with comorbid PTSD and alcohol dependence were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants also received BRENDA (supportive counseling). The naltrexone plus PE group showed a greater decline in alcohol craving symptoms than those in the placebo with no PE group. The PE plus placebo and the naltrexone without PE groups did not differ significantly from the placebo with no PE group in terms of alcohol craving. No treatment group differences were found for percentage of drinking days. Alcohol craving was moderated by PTSD severity, with those with higher PTSD symptoms showing faster decreases in alcohol craving. Both PTSD and alcohol use had a lagged effect on alcohol craving, with changes in PTSD symptoms and percentage of days drinking being associated with subsequent changes in craving. These results support the relationship between greater PTSD symptoms leading to greater alcohol craving and suggest that reducing PTSD symptoms may be beneficial to reducing craving in those with co-occurring PTSD/SUD.

Resilient but addicted: The impact of resilience on the relationship between smoking withdrawal and PTSD

Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which is reflected in one's ability to cope with stress, has been shown to be associated with lower cigarette smoking and posttraumatic stress symptoms, but relationships among these three variables have not been examined. This study investigates the relationships of resilience and nicotine withdrawal with each other and in relation to PTSD symptoms. Participants were 118 cigarette smokers with PTSD seeking treatment for PTSD and nicotine use. Data were randomly cross-sectionally sampled from three time points: week 0, week 12, and week 27 of the study. Hierarchical multiple regression analyses revealed main effects of both resilience and nicotine withdrawal symptoms on PTSD severity, controlling for the sampled time point, negative affect, and expired carbon monoxide concentration. Consistent with prior research, PTSD severity was higher among individuals who were less resilient and for those who had greater nicotine withdrawal. There was an interaction between resilience and nicotine withdrawal on self-reported PTSD severity, such that greater resilience was associated with lower PTSD severity only among participants with low nicotine withdrawal symptoms. Among individuals with high nicotine withdrawal, PTSD severity was high, regardless of resilience level. These results suggest that resilience is a protective factor for PTSD severity for those with low levels of nicotine withdrawal, but at high levels of nicotine withdrawal, the protective function of resilience is mitigated.

The roles of hyperglycaemia and oxidative stress in the rise and collapse of the natural protective mechanism against vascular endothelial cell dysfunction in diabetes

Vascular endothelial cell (VEC) dysfunction in diabetes has been associated with hyperglycaemia-induced intra- and extracellular glycation of proteins and to overproduction of glucose-derived free radicals. VEC protect their intracellular environment against an increased influx of glucose in face of hyperglycaemia by reducing the expression and plasma membrane abundance of their glucose transporter-1 (GLUT-1). We investigated the hypothesis that glucose-derived free radicals induce this down-regulatory mechanism in VEC, but proved the contrary. In fact, pro-oxidants significantly increased the expression and plasma membrane abundance of GLUT-1 and the rate of glucose transport in VEC while abolishing high-glucose-induced down-regulation of the hexose transport system. The resulting uncontrolled influx of glucose followed by overproduction of glucose-derived ROS further up-regulates the rate of glucose transport, and vice versa. This perpetuating glycoxidative stress finally leads to the collapse of the auto-regulatory protective mechanism and accelerates the development of dysfunctional endothelium in blood vessels.

Cyclooxygenase-2 (PTGS2) inhibitors augment the rate of hexose transport in L6 myotubes in an insulin- and AMPKalpha-independent manner

AIMS/HYPOTHESIS

Some cyclooxygenase-2 (COX2, also known as prostaglandin-endoperoxide synthase 2 [PTGS2]) inhibitors have been shown to increase insulin sensitivity in man or induce hypoglycaemic episodes when overconsumed or taken in combination with oral hypoglycaemic drugs. These side-effects and their impact on patients are not always recognised in routine clinical practice. We investigated whether these side-effects of COX2 (PTGS2) inhibitors result from stimulation of the glucose transport system in skeletal muscle cells.

MATERIALS AND METHODS

L6 myotube cultures were used to study effects of COX2 (PTGS2) inhibitors on the glucose transport system and their relationship to PTGS2 expression, insulin action and AMP-activated protein kinase alpha (AMPKalpha) activity.

RESULTS

The inhibitors niflumic acid, nimesulide and rofecoxib increased the rate of hexose uptake in L6 myotubes in the absence of insulin and in a dose- and time-dependent manner. They did this by increasing the total cell content of member 4 of the solute carrier family 2 (SCLC2A4, previously known as glucose transporter 4 [GLUT4]) (but not SCLC2A1 [previously known as GLUT1]) mRNA and protein and the amount of it in the plasma membrane. AMPKalpha was not involved in the latter effect since the inhibitors did not activate it. In addition, none of the inhibitors modulated the rate of hexose transport in vascular endothelial and smooth muscle cells expressing PTGS2 and SCLC2A1. Prostaglandin-endoperoxide synthase 1 (also known as cyclooxygenase 1) inhibitors (acetylsalicylic acid and indomethacin) did not alter the rate of hexose uptake and SCLC2A4 subcellular distribution in L6 myotubes.

CONCLUSIONS/INTERPRETATION

This study suggests that certain COX2 (PTGS2) inhibitors can alter glucose homeostasis in vivo by stimulating glucose uptake in skeletal muscles that express PTGS2.

Delayed autoregulation of glucose transport in vascular endothelial cells

AIMS/HYPOTHESIS

We aimed to characterise the development of autoregulation of glucose transport in vascular endothelial cells and its relationship to 12-lipoxygenase (12-LO) expression.

METHODS

Bovine aortic endothelial cells were exposed to 5.5 and 23.0 mmol/l glucose for up to 48 h. The rates of glucose transport, GLUT-1 and 12-LO expression and of 12-hydroxyeicosatetraenoic acid (12-HETE) production were determined.

RESULTS

We showed high glucose-dependent downregulation of glucose transport and transporter in vascular endothelial cells within 36-48 h. A similar time-dependent increase in the expression of 12-LO and the generation of its product 12-HETE was also observed. This downregulatory process was prevented when lipoxygenase activity was inhibited.

CONCLUSIONS/INTERPRETATION

Vascular endothelial cells, which were previously thought to be "glucose-blind", do in fact downregulate GLUT-1 expression and the rate of glucose transport in response to extended exposure to high glucose concentrations. This slow development of glucose-induced downregulation in vascular endothelial cells is related to the slower basal rate of glucose transport in these cells and the slow induction of 12-LO. These data are interesting in view of current hypotheses that attribute vascular endothelial cell dysfunction in diabetes to the lack of a glucose-induced autoregulatory response.

Leukoreduction and acute rejection in liver transplantation: An interim analysis

BACKGROUND

Little is known about the effect of blood transfusions and leukoreduction on acute rejection in liver transplantation. The purpose of this study was to assess the impact of leukoreduction on the occurrence of early rejection episodes in liver transplantation.

METHODS

In 1999, mandatory leukoreduction was implemented in our program. Data from 339 consecutive liver transplant recipients were analyzed with attention to the time period as a proxy for leukoreduction, the number of transfusions, the wait list status, the hepatitis B or C status, the recipient age, and the type of immunosuppression.

RESULTS

Using an early (6-month) rejection-free graft survival model, we observed that introduction of leukoreduction was independently associated with fewer rejection episodes (P =.001). Despite the lower rejection rate, due to a regimen of tacrolimus and antithymocyte globulin, the effect of implementation of leukoreduction remained significant (P =.021).

CONCLUSION

The use of leukoreduction is associated with fewer early rejections, irrespective of the type of immunosuppression. These data support an exploration of the immunomodulatory effect of leukoreduction.

Do biliary endoprostheses decrease biliary complications after liver transplantation?

AIM

Most technical complications after orthotopic liver transplantation (OLT) are related to the biliary tree. This report reviews the role of routine intraoperative placement of stents to reduce biliary complications.

METHODS

We retrospectively analyzed 396 consecutive OLTs. We reviewed rates of biliary complications after hepaticojejunostomy (HJA) as well as following choledochocholedochostomy (CCA) groups: "experimental" group (routine intraoperative biliary stenting, last 10 months), "recent" control group (nonstented, previous 10 months), "historical" control group (prior to that period of time).

RESULTS

All groups were matched for donor/recipient characteristics and for graft cold/warm ischemia time. The overall prevalence of biliary complications was 30.7% after CCA versus 35% after HJA. In the experimental group 21 patients had a 4.8% biliary complication rate compared to the recent control and historical groups, where biliary complication rates were 30% and 32.6%, respectively (P <.05).

CONCLUSIONS

The intraoperative use of biliary stents is feasible and appears to decrease the rate of biliary complications. These results support the need for a prospective randomized trial.

Efficacy of mycophenolate mofetil combined with very low-dose cyclosporine microemulsion in long-term liver-transplant patients with renal dysfunction

BACKGROUND

Cyclosporine (CsA)-induced renal dysfunction is common after liver transplantation. We evaluated the efficacy of tapering CsA to a very low dose and introducing mycophenolate mofetil (MMF) in long-term liver-transplant recipients with renal dysfunction. In addition, we assessed the impact of this strategy on calcineurin inhibition and on transforming growth factor (TGF)-beta levels.

METHODS

We prospectively enrolled 19 adult, long-term (>1 year) liver-transplant recipients with a decreased creatinine clearance greater than 25% compared with the first month posttransplant. MMF was introduced, and CsA was tapered to 25 mg twice daily. Calcineurin inhibition and TGF-beta were measured at baseline and 3 months thereafter.

RESULTS

The CsA dose was tapered over 13+/-3 weeks. At 1-year follow-up, serum creatinine decreased from 141+/-24 to 105+/-22 micromol/L (P=0.002), creatinine clearance increased from 53+/-9 to 71+/-19 ml/min (P=0.02), and glomerular filtration rate increased from 40+/-13 to 64+/-18 mL/min (P=0.002). The incidence of acute rejection was 29%. Antihypertensive medications were discontinued in 71% of the patients. Although CsA levels decreased significantly, serum TGF-beta did not differ from normal controls, and calcineurin inhibition remained stable. The incidence of gastrointestinal side-effects and leukopenia was 18% and 24%, respectively.

CONCLUSION

In long-term liver-transplant recipients with renal dysfunction, the introduction of MMF followed by tapering of CsA to a very low dose resulted in a significant improvement in renal function. However, this strategy maybe associated with a risk of acute rejection. The clinical pertinence of measuring serum TGF-beta levels and calcineurin inhibition remains to be determined.

Elevation of CA-125 level is due to abdominal distension in liver transplantation candidates

BACKGROUND

CA (cancer antigen) 125 is a serologic marker used in the monitoring of ovarian cancer. Elevated levels are also reported in cirrhosis. We evaluated the range of serum CA 125 levels seen before and after liver transplantation, and examined possible factors associated with CA 125 elevation.

METHODS

We examined prospectively 57 consecutive patients with cirrhosis who underwent liver transplantation. CA 125 levels were also measured in two patients with polycystic liver disease.

RESULTS

The mean serum CA 125 level before transplantation was 352+/-549 u/ml, compared with 46+/-49 u/ml after transplantation (P<0.001). Multivariate analysis identified the degree of ascites as the only significant predictive variable of preoperative CA 125 level. In five patients who underwent abdominal paracentesis, the mean ascites CA 125 level (951+/-322 u/ml) was higher than that of the serum (619+/-290 u/ml) (P<0.003). In 16 hepatectomy specimens, the grade of staining for CA 125 was 0.8+/-1.4 for the mesothelium of patients with a normal serum CA 125 level, compared with 1.5+/-1.1 in patients with elevated serum levels (P=0.37). Two patients with severe abdominal distension due to polycystic liver disease but without ascites had elevated serum CA 125 levels.

DISCUSSION

CA 125 concentration is elevated in the majority of patients with cirrhosis and normalizes after liver transplantation. It is a reflection of the abdominal distention seen in these patients. Therefore, an elevation in CA 125 should not be considered a contraindication to liver transplantation in the absence of evidence of malignancy.

Use of older donor livers is associated with more extensive ischemic damage on intraoperative biopsies during liver transplantation

Initial poor graft function is associated with increased morbidity and graft loss after liver transplantation. Donor age is a risk factor for the development of initial poor function. The severity of ischemic damage on intraoperative postreperfusion (0Post) allograft biopsy specimens is predictive of subsequent initial poor function. This study was performed to assess whether donor age is a risk factor for the development of ischemic damage on 0Post biopsy specimens. The records of 94 liver transplantations were reviewed. 0Post biopsy specimens were obtained after complete allograft revascularization. The severity of ischemic damage was graded as follows: 0, none; 1, minimal; 2, mild; 3, moderate; and 4, severe. Grafts were defined as older when donor age was 50 years or older. Other independent variables examined included donor cause of death, length of hospital stay, acidosis, serum alanine aminotransferase level, graft cold ischemia time, and degree of steatosis. Older grafts were associated with higher grades of ischemic damage than younger grafts (2.3 +/- 1.0 v 1.3 +/- 1.1; P =.003). Univariate and multivariate analysis identified donor age of 50 years or older as the only significant predictive variable of the severity of ischemic damage. In 16 transplantations involving older grafts, there was no statistically significant association between the severity of ischemic damage and incidence of initial poor function and graft loss. The use of older liver grafts is associated with more extensive ischemic damage immediately after graft reperfusion. Whether this early lesion identifies among older graft recipients those at risk for a worst outcome remains to be determined.

CD44 involvement in experimental collagen-induced arthritis (CIA)

CD44 is a pro-inflammatory cell surface molecule that supports cell migration and cell lodgment in target organs. Therefore, CD44 targeting with specific monoclonal antibodies (mAbs) should be useful for the inhibition of collagen-induced arthritis (CIA) as well as other autoimmune diseases that are dependent on inflammatory cells. In the present paper, we confirm and expand previous reports showing the anti-arthritogenic effect of anti-CD44 mAbs directed against constant epitopes of the CD44 receptor. We demonstrate that such anti-CD44 mAbs can induce resistance to CIA after disease onset. Even accelerated disease developed after two injections of type II collagen was markedly inhibited by IM7.8.1 anti-CD44 mAb. Although KM81 anti-CD44 mAb is a less efficient anti-arthritogenic reagent than IM7.8.1, its Fab' fragments partially inhibit CIA. This finding implies that the antibody blocks CD44 function rather than modulating CD44 cell surface expression or mediating Fc-dependent activities. Histopathological analysis revealed that the anti-CD44 mAb markedly reduces the synovial inflammatory cellular response and the consequent damage to the joint. As CD44 is an alternatively spliced multistructural molecule, similar anti-arthritogenic effects may be achieved by mAbs directed against CD44 isoforms expressed on the pathological cells in question, but not on normal cells, thus leaving the physiological functions intact.

Gastric toxoplasmosis in acquired immunodeficiency syndrome: antemortem diagnosis with histopathologic characterization

Gastrointestinal symptoms attributable to Toxoplasma gondii infection are distinctly unusual, and antemortem diagnosis of gastrointestinal involvement is rarely documented, particularly in the absence of cerebral manifestations or disseminated disease. This case report describes a rare example of T. gondii infection of the stomach diagnosed antemortem in a 22-year-old Haitian woman with acquired immunodeficiency syndrome (AIDS) who presented with fever and abdominal pain. An abdominal computerized tomographic scan showed thickened gastric walls. Endoscopy showed diffusely thickened gastric folds and a fundic ulcer along the greater curvature. Light and electron-microscopic examination of gastric mucosal biopsy specimens showed active Toxoplasma infection with necrosis and intracellular trophozoites within the gastric epithelium, smooth muscle cells, macrophages, and endothelial cells. Both true cysts and pseudocysts were seen. Disseminated disease was documented by the growth of T. gondii in a tissue culture from a venous blood sample. It is concluded that some patients with AIDS, particularly those from areas endemic for Toxoplasma infection, can manifest disseminated disease in unusual locations such as the gastrointestinal tract. Documentation of active T. gondii infection based on tissue cultures of venous blood or on biopsy specimens of symptomatic extracerebral sites can lead to a rapid diagnosis of toxoplasmosis, a treatable disease.

Helicobacter heilmannii-like spiral bacteria in gastric mucosal biopsies. Prevalence and clinical significance

BACKGROUND

Gastric Helicobacter pylori (Hp) is highly associated with histological gastritis and peptic ulcer disease, yet Helicobacter heilmannii (Hh, also known as Gastrospirillum hominis) may be a less frequent gastric pathogen about which less is known.

PATIENTS AND METHODS

We evaluated 1223 gastric biopsies from 1042 upper endoscopies with biopsies performed over 1 year. Spiral bacteria were specifically sought in biopsies from 912 endoscopies. Clinical and pathologic data from patients with unusual spiral bacteria were tabulated and sera were evaluated for anti-Hp antibodies.

RESULTS

The histologic prevalences of Hp and Hh-like bacteria were 59% and 0.5%, respectively, in 912 endoscopies. All four patients with Hh-like spiral bacteria had gastrointestinal symptoms and histologic gastritis. Two had immigrated from the Philippines and one from Belgium. Endoscopic findings and clinical course varied. One improved spontaneously; one improved following antibiotic therapy. One patient's symptoms and bacteria persisted without therapy. One patient coinfected with Hp was treated with apparent clearance of Hh but persistence of Hp.

CONCLUSIONS

Helicobacter heilmannii-like bacteria can be distinguished from Hp with routine histologic stains; both bacteria are irregularly distributed. Helicobacter heilmannii appears to be a significant though uncommon cause of gastric inflammation. Some patients with Hh-like bacteria may benefit from anti-Hp therapy.

Downregulation of phorbol 12-myristate 13-acetate-induced tumor necrosis factor-alpha and interleukin-1 beta production and gene expression in human monocytic cells by human alpha-fetoprotein

We previously identified a specific receptor of alpha-fetoprotein (AFP) on human monocytes. Although AFP alters many immune cell functions, the effect of AFP on monocyte cytokine production is unknown. Because tumor necrosis factor--alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta) are important cytokines in immunoregulation, we investigated whether AFP could modulate TNF-alpha and IL-1 beta production in U937, a human monocytic cell line. Our results showed that U937 cells secreted TNF-alpha and IL-1 beta in response to either phorbyl 12-myristate 13-acetate (PMA) or IFN-gamma + LPS. In contrast, AFP significantly suppressed PMA-induced TNF-alpha and IL-1 beta production by U937 cells in a time and dose dependent fashion. Pretreatment of U937 cells with AFP resulted in maximal inhibition of PMA-stimulated TNF-alpha and IL-1 beta production by 58% and 67% respectively. AFP also inhibited interferon-gamma plus lipopolysaccharide (IFN-gamma + LPS)-induced TNF-alpha and IL-1 beta production. Furthermore, Northern blot analysis showed that AFP suppressed PMA-mediated TNF-alpha and IL-1 beta messenger RNA (mRNA) expression. PMA-induced prostaglandin E2 (PGE2) production by U937 cells was enhanced by AFP. Pretreatment with indomethacin, a cyclooxygenase inhibitor, reversed AFP-inhibited TNF-alpha production by 78%. Thus, we conclude that AFP downregulates TNF-alpha and IL-1 beta production via a PGE2-dependent mechanism.

Alteration of aldolase isozymes in serum and tissues of patients with cancer and other diseases

We studied the alteration of aldolase isozymes in the serum and tissues of patients with cancer and other diseases using radioimmunoassays specific for aldolase A, B, and C subunits. Aldolase B was predominantly found in adult liver, where aldolase A and C were distinctly low. Aldolase A and B showed almost the same concentration in fetal liver, while in neonatal liver aldolase B protein concentrations were much higher than aldolase A. In contrast, aldolase A was the predominant isozyme found in hepatoma and gastric cancer tissues, whereas aldolase B was distinctly low in hepatoma tissues, and extremely low in gastric cancer tissues. These results suggest that the aldolase A is a more fetal type of liver isozyme than the aldolase B and C, and aldolase B is a more differentiated type of liver isozyme than aldolase A and C. Serum FDP aldolase activities were elevated in half of patients with liver diseases, all patients with muscle diseases and a few patients with cancer. Serum aldolase A levels were elevated in patients with muscle diseases and cancer, but not elevated in patients with liver diseases. In contrast, serum aldolase B levels were elevated in patients with liver disease, but not elevated in patients with muscle diseases and other diseases without liver injury. Serum aldolase B levels showed a trend to decrease in cancer patients with normal GPT levels. Serum aldolase A/B ratios were significantly increased in cancer patients with normal GPT levels, whereas they showed the decreased levels in patients with liver diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of M43: a novel cancer-associated mucin epitope

A monoclonal antibody to colon carcinoma mucin was found to react with a colon carcinoma-associated carbohydrate epitope. This antibody was used to develop a quantitative solid phase immunoassay, M43. We prospectively and retrospectively evaluated the assay in patients with and without gastrointestinal carcinoma and compared the sensitivity and specificity with that of carcinoembryonic antigen (CEA) and CA 19-9. One hundred ninety-two patients (181 with no evidence of malignancy) referred for upper or lower gastrointestinal endoscopy were prospectively studied. Sera from 172 patients with histologically confirmed gastrointestinal adenocarcinoma were retrospectively studied. Optimal discrimination cutoffs for M43 (5 units/ml), CEA (5 ng/ml), and CA 19-9 (30 units/ml) were determined by receiver operating characteristic curves analysis. M43 was positive in 112 of 151 patients with colorectal carcinoma (sensitivity 74%) and was negative in 167 of 181 patients without carcinoma (specificity 92%). Sensitivity and specificity were 77% and 93% for CEA and 60% and 83% for CA 19-9. Sixty-four % of 73 patients with colorectal carcinoma limited to the bowel wall had a positive M43 with a mean value of 178 units/ml. Eighty-one % of 27 patients with nonhepatic metastasis had a positive M43 with a mean value of 223 units/ml. Eighty-four % of 51 patients with hepatic metastasis had a positive M43 assay with a mean value of 2532 units/ml. Sensitivity in these three groups was 67%, 82%, and 82%, respectively, for CEA and 43%, 68%, and 79%, respectively, for CA 19-9. Of 38 carcinoma patients with a negative CEA, 45% had a positive M43. No correlation between the levels of M43 and CEA in patients with colorectal carcinoma was found. We conclude that M43 is positive in most patients with colorectal carcinoma, even in early stages. As a diagnostic test, its sensitivity and specificity are equivalent to those of CEA. However, the M43 assay is measuring a tumor antigen which is fundamentally different from CEA and which is present in a high percentage of CEA-negative patients.

Characterization of a lung-cancer-associated auto-antigen

An antigen, protein X (Px), was purified from immune complexes isolated from malignant pleural effusions from patients with adenocarcinoma of the lung by EDTA treatment, PEG 8000 precipitation, protein A affinity chromatography, and Sephadex G-200 separation in the presence of 3 M NaCl. The purified antigen had a M(r) 17,000 by SDS-PAGE, and consisted of isoelectric species of pI 6.3 and 6.6. Purified Px recombined with Ig isolated from pleural fluids from patients with lung adenocarcinoma, but not with Ig from patients with breast carcinoma. Using an autologous human and heterologous chicken antibody, Px was found, by immunohistology, in the cytoplasm of some of the well-differentiated lung adenocarcinoma cells, but was not seen in normal lung or a variety of other malignant tissues. A liquid-phase competitive-inhibition RIA was developed. Over 30 ng/ml of Px were found in 9 of 15 pleural fluids from patients with lung carcinoma, none of 20 from patients with breast, ovary, stomach or colon cancer, and in 3 of 15 patients with unknown primary tumor. Our data suggest that Px may be a lung-cancer-associated autoantigen which can elicit a host humoral response in vivo.

Isolation and partial characterization of a specific alpha-fetoprotein receptor on human monocytes

Since a large body of data has suggested a significant role for alpha-fetoprotein (AFP) in the regulation of the immune response at a number of levels, we examined the possibility of a specific receptor for AFP on the immune recognition cell, the monocyte/macrophage. Microscopic autoradiography exhibited an obvious binding of AFP almost exclusively on human peripheral monocytes but not on lymphocytes. In a human monocyte cell line (U937) Scatchard plot analysis indicated the presence of two distinct AFP-specific binding sites with a Kd of 5 x 10(-11) M, 49 binding sites per cell, and 2.5 x 10(-7) M, 7,800 binding sites per cell. 125I-ASD-AFP, AFP-radiolabeled bifunctional photoactivatable thio-cleavable cross-linker, was used to isolate the AFP binding protein from U937 cells. After ultraviolet photoactivation, 125I-sulfosuccinimidyl 2-(p-azido-salicylamido)ethyl-1,3'-dithiopropionate was covalently linked to the putative receptor. Autoradiography of SDS gradient PAGE under reducing conditions showed a major radiolabeled band at between 62 and 65 kD. To confirm the specificity of the finding, recombination of AFP with the isolated receptor was examined in artificially reconstituted membrane vesicles, which also resulted in a single band at approximately 62-65 kD by SDS-PAGE autoradiography. From the data above, we concluded that human monocytes possess a specific AFP binding protein on the membrane, a putative receptor, which may be involved with the physiological regulation of the immune response.

Congenital deficiency of alpha-fetoprotein

Although alpha-fetoprotein may play a role in fetal immune function or in maintenance of osmotic pressure, its exact function is unknown. We report two infants documented to have congenital deficiency of alpha-fetoprotein. One infant had cord blood levels less than 0.5 ng/ml. The second infant had a neonatal level of 120 ng/ml, which is about 2% of the usual concentration for a term newborn. These infants document the existence of congenital deficiency of serum alpha-fetoprotein. Because it is homologous to albumin, congenital deficiency of alpha-fetoprotein may be analogous to analbuminemia, a benign genetic trait.

Maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, and unconjugated estriol levels in midtrimester trisomy 18 pregnancies

OBJECTIVE

The purpose was to evaluate the levels of maternal serum human chorionic gonadotropin, alpha-fetoprotein, and unconjugated estriol in trisomy 18 pregnancies compared with normal singleton pregnancies.

STUDY DESIGN

Sera from 14 trisomy 18 pregnancies (13 retrospectively and one prospectively ascertained) were analyzed for human chorionic gonadotropin, alpha-fetoprotein, and unconjugated estriol.

RESULTS

The alpha-fetoprotein levels in the 10 trisomy 18 pregnancies without open neural tube or ventral wall defect had a median of 0.65 multiple of the median, although two had alpha-fetoprotein levels above 2.5 multiples of the median. The human chorionic gonadotropin levels had a median of 0.32 multiple of the median and the unconjugated estriol levels had a median of 0.56 multiple of the median. Although most women with trisomy 18 pregnancies had serum human chorionic gonadotropin levels that were less than 1.0 multiple of the median, three had markedly elevated human chorionic gonadotropin levels (greater than 5.0 multiples of the median).

CONCLUSION

Our data are partially consistent with those previously published but suggest the possibility of a bimodal distribution of alpha-fetoprotein and human chorionic gonadotropin levels in trisomy 18-affected pregnancies, unrelated to a neural tube or abdominal wall defect. The efficiency of screening for trisomy 18 prospectively, using the three serum markers, requires further evaluation.

Alpha-fetoprotein levels in normal adults

Alpha-fetoprotein (AFP) is a fetal specific glycoprotein normally produced primarily by the fetal liver. Normally, AFP levels decline rapidly after birth, reaching undetectable levels (less than 10 ng/ml) within several months after birth. The authors have developed a more sensitive radioimmunoassay, which has allowed them to study low levels of AFP in normal adults and to determine factors which may affect its normal level. Two hundred and seventy normal Houston blood donors were screened for the absence of hepatitis B and normal ALT levels. The mean AFP level was 3.04 ng/ml +/- 1.9 SD. There was a statistically significant higher level in men compared to women (p less than .004). Regression analysis demonstrated a statistically significant increase of AFP levels with age both in men (p less than .05) and in women (p less than .01). These data delineate the normal level of serum AFP in normal adults in the United States. With the normal level now defined, it becomes possible to compare levels in different populations including those exposed to hepatotoxins or hepatocarcinogens in the environment.

The effect of gestational age on the detection rate of Down's syndrome by maternal serum alpha-fetoprotein screening

Low levels of maternal serum alpha-fetoprotein are currently being used to screen for Down's syndrome in midpregnancy. Because of the possibility that gestational age may affect the detection rate of Down's syndrome, we analyzed maternal serum AFP levels and gestational age in 51 Down's syndrome pregnancies that had been confirmed by amniocentesis or at birth, and we compared these pregnancies with 3239 screened singleton pregnancies with known normal outcomes. The highest yield of a low risk for Down's syndrome associated with maternal serum alpha-fetoprotein occurred at 16.5 to 17.5 weeks' gestation. Our data suggest that maternal serum alpha-fetoprotein screening for Down's syndrome should be done between 16 and 18 weeks' gestation, which is the gestational age currently recommended for neural tube defect screening.

A double-blinded, randomized trial of hydrocortisone in acute hepatic failure. The Acute Hepatic Failure Study Group

The Acute Hepatic Failure Study Group (AHFSG) has conducted a double-blinded, randomized evaluation of hydrocortisone in patients with acute hepatic failure. From July 1975 through August 1978, a 38-month period, 18 medical centers in the United States and one in Canada participated in this trial. A total of 64 patients were accessed and found eligible to participate in the study; two of them were subsequently eliminated from our analysis. Eighteen patients received placebo; 23 received 400 mg hydrocortisone per day, and 21 patients were administered 800 mg hydrocortisone per day. We did not observe any therapeutic effect of hydrocortisone, and the survival rates for placebo versus 400 mg and versus 800 mg hydrocortisone per day were 22%, 9%, and 24%, respectively. Fulminant hepatitis associated with drug hepatotoxicity or non-A, non-B hepatitis seemed to have a worse prognosis than fulminant B, although these differences were not significant. Serum alpha-fetoprotein had a modest prognostic value of survival and seemed to be limited to fulminant B. The AHFSG recommends, therefore, that corticosteroid use in acute hepatic failure with hepatic encephalopathy be discontinued.