Impact of a financial incentive on the completion of educational metrics

Background

The Accreditation Council for Graduate Medical Education (ACGME) requires all emergency medicine (EM) training programs to evaluate resident performance and also requires core faculty to attend didactic conference. Assuring faculty participation in these activities can be challenging. Previously, our institution did not have a formal tracking program nor financial incentive for participation in these activities. In 2017, we initiated an educational dashboard which tracked and published all full-time university faculty conference attendance and participation in resident evaluations and other educational activities.

Objectives

We sought to determine if the implementation of a financially-incentivized educational dashboard would lead to an increase in faculty conference attendance and the number of completed resident evaluations.

Methods

We conducted a pre- and post-intervention observational study at our EM residency training program between July 2017 and July 2019. Participants were 17 full-time EM attendings at one training site. We compared the number of completed online resident evaluations (MedHub) and number of conference days attended (call-in verification) before and after the introduction of our financial incentive in June 2018. The incentive required 100% completion of resident evaluations and at least 25% attendance at eligible didactic conference days. We calculated pre- and post-intervention averages, and comparisons were made using a chi-square test.

Results

Prior to implementation of the intervention, the 90-day resident evaluation completion rate was 71.8%. This increased to 100% after implementation (p < 0.001). Conference attendance prior to implementation was 43.8%, which remained unchanged at 41.3% after implementation of the financial incentive (p = 0.920).

Conclusions

Attaching a financial incentive to a tracked educational dashboard increased faculty participation in resident evaluations but did not change conference attendance. This difference likely reflects the minimum thresholds required to obtain the financial incentive.

One year update following removal of high sugar sweetened beverages from a university campus

Key messages

Removal of high sugar sweetened drinks from a university campus is possible; advice must be provided to those who may feel negatively impacted by the change. Sales can grow despite health-related changes of the food environment.

Complications of percutaneous nephrostomy in a district general hospital

OBJECTIVE

Percutaneous nephrostomy (PCN) is one of the commonest procedures performed. There are currently no European recommendations on the accepted rate of complications. The aim of the present study is to report the complication rate of PCN with the specific emphasis on sepsis and septic shock, the causative organisms, sensitivities to antibiotics, and associated risk factors.

MATERIAL AND METHODS

Retrospectively collected data on patients undergoing acute or elective PCN at the Department of Radiology, Countess of Chester Hospital (COCH), in the UK between January 2014 and December 2016 were analyzed after the study was approved by Local Audit Department at COCH.

RESULTS

A total of 66 patients underwent 90 acute or elective PCNs. Three patients developed major post-PCN complication (two patients developed septic shock and the third suffered a hemorrhagic episode requiring blood transfusion). Nephrostomy tube complications (blockage, leaking, fracturing and kinking of the catheter) occurred in 4 patients. Complications were more common when the PCN was performed out of working hours (71.4% [10/14], and 17.3% [9/52] for PCNs performed within, and out of working hours, respectively: p<0.001). The age of the patients did not seem to correlate with the development of complications (p<0.001). Of all 25 patients, in whom septicemia was diagnosed prior to PCN tube insertion, 12 developed septic shock and 13 had signs of sepsis for longer than 24 h. Fifteen patients had positive urine cultures. The most common organism isolated was Escherichia coli. Blood culture isolates included: Escherichia coli, Eggerthella lenta, Enterococcus, Proteus mirabilis, Pseudomonas aeruginosa and Streptococcus pneumonia.

CONCLUSION

Our complication rates were within United States proposed target ranges. Our data may help to serve as a baseline for outcome targets in the European centres.

Is magnetic resonance imaging helpful in detecting significant prostate cancer in patients with haematospermia, normal prostate specific antigen level and digital rectal examination. A single institution, observational, and retrospective study in a United Kingdom hospital

Introduction

Haematospermia is an uncommon clinical condition that may be associated with prostate cancer. The optimal investigation of haematospermia is unknown. The aim of this study was to investigate haematospermia as a presenting symptom of significant pathology and to assess the diagnostic value of magnetic resonance imaging (MRI).

Material and methods

Patient and treatment parameters were collected from a practice cohort of men referred to a urology center presenting with haematospermia. We used a multivariate logistic regression model to test the independent significance of MRI in detecting prostate cancer (PCa) after adjusting for other known predictors of PCa detection.

Results

A total of 125 men (median age 58 years) were evaluated between 2012-2015. In the univariate and multivariate logistic regression model MRI was a significant predictor of PCa diagnosis after adjusting for age, prostate specific antigen (PSA) and digital rectal examination (DRE) results (Odds Ratio (OR) 14.15, p = 0.001). Of 107 patients who underwent MRI prostate imaging, 31 (28.9%) had reports suspicious of PCa. In 26 patients, other benign conditions were detected on MRI. PCa was detected in 12 (25.5%) of the 47 men (median age 61 years; range 43 to 85) who underwent prostate biopsies. Eight (17%) of these patients had Gleason ≥7 grade cancer. The persistence of haematospermia was not an independent predictor of cancer diagnosis (OR 0.20, p = 0.15).

Conclusions

PCa is not commonly associated with haematospermia. MRI seems to be improving detection rate of a significant PCa, particularly in patients presenting with haematospermia and normal PSA levels and DRE examination. Duration of haematospermia does not predict the presence of PCa.

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Small and medium agility dogs alter their kinematics when the distance between hurdles differs

There is currently a lack of research examining the health and welfare implications for competitive agility dogs. The aim of this study was to examine if jump kinematics and apparent joint angles in medium (351-430 mm to the withers) and small (<350 mm to the withers) agility dogs altered when distances between consecutive upright hurdles differ. Dogs ran a course of nine hurdles; three set at 3.6 m apart; three at 4 m apart and three at 5 m apart. Both medium (P=0.044) and small (P=0.006) dogs landed closer to the hurdle when consecutive hurdles were set 3.6 m apart, with small dogs jumping slower at this distance (P=0.006). Results indicate that jump kinematics, but not apparent joint angles, alter when the spacing between hurdles differs. These findings may have implications for the health and welfare of agility dogs and should be used to inform future changes to rules and regulations.

Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project

Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes. Although national programs exist, there is no EU-wide strategy for diabetes self-management education, and patients with limited literacy face barriers to effective self-management. The Diabetes Literacy project, initiated with the support of the European Commission, aims to fill this gap. The project investigates the effectiveness of diabetes self-management education, targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States, as part of a comprehensive EU-wide diabetes strategy. National diabetes strategies in the EU, US, Taiwan, and Israel are compared, and diabetes self-management programs inventorized. The costs of the diabetes care pathway are assessed on a per person basis at national level. A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support, and the moderating role of health literacy, organization of the health services, and implementation fidelity of education programs are considered. Web-based materials are developed and evaluated by randomized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy. The 3-year project started in December 2012. Several literature reviews have been produced and protocol development and research design are in the final stages. Primary and secondary data collection and analysis take place in 2014. The results will inform policy decisions on improving the prevention, treatment, and care for persons with diabetes across literacy levels.

Circulating melanoma cells and survival in metastatic melanoma

A validated assay for the enumeration of circulating melanoma cells (CMCs) may facilitate the development of more effective therapies for metastatic melanoma patients. In this study CD146+ cells were immunomagnetically enriched from 7.5 ml of blood. Isolated cells were fluorescently stained with DAPI, anti-molecular weight melanoma-associated antigen (HMW-MAA), anti-CD45 and CD34 and Ki67. CMCs were identified as CD146+, HMW-MAA+, CD45-, CD34-, Ki67-/+ cells. Eighty-eight percent of spiked SK-MEL28 cells in 7.5 ml blood were recovered. In all 55 healthy donors ≤1 CMCs were detected in 7.5 ml of blood. A retrospective analysis was conducted comparing CMC counts and overall survival in 79 blood samples from 44 melanoma patients. CMCs ranged from 0 to 8,042 per 7.5 ml. Two or more CMCs were detected in 18 (23%) of the patients and 30-100% (mean 84%) of the CMCs expressed the proliferation marker Ki67. Patients with ≥2 CMCs per 7.5 ml of whole blood, as compared with the group with <2 CMCs, had a shorter overall survival (2.0 months vs. 12.1 months, P=0.001).

Abstract P3-02-06: Correlation of BCL-2 and Apoptosis on Circulating Tumor Cells and Breast Cancer Tissue

Background: Circulating Tumor Cell (CTC) levels are prognostic markers in metastatic breast cancer (MBC). Further phenotypic characterization of CTC may provide an opportunity for non-invasive evaluation of predictive and prognostic markers. Apoptosis is a common form of chemotherapy-induced cell death. Monoclonal antibody (MAb) M30 recognizes a neo-epitope on fragmented cytokeratin and is a marker of apoptosis. BCL-2 is an anti-apoptotic marker and may predict for resistance to anti-neoplastic therapy. We have previously reported the results of a pilot clinical trial to estimate M30 and BCL-2 expression in CTC from patients with MBC. The current study was performed to correlate the expression of both BCL-2 and M30 in CTC with breast cancer tissue samples. Methods: Of the 85 patients in the original pilot study, 52 (61%) had evaluable tissue available (39 primary and 12 metastatic lesions; one unknown) and were included in this analysis. CTC were collected at baseline and were isolated, enumerated, and phenotypically characterized for M30 and BCL-2 using the CellSearch® System. CTC phenotype is reported as percentage of cells with positive staining. Tissue Microarrays (TMA) were constructed and immunohistochemically stained for M30 (anti-Cytodeath™ M30, Roche) and Bcl-2 (M-0887, DAKO) and scored using the Allred method.

Results: Tissue staining for M30 and Bcl-2 were inversely correlated. Of the 52 patients with TMA available for investigation, 22 (42%) had &gt; 5 CTC/7.5 ml whole blood. A positive, but non-significant, correlation was observed between increasing numbers of CTC levels and tissue BCL-2 Allred Score (Spearman r=0.36; p=0.1310). M30 staining was detected in ≥10% of CTC in 20 of the 22 (91%) patients with elevated CTC, while BCL-2 staining was detected in ≥10% of CTC in 19 of the 22 (86%) patients. Little if any correlation was observed between CTC M30 and tissue M30 expression, however CTC BCL-2 was positively correlated with tissue Bcl-2 expression (Spearman r=0.47; p=0.0440). Conclusions: BCL-2 and M30 can be characterized in both CTC and breast cancer tissue. The likelihood of having elevated CTC may be associated with higher BCL-2 expression, and CTC BCL-2 was associated with tissue BCL-2 expression. Although the clinical implications of these findings are unknown, they offer the opportunity for future trials to investigate whether CTC BCL-2 and M30 might be useful to identify patients with cancers that are resistant to standard therapies. Furthermore, CTC BCL-2 and M30 might be monitored in clinical trials of novel, apoptosis-inducing therapeutic agents.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-06.

Multi-center study evaluating circulating tumor cells (CTCs) as a surrogate for survival in men treated for castration refractory prostate cancer (CRPC)

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Background: Monitoring CTCs in patients undergoing therapy for metastatic breast cancer is an effective means to predict outcome and monitor treatment. The primary endpoint of this prospective multi-center study was to demonstrate a significant relation between the presence of CTCs and survival in men treated for CRPC. Methods: 276 patients with diagnosed CRPC, PSA progression, and an ECOG score of 0–2 about to begin initial or salvage chemo and/or combination therapy were enrolled. CTCs were enumerated with the CellSearch System in blood drawn pre-treatment and monthly thereafter for up to 18 months. Patient data were collected and maintained by an independent CRO. Median overall survival (OS) was determined for patients with =5 CTC /7.5mL at baseline and specified intervals. Results: Of 240 evaluable patients, 142 (59%) are alive - mean follow-up 11.4 ± 4.4 months. Median OS (in months) and significance between the two groups (logrank p-value) at different time points after the initiation of therapy are indicated in the table . Median OS for 40 (19%) patients with a reduction of CTCs below 5 CTCs 2–5 weeks after initiation of therapy was significantly longer as compared to those 78 (38%) patients that remained above 5 CTCs (>20 vs. 9.3mth, p=0.0000) and was not significantly different from the 83 (40%) patients with 20 vs. >20mth, p=0.2725). In multivariate analyses, which included stage at diagnosis, age, ECOG, Gleason score, LDH, Alkaline Phosphotase, and PSA, CTCs remained the most significant independent predictor of outcome. Conclusions: CTC levels in CRPC patients are a strong predictor of OS. The persistence of CTCs after initiation of therapy suggests that the patients are deriving less than optimal benefit from their current therapy. CTC levels may be a valid surrogate end-point in monitoring response to chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

Preliminary study of immunomagnetic quantification of circulating tumor cells in patients with advanced disease

OBJECTIVES

To enumerate the amount of circulating tumor cells (CTCs) in patients with advanced prostate cancer and to investigate the relationship between these numbers, prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSM) expression, and clinical parameters.

METHODS

Whole blood was collected in proprietary CellSave tubes. Mononuclear cell fractions were isolated using epithelial cell antibody-coated magnetic nanoparticles. On one half of each immunomagnetically enriched cell fraction, automated fluorescent microscopy was used to identify the epithelial tumor cells. From the remainder of each sample, RNA extraction, cDNA synthesis, and polymerase chain reaction amplification of PSA and PSM were performed.

RESULTS

Eighty-four patients with advanced prostate cancer submitted 130 samples for analysis. Intact CTCs were identified in 62% of samples; 83.3% of CTC-positive and 0% of CTC-negative samples were reverse transcriptase-polymerase chain reaction positive for PSA and PSM (P = 0.001). A significant positive correlation was found between the CTC number and PSA (r = 0.49), alkaline phosphatase (r = 0.47), and lactate dehydrogenase (r = 0.55) levels, and a significant negative correlation with hemoglobin (r = -0.35). The initial Gleason grade, prior therapy, current therapy, and type of metastasis (bone, soft tissue) did not correlate significantly with the CTC number.

CONCLUSIONS

The presence of intact CTCs and the expression of PSA and PSM demonstrated robust agreement. The tumor cell numbers reflected current disease status and correlated significantly with the clinical disease indicators of PSA, hemoglobin, and liver function tests. These findings warrant further investigation of the diagnostic and prognostic value of enumerating intact CTCs.

Carpal tunnel syndrome - is high-frequency ultrasound a useful diagnostic tool?

This study assessed the clinical use of three ultrasound measurements; median nerve cross-sectional area, median nerve flattening ratio and palmar displacement of the flexor retinaculum, for the diagnosis of carpal tunnel syndrome. The measurements were made in 20 carpal tunnel sufferers and 20 controls. The sensitivity, specificity and predictive values of each were calculated in various clinical settings. Values for each of the three variables were significantly different in the patient and control populations. The differences we recorded were smaller than those found in previous studies. The tests had a sensitivity of 72% and a specificity of 90%. Alterations in the morphology of the carpal tunnel in patients with carpal tunnel syndrome can be measured in the district general hospital setting. The measurements described maybe a useful non-invasive confirmatory test in patients in whom there is a strong clinical suspicion of carpal tunnel syndrome. However, they would be of no benefit in epidemiological surveys of populations with a low incidence of carpal tunnel syndrome.

Onset of analgesia for liquigel ibuprofen 400 mg, acetaminophen 1000 mg, ketoprofen 25 mg, and placebo in the treatment of postoperative dental pain

Ibuprofen is a peripherally acting nonsteroidal anti-inflammatory drug indicated fo ranalgesia, antipyresis, and various arthritic conditions. A solubilized 200 mg liquigel formulation of ibuprofen has been shown to have a more rapid rate of absorption compared with ibuprofen 200 mg tablets. Ibuprofen liquigels have a kinetic profile similar to ibuprofen suspension, with both a higher Cmax and an earlier tmax than any solid tablet. The objective of this single-dose, double-blind, triple-dummy, parallel-group study was to assess the time to onset of relief and overall analgesic efficacy of liquigel ibuprofen 400 mg, ketoprofen 25 mg compared with acetaminophen 1000 mg, and placebo in 239 patients with moderate or severe pain following third molar extractions. Treatments were compared over 6 hours using standard scales for pain intensity and relief and stopwatch onset of meaningful relief. All active treatments provided meaningful relief significantly faster compared with placebo. Ibuprofen provided significantly faster relief compared with acetaminophen and ketoprofen. By the end of the study (6 h), onset of meaningful relief was achieved by 36%, 99%, 96%, and 88% of the patients in the placebo, ketoprofen, ibuprofen, and acetaminophen groups, respectively. The median times to onset of relief were > 6 hours for placebo, 25.5 minutes for ketoprofen, 24.2 minutes for ibuprofen, and 29.9 minutes for acetaminophen. In addition, both ibuprofen and ketoprofen showed statistical superiority over acetaminophen at earlier time points on the time-effect curves for pain relief and pain intensity difference. Consistent results were seen with respect to the 6-hour summary efficacy variables: the three active treatments were significantly better than placebo, and ibuprofen was significantly better than both acetaminophen and ketoprofen. Liquigel ibuprofen 400 mg was shown to provide faster relief and superior overall efficacy compared with ketoprofen 25 mg, acetaminophen 1000 mg, and placebo. No serious adverse effects were reported in this single-dose study.

Changes in circulating carcinoma cells in patients with metastatic prostate cancer correlate with disease status

OBJECTIVES

To investigate the diurnal variations in circulating tumor cells (CTCs) in metastatic carcinoma of the prostate (CAP) and to determine whether the change in CTCs correlated with disease progression.

METHODS

Samples were prepared by immunomagnetic selection of cells from 7 mL of blood targeting the epithelial cell adhesion molecule and differential fluorescent labeling of the collected cells using a nucleic acid dye, antibodies directed against the common leukocyte (CD45), and cytokeratin antigens. Events that stained with the nucleic acid dye and expressed cytokeratin but lacked CD45 were defined as CTCs by multiparameter flow cytometry.

RESULTS

Male controls (n = 22) exhibited 0.8 +/- 1.2 events per 7 mL blood compared with 5.9 +/- 4.7 in 10 samples from patients with localized CAP and 46.6 +/- 65.6 events in 10 samples from patients with metastatic CAP. Diurnal testing of 8 cases demonstrated stable levels of CTCs. Ten patients were serially analyzed during a 6-month period for serum prostate-specific antigen and CTCs. The correlation between the prostate-specific antigen level and CTC number was fair. Slow disease progression was found in 4 patients with low CTC numbers (3.0 +/- 3) but it was significantly higher than the control group (P <0.002). Rapid disease progression occurred in 6 patients who demonstrated high CTC numbers (68.5 +/- 71.9). Two patients received chemotherapy that caused substantial fluctuations in the CTCs with less pronounced changes in the prostate-specific antigen level.

CONCLUSIONS

We conclude that the level of CTCs can be quantified in the circulation of patients with metastatic CAP and that the change in CTCs correlates with disease progression with no diurnal variations.

Ibuprofen liquigel for oral surgery pain

BACKGROUND

Ibuprofen liquigel is a solubilized potassium ibuprofen 200-mg gelatin capsule formulation that was approved for over-the-counter use in 1995.

OBJECTIVE

This study compared the analgesic efficacy and tolerability of ibuprofen liquigel 200 mg, ibuprofen liquigel 400 mg, acetaminophen caplets 1000 mg, and placebo in patients experiencing moderate or severe pain after surgical removal of impacted third molars.

METHODS

This randomized, double-blind, parallel-group, 6-hour study was conducted in 210 patients experiencing moderate or severe postoperative pain. Ratings of pain intensity and pain relief were recorded every 15 minutes for the first hour, at 90 and 120 minutes, and then hourly through hour 6. The onsets of first perceptible relief and meaningful relief were recorded using 2 stopwatches. An analysis of variance model was employed to test for significant differences (P < or = 0.05) between treatment groups with respect to pain relief, pain intensity difference, total pain relief (TOTPAR), and summed pain intensity difference (SPID). Stopwatch measures were analyzed using the Cox proportional hazards model. Drug tolerability was assessed by monitoring the occurrence of adverse events.

RESULTS

During the first 2 hours of the study (TOTPAR 2 and SPID 2), all active treatments were significantly more efficacious than placebo (P < 0.001), with ibuprofen liquigel 200 and 400 mg significantly more efficacious than acetaminophen 1000 mg (P < 0.05 and P < 0.01, respectively). For the entire duration of the study (TOTPAR 6 and SPID 6), only the 2 doses of ibuprofen liquigel were significantly more efficacious than placebo (P < 0.001). Ibuprofen liquigel 200 and 400 mg were also significantly more efficacious than acetaminophen 1000 mg on the summary measures TOTPAR 6 and SPID 6 (P < 0.01 and P < 0.001, respectively). Analysis of the stopwatch data revealed that all active treatments displayed significantly more rapid onsets to confirmed first perceptible relief (P < 0.001 to < 0.05) and meaningful relief (P < 0.001 to < 0.01) than did placebo, with ibuprofen liquigel 400 mg displaying a significantly more rapid onset to meaningful relief than acetaminophen 1000 mg (P < 0.05) and a significantly more rapid onset to confirmed first perceptible relief than acetaminophen 1000 mg (P < 0.001) and ibuprofen liquigel 200 mg (P < 0.01). All adverse events were considered mild or moderate, with an overall incidence of 11.5% in the ibuprofen liquigel 200-mg group, 6.8% in the ibuprofen liquigel 400-mg group, 19.0% in the acetaminophen 1000-mg group, and 25.9% in the placebo group.

CONCLUSIONS

Ibuprofen liquigel provided greater peak and overall analgesic effects and a more rapid onset to analgesia than did acetaminophen 1000 mg.

Performance of screening mammography in organized programs in Canada in 1996. The Database Management Subcommittee to the National Committee for the Canadian Breast Cancer Screening Initiative

BACKGROUND

The results of randomized trials show that breast cancer screening by mammography reduces breast cancer mortality by up to 40% in women aged 50-69 years. Because of these results, by 1998, 22 countries, including Canada, had established population-based organized screening programs. This paper presents the results of screening mammography in 1996 for 7 provincially organized breast cancer screening programs in Canada.

METHODS

Analyses of interim performance indicators for screening mammography have been calculated from data submitted to the Canadian Breast Cancer Screening database. The data set consisted of data from 7 provincial programs and was limited to mammographic screens for women aged 50-69 years (n = 203,303). Screening outcomes and performance indicators were calculated for abnormalities detected by screening mammography only.

RESULTS

The abnormal recall rate was 9.5% for first screens and 4.6% for subsequent screens, and the cancer detection rate per 1000 women screened was 6.9 for first screens and 3.8 for subsequent screens. The positive predictive value (i.e., the proportion of women who tested positive by mammography who were found to have breast cancer on screen-initiated diagnostic work-up) increased from 7.2% at the first screen to 8.2% at subsequent screens. Estimated participation rates within organized programs varied from 10.6% to 54.2%, depending on the province.

INTERPRETATION

For 1996, organized breast cancer screening programs met or exceeded many of the interim measures used in international programs. It is possible to translate the benefits of breast cancer screening by mammography, as demonstrated in randomized trials, into population-based community programs. Screening mammography through organized programs should increase to allow more comprehensive monitoring in Canada.

Solubilized ibuprofen: evaluation of onset, relief, and safety of a novel formulation in the treatment of episodic tension-type headache

OBJECTIVE

To evaluate the relative efficacy of a new solubilized formulation of ibuprofen compared with acetaminophen caplets.

METHODS

This double-blind, randomized, parallel group study evaluated 154 subjects taking a single dose of solubilized ibuprofen, 400 mg; acetaminophen, 1000 mg; or placebo for the relief of episodic tension-type headache. Time to relief was measured using a stopwatch, and overall efficacy was measured using traditional categorical pain and relief scales.

RESULTS

Ibuprofen capsules (liquigel), 400 mg, were significantly faster than both acetaminophen, 1000 mg, and placebo for all time-to-relief measures. Ibuprofen liquigel had a median time to first perceptible pain relief of 39 minutes compared with 47 minutes for acetaminophen and 113 minutes for placebo. For median time to meaningful relief, ibuprofen liquigel had a time of 39 minutes compared with 53 minutes for acetaminophen and more than 180 minutes for placebo (P</=.02 for both measures). In addition, ibuprofen liquigels demonstrated significantly superior overall analgesic efficacy compared with acetaminophen, 1000 mg, for the relief of episodic tension-type headache. Both active treatments had a side effect profile similar to placebo.

CONCLUSIONS

Although several other studies have demonstrated the overall analgesic superiority of ibuprofen to acetaminophen, this study demonstrated that the liquigel formulation also provides a clinically relevant advantage for time to analgesic effects.

Effects of composite thickness on the shear bond strength to dentin

The manufacturers of some condensable posterior composites claim that their products can be placed in bulk and light-cured in 5-mm-thick increments. This study compared the shear bond strengths of three composite resins when bonded to dentin in 2- and 5-mm-thick increments. Overall the bond strengths were adversely affected by the composite thickness (p < 0.0001). The shear bond strength of each composite tested was much lower when polymerized in a 5-mm increment than in a 2-mm increment of composite (p < or = 0.0005). The two condensable composites tested had a lower bond strength than the conventional composite when polymerized in a 5-mm bulk increment (p < or = 0.01).

Gastrointestinal safety and tolerance of ibuprofen at maximum over-the-counter dose

BACKGROUND

Delineation of non-steroidal anti-inflammatory drug (NSAID) gastrointestinal toxicity has largely depended on retrospective epidemiologic studies which demonstrate that lower doses of NSAIDs pose a lower risk of gastrointestinal toxicity. Ibuprofen, a propionic acid NSAID, has, in most such studies, exhibited a favourable profile in terms of gastrointestinal bleeding. Since 1984, ibuprofen has been available as a non-prescription analgesic/antipyretic with a limit of 1200 mg/day for 10 days of continuous use. Trials and spontaneously reported adverse experiences suggest that gastrointestinal symptoms and bleeding are rare.

METHODS

This study prospectively evaluated the gastrointestinal tolerability, as compared to placebo, of the maximum non-prescription dose and duration of ibuprofen use in healthy subjects representative of a non-prescription analgesic user population.

RESULTS

Gastrointestinal adverse experiences were similar in the placebo and ibuprofen groups (67 out of 413, 16% with placebo vs. 161 out of 833, 19% with ibuprofen). There was no difference between the two groups in the proportion discontinuing due to a gastrointestinal event. Gastrointestinal adverse experiences reported by >/= 1% of subjects were: dyspepsia, abdominal pain, nausea, diarrhoea, flatulence, and constipation. Seventeen (1.4%) subjects had positive occult blood tests: their frequency was comparable between treatments.

CONCLUSIONS

When used as directed to treat episodic pain, non-prescription ibuprofen at the maximum dose of 1200 mg/day for 10 days, is well-tolerated.

Predicting infection in localized intraabdominal fluid collections: value of pH and pO2 measurements

PURPOSE

To evaluate the use of pH, pO2, and the subjective opinion of the radiologist compared with bacterial culture in accurate diagnoses of bacterial infection in intraabdominal fluid collections.

MATERIALS AND METHODS

Prospectively, 79 patients who were suspected of having an intraabdominal fluid collection underwent diagnostic fluid aspiration. The aspirate was cultured and measured for pH and pO2. A pH < or = 7.1 and a PO2 < or = 49 mm Hg were threshold values used to separate infected from sterile fluid collections.

RESULTS

pH alone had a 92% sensitivity and 79% specificity, whereas PO2 alone had a 51% sensitivity and 79% specificity. pH or pO2 combined yielded a 92% sensitivity and 60% specificity. The radiologist's opinion produced a 83% sensitivity and 92% specificity. pH and the radiologist's opinion combined produced a 78% sensitivity and 96% specificity. pH or the radiologist's opinion combined had a 95% sensitivity and a 63% specificity.

CONCLUSION

pH is the most sensitive indicator of infection and the radiologist's opinion is the most specific. We recommend proceeding to drainage if the radiologist believes the collection to be infected and performing pH analysis if not. If the pH < or = 7.04, proceed to drainage. If neither of the above criteria are met, drainage could be delayed, pending the results of culture.

Axillary vein thrombosis during pregnancy in association with a lupus anticoagulant

A 42-year-old multiparous pregnant woman presented with swelling and pain of the left arm at 34 weeks gestation. She had no discoloration of her arm nor a loss of radial pulse. Duplex scanning demonstrated a thrombosis in the axillary vein. She was found to have a positive circulating lupus anticoagulant. Intravenous heparin was administered and resulted in resolution of discomfort and swelling on day four of therapy. The patient was maintained on therapeutic doses of subcutaneous heparin until vaginal delivery at 39 weeks. Prenatal course was complicated by a resolving infection believed to be due to cat-scratch disease which produced a five centimeter cystic lesion in the left axillae which was removed in the first trimester. Titers for cat-scratch disease were positive for mother and infant at delivery but infant titers were negative at six weeks. Axillary vein thrombosis in pregnancy can be complicated by pulmonary embolism and should be treated by heparin.

RFLP mapping of the centromere of chromosome 4 in maize using isochromosomes for 4S

The centromere of maize chromosome 4 was previously localized to a 26-cM interval using molecular markers and B-A translocations. The objective of the present study was to refine the placement of the centromere using secondary trisomics. Two independently isolated secondary trisomics (having an isochromosome plus two normal homologs) for 4S were recovered. RFLP analysis of populations segregating for them placed the centromere of chromosome 4 between bnl15.45 and bnl7.20, two RFLP loci that are 5.4-cM apart on the UMC map and 11.5-cM apart on the BNL map.

Clinical evaluation in prosthodontics: practical methods to improve validity and reliability at the undergraduate level

The potential causes of reliability and validity problems with traditional methods of evaluating a student's clinical prosthodontic skills are reviewed. Practical methods of evaluating critical skills in a reliable and valid way are presented. These methods include clinical tests using written criteria and anonymous examiners, skills assessment by faculty members, patient-based written examinations, and bell ringer examinations.

A new breed of parasuicide patient

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Glomerulonephritis after ventriculo-atrial shunt

We describe five patients with glomerulonephritis (GN) associated with cerebrospinal fluid shunt insertion to relieve hydrocephalus. A ventriculo-atrial (V-A) shunt had been placed on average 12.5 years prior to the diagnosis of nephritis (range 0.5-21 years). Four patients developed membranoproliferative glomerulonephritis (MPGN) with associated hypocomplementaemia. A single patient developed focal proliferative glomerulonephritis. Coagulase-negative staphylococci were cultured in four patients, either from blood or from the shunt. Four patients had their shunts removed, two of whom also received antibiotics. The other patient received antibiotics alone for infective endocarditis due to staphylococcal bacteraemia which originated in the shunt. All patients had substantial renal impairment at the time of diagnosis (GFR, glomerular filtration rate, 20-45 ml/min). There was significant improvement in renal function after appropriate treatment; four of the five patients doubled their GFRs and two patients regained normal function.

Pharmacokinetics of the anti-inflammatory drug ximoprofen in healthy subjects and in disease states

The pharmacokinetics of ximoprofen, a potent new non-steroidal anti-inflammatory agent, has been investigated in normal healthy subjects and in patients with hepatic or renal disease. After intravenous infusion of 22.8 mg to healthy subjects, plasma ximoprofen concentrations declined in a polyexponential manner with a terminal phase half-life of 1.9 h. The systemic clearance of ximoprofen was 115 ml.min-1 and the volumes of distribution were 18.01 Vz and 13.81 Vss. Ximoprofen was 80-90% bound to plasma proteins. The systemic availabilities (f) of orally and rectally administered doses of 30 mg of ximoprofen were 98% and 56% respectively and, in the case of the rectal dose, absorption appeared to be prolonged leading to "flip-flop" kinetics. After single oral doses of 30 mg of ximoprofen to patients with hepatic disease, half-life (2.2 h), peak plasma concentrations (1.55 micrograms.ml-1 cf 1.04 micrograms.ml-1 in healthy subjects) and areas under the curve (6.12 micrograms.h.ml-1 cf 3.54 micrograms.h.ml-1 in healthy subjects) were significantly different from those in healthy subjects. After single oral doses of 30 mg of ximoprofen to patients with renal disease, pharmacokinetic parameters of half-life (4.0 h), mean residence time (6.0 h) and area under the curve (9.2 micrograms.h.ml-1) were significantly different from those in healthy subjects. There were no significant differences in pharmacokinetic parameters between patients having differing degrees of renal disease. These data nevertheless suggest that accumulation of ximoprofen in hepatic or renal disease would be of slight or negligible clinical relevance and that no alteration of the dose regimen (up to 15 mg twice daily) may be required when ximoprofen is administered in these disease states.

The use of cyclosporin A in adult nephrotic syndrome: nine cases and literature review

Nine adult patients with resistant nephrotic syndrome were treated with cyclosporin A (CyA). All had failed to respond to high dose corticosteroids with or without cyclophosphamide. Three patients had minimal change disease, 3 had focal sclerosing glomerulosclerosis (FSGS), 2 had mesangiocapillary GN, and one had membranous nephropathy. The mean age of the patients was 26.4 years (range 16 to 39 years). CyA was given orally twice daily at a mean dose of 6.7 mg/kg/24 hours (range 6-10 mg/kg/24 hours). Four patients achieved full remission, two patients went into partial remission and three failed to respond. Two patients developed clinical nephrotoxicity, which reversed on dose reduction or cessation of CyA. All 3 patients with minimal change disease who responded subsequently relapsed after stopping CyA, but remitted rapidly on reintroduction of the drug. We suggest that the mode of action of CyA in nephrotic syndrome may be related to intra-renal vasoconstriction in addition to its direct immunosuppressive effect. In this limited series, we found that CyA can be an effective therapy for otherwise refractory nephrotic syndrome, although relapse on withdrawal of CyA may well be a significant clinical problem.

Systemic vasculitis with renal involvement--a review

Twenty five patients with renal vasculitis presenting over an eight year period were reviewed. Ten had microscopic polyarteritis, 6 classic polyarteritis, 5 overlap syndrome, 2 Churg-Strauss syndrome and 2 Wegener's granulomatosis. Clinical features included hypertension, pulmonary involvement, neurological involvement and arthralgia. Serum creatinine was over 500 umol/l in 13 patients, 10 of whom required dialysis. Visceral angiography was positive in 80% of those studied, Focal and segmental necrotising glomerulonephritis was the commonest renal lesion. Treatment consisted of corticosteroids and cytotoxic agents in most cases. Plasmapheresis was used for rapidly progressive renal failure, severe pulmonary haemorrhage or cerebral vasculitis. Improvement or stabilisation of renal function was seen in 68% of patients treated. There were 4 early deaths and one late death. The diagnosis, histology, treatment and outcome of renal vasculitis is discussed. The importance of early diagnosis and treatment is emphasised in this potentially reversible cause of acute renal failure.

DNA repair synthesis in individuals with and without a family history of cancer

The influence of family history on DNA repair synthesis, unscheduled DNA synthesis (UDS), was assessed in volunteers with or without a family history of cancer. UDS, following treatment of mononuclear leukocytes with N-acetoxy-2-acetylaminofluorene, was measured as the incorporation of [3H]thymidine into DNA in the presence of hydroxyurea. The positive family history group (n = 71) had an average of 2.4 first-degree relatives with cancer, defined as any major cancer, excluding skin cancer: 31 participants reported that cancer occurred in both their parents. The "no family history' comparison group (n = 29) had no family history of cancer through the second degree. There was a significant reduction in UDS in cells from individuals with family history, compared to those with no family history (P greater than 0.002). This relationship was not explained by factors known to influence UDS, such as age, smoking or hypertension. We conclude that reduced UDS in mononuclear leukocytes is associated with a family history of any major cancer, and is not confined to a history of cancer of any single organ site. This conclusion is further supported by the observation that individuals (n = 13) with parents who had an earlier onset of cancer (less than 60 years) also had a significantly lower DNA repair synthesis than those (n = 18) whose parents had later diagnosis of cancer (greater than 60 years).

Demonstration of shared antigenic determinants between Streptococcus mutans BHT cell membrane, human heart tissue and myosin using monoclonal antibodies to S. mutans

Monoclonal antibodies (MAb) raised to intact Streptococcus mutans P-4 cells (serotype e) were used to demonstrate the presence of shared antigenic determinant(s) between S. mutans BHT (serotype b) cell membranes and human heart tissue. MAb binding to both BHT membrane and human heart tissue was demonstrated by ELISA. Common antigens were identified by immunoblot analysis following separation of BHT membrane components and human heart antigens by SDS-PAGE. MAb 22C4 recognized three polypeptides from the BHT membrane preparation, having molecular masses of 42, 56 and 85 kDa. MAb 22C4 also recognized an 85 kDa component and a 200 kDa component from human heart tissue. MAb D159 was specific for a single 82 kDa polypeptide in BHT membrane, and also bound to two high molecular mass components in human heart (165 and 200 kDa). When both MAb D159 and 22C4 were first absorbed with S. mutans P-4 cells, subsequent reactivity to the aforementioned BHT membrane components was inhibited, indicating that these cross-reactive components are found in S. mutans P-4 as well as in S. mutans BHT micro-organisms. Competitive binding analysis showed that both MAb D159 and MAb 22C4 bound to myosin, indicating that S. mutans BHT membrane, human heart tissue and myosin share at least one immunodeterminant. This indicates that myosin could be the cross-reactive tissue component in human heart.