Near-range atmospheric dispersion of an anomalous selenium-75 emission

On May 15th of 2019, an anomalous emission of selenium-75 was detected at the stack of the Belgian Reactor 2 (BR2) in Mol. Although the release exceeded the prescribed limits for BR2, there was no harm to the population or food chain and so the event was classified as INES 1. However, it was very interesting from the perspective of near-range atmospheric dispersion. This publication brings together all available information at the near range - stack-monitored source term data, on-site meteorological data, ambient dose equivalent rates, deposition and concentration measurements - in one dataset that covers the initial puff release on May 15th, 2019 as well as a residual release through early November 2019. To demonstrate the consistency of this dataset, supporting atmospheric transport and dispersion calculations are performed using a Gaussian plume model. These calculations, in turn, are supported by near-range Flexpart calculations in the context of the residual release.

Efficacy of Preoperative mFOLFIRINOX vs mFOLFIRINOX Plus Hypofractionated Radiotherapy for Borderline Resectable Adenocarcinoma of the Pancreas: The A021501 Phase 2 Randomized Clinical Trial

Importance

National guidelines endorse treatment with neoadjuvant therapy for borderline resectable pancreatic ductal adenocarcinoma (PDAC), but the optimal strategy remains unclear.

Objective

To compare treatment with neoadjuvant modified FOLFIRINOX (mFOLFIRINOX) with or without hypofractionated radiation therapy with historical data and establish standards for therapy in borderline resectable PDAC.

Design, Setting, and Participants

This prospective, multicenter, randomized phase 2 clinical trial conducted from February 2017 to January 2019 among member institutions of National Clinical Trials Network cooperative groups used standardized quality control measures and included 126 patients, of whom 70 (55.6%) were registered to arm 1 (systemic therapy; 54 randomized, 16 following closure of arm 2 at interim analysis) and 56 (44.4%) to arm 2 (systemic therapy and sequential hypofractionated radiotherapy; all randomized before closure). Data were analyzed by the Alliance Statistics and Data Management Center during September 2021.

Interventions

Arm 1: 8 treatment cycles of mFOLFIRINOX (oxaliplatin, 85 mg/m2; irinotecan, 180 mg/m2; leucovorin, 400 mg/m2; and infusional fluorouracil, 2400 mg/m2) over 46 hours, administered every 2 weeks. Arm 2: 7 treatment cycles of mFOLFIRINOX followed by stereotactic body radiotherapy (33-40 Gy in 5 fractions) or hypofractionated image-guided radiotherapy (25 Gy in 5 fractions). Patients without disease progression underwent pancreatectomy, which was followed by 4 cycles of treatment with postoperative FOLFOX6 (oxaliplatin, 85 mg/m2; leucovorin, 400 mg/m2; bolus fluorouracil, 400 mg/m2; and infusional fluorouracil, 2400 mg/m2 over 46 hours).

Main Outcomes and Measures

Each treatment arm's 18-month overall survival (OS) rate was compared with a historical control rate of 50%. A planned interim analysis mandated closure of either arm for which 11 or fewer of the first 30 accrued patients underwent margin-negative (R0) resection.

Results

Of 126 patients, 62 (49%) were women, and the median (range) age was 64 (37-83) years. Among the first 30 evaluable patients enrolled to each arm, 17 patients in arm 1 (57%) and 10 patients in arm 2 (33%) had undergone R0 resection, leading to closure of arm 2 but continuation to full enrollment in arm 1. The 18-month OS rate of evaluable patients was 66.7% (95% CI, 56.1%-79.4%) in arm 1 and 47.3% (95% CI 35.8%-62.5%) in arm 2. The median OS of evaluable patients in arm 1 and arm 2 was 29.8 (95% CI, 21.1-36.6) months and 17.1 (95% CI, 12.8-24.4) months, respectively.

Conclusions and Relevance

This randomized clinical trial found that treatment with neoadjuvant mFOLFIRINOX alone was associated with favorable OS in patients with borderline resectable PDAC compared with mFOLFIRINOX treatment plus hypofractionated radiotherapy; thus, mFOLFIRINOX represents a reference regimen in this setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT02839343.

Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Early-Onset Colorectal Adenocarcinoma in the IDEA Database: Treatment Adherence, Toxicities, and Outcomes With 3 and 6 Months of Adjuvant Fluoropyrimidine and Oxaliplatin

PURPOSE

Early-onset (EO) colorectal cancer (CRC, age < 50 years) incidence is increasing. Decisions on optimal adjuvant therapy should consider treatment adherence, adverse events, and expected outcomes in a population with life expectancy longer than later-onset (LO) CRC (age ≥ 50 years).

MATERIALS AND METHODS

Individual patient data from six trials in the International Duration Evaluation of Adjuvant Chemotherapy database were analyzed. Characteristics, treatment adherence, and adverse events in stage II or III EO-CRC and LO-CRC were compared. To reduce confounders of non-cancer-related deaths because of age or comorbidities, time to recurrence (3-year relapse-free rate) and cancer-specific survival (5-year cancer-specific mortality rate) were considered.

RESULTS

Out of 16,349 patients, 1,564 (9.6%) had EO-CRC. Compared with LO-CRC, EO-CRC had better performance status (86% v 80%, P < .01), similar T stage (% T1-3/T4: 76/24 v 77/23, P = .97), higher N2 disease rate (24% v 22%, P < .01), more likely to complete the planned treatment duration (83.2% v 78.2%, P < .01), and received a higher treatment dose intensity, especially with 6-month regimens. Gastrointestinal toxicity was more common in EO-CRC; hematologic toxicity was more frequent in LO-CRC. Compared with LO-CRC, significantly worse cancer-specific outcomes were demonstrated especially in high-risk stage III EO-CRC: lower 3-year relapse-free rate (54% v 65%; hazard ratio [HR] 1.33; 95% CI, 1.14 to 1.55; P value < .001) and higher 5-year cancer-specific mortality rate (24% v 20%; HR 1.21; 95% CI, 1.00 to 1.47; P value < .06). In this subgroup, no difference was observed with 3 or 6 months of therapy, with equally poor disease-free survival rates (57% v 56%; HR 0.97; 95% CI, 0.73 to 1.29; P value = .85).

CONCLUSION

Young age is negatively prognostic in high-risk stage III CRC and associated with significantly higher relapse rate; this is despite better treatment adherence and higher administered treatment intensity, suggesting more aggressive disease biology.

Combining tumor deposits with the number of lymph node metastases to improve the prognostic accuracy in stage III colon cancer: a post hoc analysis of the CALGB/SWOG 80702 phase III study (Alliance)☆

BACKGROUND

In colon cancer, tumor deposits (TD) are considered in assigning prognosis and staging only in the absence of lymph node metastasis (i.e. stage III pN1c tumors). We aimed to evaluate the prognostic value of the presence and the number of TD in patients with stage III, node-positive colon cancer.

PATIENTS AND METHODS

All participants from the CALGB/SWOG 80702 phase III trial were included in this post hoc analysis. Pathology reports were reviewed for the presence and the number of TD, lymphovascular and perineural invasion. Associations with disease-free survival (DFS) and overall survival (OS) were evaluated by multivariable Cox models adjusting for sex, treatment arm, T-stage, N-stage, lymphovascular invasion, perineural invasion and lymph node ratio.

RESULTS

Overall, 2028 patients were included with 524 (26%) TD-positive and 1504 (74%) TD-negative tumors. Of the TD-positive patients, 80 (15.4%) were node negative (i.e. pN1c), 239 (46.1%) were pN1a/b (<4 positive lymph nodes) and 200 (38.5%) were pN2 (≥4 positive lymph nodes). The presence of TD was associated with poorer DFS [adjusted hazard ratio (aHR) = 1.63, 95% CI 1.33-1.98] and OS (aHR = 1.59, 95% CI 1.24-2.04). The negative effect of TD was observed for both pN1a/b and pN2 groups. Among TD-positive patients, the number of TD had a linear negative effect on DFS and OS. Combining TD and the number of lymph node metastases, 104 of 1470 (7.1%) pN1 patients were re-staged as pN2, with worse outcomes than patients confirmed as pN1 (3-year DFS rate: 65.4% versus 80.5%, P = 0.0003; 5-year OS rate: 87.9% versus 69.1%, P = <0.0001). DFS was not different between patients re-staged as pN2 and those initially staged as pN2 (3-year DFS rate: 65.4% versus 62.3%, P = 0.4895).

CONCLUSION

Combining the number of TD and the number of lymph node metastases improved the prognostication accuracy of tumor-node-metastasis (TNM) staging.

Impact of geography on prognostic outcomes of 21,509 patients with metastatic colorectal cancer enrolled in clinical trials: an ARCAD database analysis

BACKGROUND

Benchmarking international cancer survival differences is necessary to evaluate and improve healthcare systems. Our aim was to assess the potential regional differences in outcomes among patients with metastatic colorectal cancer (mCRC) participating in international randomized clinical trials (RCTs).

DESIGN

Countries were grouped into 11 regions according to the World Health Organization and the EUROCARE model. Meta-analyses based on individual patient data were used to synthesize data across studies and regions and to conduct comparisons for outcomes in a two-stage random-effects model after adjusting for age, sex, performance status, and time period. We used mCRC patients enrolled in the first-line RCTs from the ARCAD database, which provided enrolling country information. There were 21,509 patients in 27 RCTs included across the 11 regions.

RESULTS

Main outcomes were overall survival (OS) and progression-free survival (PFS). Compared with other regions, patients from the United Kingdom (UK) and Ireland were proportionaly over-represented, older, with higher performance status, more frequently male, and more commonly not treated with biological therapies. Cohorts from central Europe and the United States (USA) had significantly longer OS compared with those from UK and Ireland (p = 0.0034 and p < 0.001, respectively), with median difference of 3-4 months. The survival deficits in the UK and Ireland cohorts were, at most, 15% at 1 year. No evidence of a regional disparity was observed for PFS. Among those treated without biological therapies, patients from the UK and Ireland had shorter OS than central Europe patients (p < 0.001).

CONCLUSIONS

Significant international disparities in the OS of cohorts of mCRC patients enrolled in RCTs were found. Survival of mCRC patients included in RCTs was consistently lower in the UK and Ireland regions than in central Europe, southern Europe, and the USA, potentially attributed to greater overall population representation, delayed diagnosis, and reduced availability of therapies.

P2862Complementary use of contact force and local catheter impedance during RF ablation reduces ablation time in an in vivo swine model

Acknowledgement/Funding

This study was funded by Boston Scientific.

Prognostic value of primary tumour resection in synchronous metastatic colorectal cancer: Individual patient data analysis of first-line randomised trials from the ARCAD database

Indication for primary tumour resection (PTR) in asymptomatic metastatic colorectal cancer (mCRC) patients is unclear. Previous retrospective analyses suggest a survival benefit for patients who underwent PTR. The aim was to evaluate the prognostic value of PTR in patients with synchronous mCRC by analysis of recent large RCTs including systemic therapy with modern targeted agents. Individual patient data (IPD) of 3423 patients enrolled into 8 randomised controlled trials (RCTs) with first-line systemic therapy in the ARCAD (Aide et Recherche en Cancérologie Digestive) database were analysed. The number of patients with unresected synchronous mCRC, resected synchronous mCRC and metachronous mCRC was 710 (21%), 1705 (50%) and 1008 (29%), respectively. Adjusting for age, gender, performance status (PS) and prior chemotherapy, the unresected group had a significantly worse median overall survival (16.4 m) compared with the synchronous resected (22.2 m; hazard ratio [HR] 1.60, 95% CI 1.43-1.78) and metachronous (22.4 m; HR 1.81, 95% CI 1.58-2.07) groups. Similarly, median progression-free survival was significantly worse for the unresected group compared with the synchronous resected (HR 1.31, 95% CI 1.19-1.44) and metachronous (HR 1.47, 95% CI 1.30-1.66) groups. In a multivariate analysis, the observed associations remained significant. This largest IPD analysis of mCRC trials to date demonstrates an improved survival in synchronous mCRC patients after PTR. These results may be subject to bias since reasons for (non)resection were not available. Until results of ongoing RCTs are available, both upfront PTR followed by systemic treatment and upfront systemic treatment are considered appropriate treatment strategies.

Statistical controversies in clinical research: Value of adverse events relatedness to study treatment: analyses of data from randomized double-blind placebo-controlled clinical trials

Background

Collection and reporting of adverse events (AEs) and their relatedness to study treatment, known commonly as attribution, in clinical trials is mandated by regulatory agencies (the National Cancer Institute and the Food and Drug Administration). Attribution is assigned by the treating physician using judgment based on various factors including patient's baseline status, disease history, and comorbidity as well as knowledge about the safety profile of the study treatments. We evaluate the patterns of AE attribution (unrelated, unlikely, possibly, probably, and definitely related to the treatment) in treatment, symptom intervention (cancer patients) and cancer prevention (participants at high risk for cancer) setting.

Materials and methods

Nine multicenter placebo-controlled trials (two treatment, two symptom intervention, and five cancer prevention) were analysed separately (2155 patients). Frequency and severity of AEs were summarized by arm. Attribution and percentage of repeated AEs whose attribution changed overtime were summarized for the placebo arms. Percentage of physician over- or under-reporting of AE relatedness was calculated for the treatment arms using the placebo arm as the reference.

Results

Across all trials and settings, a very high proportion of AEs reported as related to treatment were classified as possibly related, a significant proportion of AEs in the placebo arm were incorrectly reported as related to treatment, and clinician-reported attribution over-estimated the rate of AEs related to treatment. Fatigue, nausea, vomiting, diarrhea, constipation, and neurosensory were the common AEs that were over reported by clinician as related to treatment.

Conclusions

These analyses demonstrate that assigning causality to AE is a complex and difficult process that produces unreliable and subjective data. In randomized double-blind placebo-controlled trials where data are available to objectively assess relatedness of AE to treatment, attribution assignment should be eliminated.

Evaluation of DFO-HOPO as an octadentate chelator for zirconium-89

The future of 89Zr-based immuno-PET is reliant upon the development of new chelators with improved stability compared to the currently used deferoxamine (DFO). Herein, we report the evaluation of the octadentate molecule DFO-HOPO (3) as a suitable chelator for 89Zr and a more stable alternative to DFO. The molecule showed good potential for the future development of a DFO-HOPO-based bifunctional chelator (BFC) for the radiolabelling of biomolecules with 89Zr. This work broadens the selection of available chelators for 89Zr in search of improved successors to DFO for clinical 89Zr-immuno-PET.

An optimal control framework for dynamic induction control of wind farms and their interaction with the atmospheric boundary layer

Complex turbine wake interactions play an important role in overall energy extraction in large wind farms. Current control strategies optimize individual turbine power, and lead to significant energy losses in wind farms compared with lone-standing wind turbines. In recent work, an optimal coordinated control framework was introduced (Goit & Meyers 2015 J. Fluid Mech.768, 5-50 (doi:10.1017/jfm.2015.70)). Here, we further elaborate on this framework, quantify the influence of optimization parameters and introduce new simulation results for which gains in power production of up to 21% are observed.This article is part of the themed issue 'Wind energy in complex terrains'.

On the construction and use of linear low-dimensional ventilation models

The construction of fast reliable low-dimensional models is important for monitoring and control of ventilation applications. We employ a discrete Green's function approach to derive a linear low-dimensional ventilation model directly from the governing equations for indoor ventilation (i.e., the Navier-Stokes equations supplemented with a transport equation for indoor-pollutant concentration). It is shown that the flow equations decouple from the concentration equation when the ratio α of air-mass-flow rate to pollutant-mass-flow rate increases to infinity. A low-dimensional discrete representation of the Green's function of the concentration equation can then be constructed, based on either numerical simulations or experiments. This serves as a linear model that allows for the reconstruction of concentration fields resulting from any type of pollutant-source distribution. We employ a suite of Reynolds-averaged Navier-Stokes (RANS) simulations to illustrate the methodology. We focus on a simple benchmark ventilation case under constant-density conditions. Discrete linear ventilation models for the concentration are then derived and compared with coupled RANS simulations. An analysis of errors in the discrete linear model is presented: dependence of the error on the (low-dimensional) resolution in the discrete model is quantified, and errors introduced by too low values of α are also investigated.

PRACTICAL IMPLICATIONS

The paper introduces the derivation and construction of linear low-dimensional ventilation models, which allow reconstructing concentration fields resulting from any type of indoor-pollutant-source distribution. Once constructed, these ventilation models are very efficient to estimate indoor contaminant concentration distributions, compared to direct CFD simulation approaches. Therefore, these models can facilitate monitoring and control of ventilation systems, to remove indoor contaminants.

DRD2 and DRD4 in relation to regular alcohol and cannabis use among adolescents: does parenting modify the impact of genetic vulnerability? The TRAILS study

AIMS

The aims of the present study were to determine the direct effect of DRD2 and DRD4, as well as their interaction with parenting (i.e. rejection, overprotection and emotional warmth), on the development of regular alcohol and cannabis use in 1192 Dutch adolescents from the general population.

METHODS

Information was obtained by self-report questionnaires. Perceived rejection, overprotection and emotional warmth were assessed at age 10-12. Regular alcohol and cannabis use were determined at age 15-18 and defined as the consumption of alcohol on 10 or more occasions in the past four weeks, and the use of cannabis on 4 or more occasions in the past four weeks. Models were adjusted for age, sex, parental alcohol or cannabis use, and externalizing behavior.

RESULTS

Carrying the A1 allele of the DRD2 TaqIA polymorphism, or the 7 repeat DRD4, was not directly related to regular alcohol or cannabis use. In addition, adolescent carriers of these genetic risk markers were not more susceptible to the influence of less optimal parenting. Main effects for parenting indicated that overprotection increased the risk of regular alcohol use, whereas the risk of cannabis use was enhanced by parental rejection and buffered by emotional warmth.

CONCLUSIONS

Our findings do not support an association between DRD2/DRD4 and regular alcohol and cannabis use in adolescents. Given the substance-specific influences of rejection, overprotection and emotional warmth, these parenting factors might be promising candidates for prevention work.

Reaching teen farm workers with health and safety information: an evaluation of a high school ESL curriculum

While childhood agricultural injury has long been recognized as an important public health issue, most research has focused on family farms and there have not been many interventions targeting hired youth. This study evaluated the impact of a high school English as a Second Language (ESL) curriculum, designed to provide teen agricultural workers with the knowledge and tools to protect their health and safety in the fields. Using a quasi-experimental design, the research consisted of two intervention groups and a comparison group, and included over 2,000 students from communities that lead California in agricultural production. The research findings revealed that the curriculum had significant impact in terms of increases in knowledge and attitudes, and nearly half of those interviewed after a summer of working in the fields reported implementing new behaviors to protect their health and safety. The curriculum also had extended effects in the broader community, as the majority of students reported sharing the new information with others. The study found that a school-based ESL curriculum is an effective intervention to reach and educate teen farm workers and that ESL classes can serve as a much-needed access point for young farm workers.

Nesiritide utilization evaluation in a university teaching hospital

BACKGROUND AND OBJECTIVES

Nesiritide is a new vasodilator approved for decompensated heart failure (DHF). Compared with nitroglycerin, nesiritide improves haemodynamics and symptoms in the first 3 h of therapy. However, nesiritide is more expensive than nitroglycerin (US$380-1500 daily vs. US$2-5 daily). Since its approval in the US in late 2001, nesiritide use has increased dramatically in our institution. Nesiritide has become a focus of our multidisciplinary drug utilization initiative, aimed at performing a nesiritide utilization evaluation (NUE) and developing a nesiritide usage guideline.

METHODS

Medical records of patients who received nesiritide from 1 October 2003 to 31 March 2004 were reviewed. Nesiritide utilization pattern was presented to the initiative group for guideline development.

RESULTS

A total of 162 records were reviewed. A 22.6% of inappropriate usage was reported. The most significant inappropriate usage was in patients who received the agent for precardiac valvular surgery optimization, followed by those for diuresis in non-cardiac-related fluid overload states. The median duration of nesiritide therapy was 6 days (range 1-94). The median length of stay (LOS) in our institution was 14 days (National statistics DHF LOS: 5.3 days). Eliminating inappropriate nesiritide usage can lead to a potential of US$141 886 savings per year.

CONCLUSION

Based on the results, a 48-h nesiritide restriction policy was implemented. Usage beyond 48 h requires Heart Failure Service approval. Future NUE will evaluate the effectiveness of this policy. The overall management of DHF also needs to be evaluated to improve efficiency of care.

Restricted growth of avirulent avian reovirus strain 2177 in macrophage derived HD11 cells

The replication of two pathotypes of avian reovirus, 1733 and 2177 in transformed chicken lymphoid and myeloid cell lines was examined, showing that only the macrophage cell line, HD11, supports replication. The virulent strain 1733 causes a lytic infection producing 100-1000 fold more virus than the avirulent strain 2177. Cells infected with strain 2177 display delayed viral RNA and protein synthesis as well as a suppressed expression of the major capsid protein muB. These features may contribute to the lower virulence of the strain 2177 in their natural host in vivo.

Interleukin-4 up-regulates mouse mammary tumor virus expression yet is not required for in vivo virus spread

The mouse mammary tumor virus (MMTV) superantigen induces T-cell production of cytokines, such as interleukin-4, which in turn increase MMTV transcription. However, interleukin-4 is not required for in vivo virus spread, because mice lacking interleukin-4 or the STAT6 transcription factor showed wild-type infection of lymphoid and mammary tissue. In spite of this, mammary tumor incidence was decreased in STAT6 null mice.

An instrument to measure musculoskeletal symptoms among immigrant Hispanic farmworkers: validation in the nursery industry

We report on the construction and psychometrics of a survey measure of musculoskeletal symptomatology for use with Spanish-speaking immigrant farmworkers. Survey development included focus groups with workers, forward and backward translations, and pilot testing. The final survey includes a body diagram and items about symptom severity, frequency, and duration and about self-treatment, medical care, and job tasks. We report on the initial test of the survey with 213 commercial nursery workers in Southern California. Fifty-five percent of the workers reported pain, with 30% reporting back pain, 21% reporting upper extremity pain, 19% reporting lower extremity pain, and 10% reporting neck and shoulder pain. A composite symptom score exhibited acceptable test-retest reliability (r = 0.41, p < 0.01) over the annual agricultural cycle. Greater symptomatology was associated with greater frequency of self-treatment (r = 0.42, p < 0.01), seeking professional health care (t = 2.49, p < 0.05), and exposure to high-risk jobs (OR = 2.1, p < 0.05, CI = 1.0 to 4.4), supporting the validity of composite score.

The psychiatric interview in the emergency department

Psychiatric assessment of patients in the emergency department requires a psychological and medical approach. Acute medical problems must be investigated immediately, before a more nuanced exploration of emotional, cognitive, and behavioral aspects of these patients is undertaken. A multidimensional, nonreductive description then guides the treatment and disposition of patients in the emergency department.

Mutations in the KCNQ4 gene are responsible for autosomal dominant deafness in four DFNA2 families

We have previously found linkage to chromosome 1p34 in five large families with autosomal dominant non-syndromic hearing impairment (DFNA2). In all five families, the connexin31 gene ( GJB3 ), located at 1p34 and responsible for non-syndromic autosomal dominant hearing loss in two small Chinese families, has been excluded as the responsible gene. Recently, a fourth member of the KCNQ branch of the K+channel family, KCNQ4, has been cloned. KCNQ4 was mapped to chromosome 1p34 and a single mutation was found in three patients from a small French family with non-syndromic autosomal dominant hearing loss. In this study, we have analysed the KCNQ4 gene for mutations in our five DFNA2 families. Missense mutations altering conserved amino acids were found in three families and an inactivating deletion was present in a fourth family. No KCNQ4 mutation could be found in a single DFNA2 family of Indonesian origin. These results indicate that at least two and possibly three genes responsible for hearing impairment are located close together on chromosome 1p34 and suggest that KCNQ4 mutations may be a relatively frequent cause of autosomal dominant hearing loss.

Rural attitudes, opinions, and drug use

There are two primary purposes of this paper. The first is to summarize the results of a survey conducted in a rural area of Kentucky on attitudes and behaviors regarding substance use. The second purpose is to examine differences in drug attitudes and behaviors for higher and lower density rural areas. Participants for this study were contacted by telephone in March 1996. The sample was generated by random digit dialing for eight county telephone exchanges. The sample included 334 respondents from the eight counties who were grouped into respondents from higher density areas (n = 132) and lower density areas (n = 202). Results indicated that respondents from both higher density and lower density areas were similar on drug use and attitudes. However, lower density areas reported their county as a worse place to live and less safe than respondents from higher density areas. Respondents from lower density areas were also more likely to report there was more alcohol/drug use and more alcohol bootlegging in the past year, and that bootlegging alcohol is a serious problem in their county. Future research could include the examination of heterogeneity of rural areas using different indices.

A single nucleotide polymorphism in the matrix metalloproteinase-1 promoter creates an Ets binding site and augments transcription

Matrix metalloproteinases (MMPs) facilitate cellular invasion by degrading the extracellular matrix, and their regulation is partially dependent on transcription. Binding sites for members of the Ets family of transcription factors are present within MMP promoters and are potent positive regulators. We report a single nucleotide polymorphism at -1607 bp in the MMP-1 promoter, where an additional guanine (G) creates an Ets binding site, 5'-GGA-3'. This polymorphism displays significantly higher transcription in normal fibroblasts and in melanoma cells than the 1 G polymorphism, and it binds substantially more nuclear extract and recombinant ETS-1. Analysis of control DNAs from the Center d'Etude du Polymorphisme Humain pedigrees reveals that this polymorphism is not a mutation, with a frequency of the 2 G polymorphism at 30%. In contrast, in eight tumor cell lines, this frequency increased to 62.5% (P < 0.0001). Thus, this MMP-1 polymorphism contributes to increased transcription, and cells expressing the 2 G polymorphism may provide a mechanism for more aggressive matrix degradation, thereby facilitating cancer progression.

Enhancement of compliance among patients with hypertension

Studies of patient compliance with medical advice consistently demonstrate a high level of noncompliance. Not following recommendations can have serious negative consequences in the management of disease. This study was an assessment of the effect on compliance of a longitudinal, individualized educational program for patients with hypertension in a managed care setting. A before-and-after self-paired design was used to assess the behavior of 107 patients with hypertension. Trained nurses using an interactive interview format reinforced prescribed treatment and provided appropriate printed material to participants. Brief telephone follow-up interviews at prescribed intervals were used to elicit problems, provide additional education, and reinforce compliance behaviors. Most of the patients who participated showed a statistically significant (P < 0.01) decrease in both systolic and diastolic blood pressure. There was also an effect on various recommended behaviors, including compliance with medication taking, ideal body weight, salt restriction, stress, and exercise. A statistically significant relation existed between improved compliance with individual behavior changes and decreased blood pressure (P < 0.01). Elderly persons were particularly likely to show statistically significant reductions in blood pressure (75.4% versus 50.0%). A chi 2 test indicated that those differences were significant at the 0.01 level. A relatively inexpensive, office-based educational protocol can have a statistically significant effect on treatment compliance among patients with hypertension. The intervention has particular implications for geriatric patients, whose high blood pressure is disproportionately represented.

Linkage analysis of progressive hearing loss in five extended families maps the DFNA2 gene to a 1.25-Mb region on chromosome 1p

Thus far, 13 genes for autosomal dominant hearing loss have been localized to specific chromosomal regions, but none of the genes has been cloned. Only a single family has been linked to each of these loci, with the exception of DFNA2. DFNA2 was originally mapped in two extended families originating from Indonesia and the United States. In this study we report linkage to DFNA2 in three additional large families with autosomal dominant hearing loss from Belgium and The Netherlands. These five DFNA2 families show a similar progressive sensorineural hearing loss, starting in the high frequencies and also affecting the middle and low frequencies later in life. Combining the information from all linked families, the candidate region that is most likely to contain the DFNA2 gene was reduced to a 1.25-Mb region between markers D1S432 and MYCL1. Different haplotypes segregating with the hearing loss were found in all five families, suggesting that different mutations are present in the same gene. These results indicate that DFNA2 is most likely an important gene for autosomal dominant hearing loss.

Conduct disorder, substance dependence, and adolescent motherhood

Of 26 teenage mothers in a nonclinical sample, one-third were found to have a diagnosis of conduct disorder; of these, two-thirds were also diagnosed with substance abuse or dependence. Conduct disorder as a risk factor for adolescent pregnancy and substance use is discussed, as are the implications for preventive intervention.

Nosocomial infections with vancomycin-resistant Enterococcus faecium in liver transplant recipients: risk factors for acquisition and mortality

The risk factors for acquisition of and mortality due to nosocomial infection with vancomycin-resistant Enterococcus faecium (VREF) in orthotopic liver transplant (OLT) recipients were studied at a tertiary care hospital; 32 VREF-infected OLT patients (cases) were compared with 33 randomly selected OLT recipients (controls). More antibiotics were administered preoperatively to cases (mean, 4 antibiotics per patient for 474 antibiotic-days) than to controls (mean, 1.8 antibiotics per patient for 131 antibiotic-days). Cases were more likely than controls to have received vancomycin therapy preoperatively and to have been hospitalized in the intensive care unit (ICU) preoperatively. Logistic regression revealed that the risk factors for acquisition of VREF infection were surgical reexploration and a prolonged stay in the surgical ICU postoperatively. In the cases, the risk factors for mortality were admission to the ICU preoperatively and hemodialysis. The mortality rate associated with polymicrobial bloodstream infections was 100% despite appropriate therapy. Sixteen and 18 cases received parenteral chloramphenicol and doxycycline, respectively, for treatment of VREF infection. There were no hematologic adverse effects attributed to chloramphenicol treatment. DNA analysis of selected E. faecium isolates suggested that infections were due to multiple clones. In summary, the source of VREF infection in OLT patients is the gastrointestinal tract. Antibiotic selective pressure may contribute to colonization. Infection with VREF is a predictor of morbidity and mortality in OLT patients.

The blue light-responsive AthH2 gene of Arabidopsis thaliana is primarily expressed in expanding as well as in differentiating cells and encodes a putative channel protein of the plasmalemma

According to our previous studies the Arabidopsis gene AthH2 which is inducible by blue light and phytohormones codes for an intrinsic membrane protein. It bears a resemblance to several distinct channel proteins of plant and animal species classified as the MIP/NOD-26/GlpF family. In the present study biochemical analyses and electron microscopic immunochemistry were used to elucidate the subcellular location of the AthH2 protein. The results clearly demonstrate that it is an exclusive constituent of the plasmalemma. Furthermore, the expression of the AthH2 gene in transgenic Arabidopsis plants containing the promoter region of AthH2 fused to the beta-glucuronidase (gus) reporter gene was studied. The in situ localization of gus activity revealed that the specific promoter is temporally activated by light in expanding and/or differentiating cells comprising newly formed tissues and organs: root elongation zone, guard cells of stomata, vascular bundle sheaths, filaments of stamen and young siliques. Several sites of gus expression coincide spatially with those of in situ hybridization and the immunocytochemical reaction, respectively, suggesting that the AthH2 promoter had correctly responded to light as an important exogenous factor with relevance to the complex pattern of differentiation. Studies with protoplasts from plants transformed with an antisense construct revealed a water transport capacity of the AthH2 protein.

The importance of social interaction: a new perspective on social epidemiology, social risk factors, and health

Social epidemiology research has provided persuasive evidence of the link between the social environment--especially socioeconomic status--and health outcomes, but has failed to identify underlying mechanisms that might account for the association. The research may have been limited to date by its reliance on traditional epidemiological methods that emphasize a search for specific causal factor-disease relationships. It is time to take the research evidence and recast it to find practical solutions. We argue that the human development perspective supplies a framework for understanding the critical interaction between elements of social environment and health: Analyzing the social epidemiological research from this perspective can help to explain why and how the most potent factor, socioeconomic status, affects health outcomes. Equally important, this alternative perspective also presents health education practice implications.

Long-term follow-up of patients with invasive fungal disease who received adjunctive therapy with recombinant human macrophage colony-stimulating factor

Mortality of bone marrow transplant (BMT) patients who develop invasive fungal infection is greater than 80%. Long-term follow-up of 46 consecutive BMT patients who received recombinant human macrophage colony-stimulating factor (rhM-CSF) as adjunctive therapy with standard antifungal treatment who were entered into phase I/II trials at The Fred Hutchinson Cancer Research Center is reported. rhM-CSF (100 micrograms/m2 to 2,000 micrograms/m2; Chiron/Cetus Corporation, Emeryville, CA) was administered from day 0 to 28 after determination of progressive fungal disease. Results of long-term follow-up of fungal infection, relapse, and survival were compared with 58 similar historical controls. Multivariable analysis of the patients who received rhM-CSF showed two factors that significantly correlated with poor survival: Karnofsky score < or = 20% and Aspergillus infection. Overall, survival of patients who received rhM-CSF was greater than that of historical patients (27% v 5%) and was entirely because of a 50% survival rate in patients with Candida infection and Karnofsky scores greater than 20%. Prospective, randomized, controlled trials to determine efficiency of rhM-CSF are indicated and should be directed at patients with invasive candidiasis.

Activation-driven T cell death. II. Quantitative differences alone distinguish stimuli triggering nontransformed T cell proliferation or death

Clonal deletion is the major mechanism by which T cell tolerance is achieved in vivo. The process of activation-driven cell death, originally characterized with T cell hybridomas, likely represents the mechanism of clonal deletion because it shares a number of properties with the in vivo process, especially the ability to be triggered in an Ag-specific manner, the cell-autonomous nature of the response, and its sensitivity to the drug cyclosporin A. We now have extended our analysis of activation-driven cell death to clonal populations of nontransformed T cells. Activation-driven cell death can be induced in nontransformed T lymphocytes by combinations of mitogenic stimuli. In particular, two mitogenic stimuli at high dose, one a lymphokine and the other delivered via the TCR or another activation structure, are required to induce activation-driven cell death. Activation-driven cell death is an active cell suicide process with attributes typical of physiological cell death, including early nuclear disintegration and a requirement for macromolecular synthesis, and is distinct from death by factor deprivation. Susceptibility to the induction of cell death by antigenic or activating stimulation is a common aspect of most T cells and is consistent with observations that clonal deletion can occur throughout T cell ontogeny. Most importantly, the alternative cellular responses of cell death and cell proliferation in nontransformed T cells appear to be triggered solely as a function of quantitative differences in the doses of identical stimuli. This can be viewed as a dose-dependent switch that determines cell fate. Developmental regulation of this switch may explain the processes of positive and negative selection during T cell ontogeny and also provide a mechanistic rationale for a strategy of selective anti-tumor therapy.