Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial

BACKGROUND

Anxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life.

OBJECTIVES

The Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities.

METHODS

The PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups.

DISCUSSION

PACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

A Challenging Case of Atypical Papillary Proliferation of Nipple with Loss of Myoepithelial Layer Cells; a Diagnostic Dilemma

Introduction/Objective

Papillary breast lesions are comprised of a broad spectrum of entities ranging from benign conditions like intraductal papilloma to invasive carcinoma. These lesions account for less than 3% percent of breast tumors and less than 2% of breast malignancies. The wide range and overlap in the clinical, imaging, and histologic characteristics of these lesions can often make them difficult to classify. Here we present a case of a challenging neoplastic nipple papillary lesion with a differential diagnosis ranging from nipple adenoma with atypia to papillary carcinoma.

Methods/Case Report

48-year-old female with history of left nipple mass for 6 months, presented to the emergency department with mild bleeding from the left nipple for two hours. Breast ultrasound showed a group of fine pleomorphic calcifications within a mass arising from the left nipple, highly concerning for Paget's disease. Histopathology revealed papillary proliferation of well-formed round structures within a variably fibrous/hemorrhagic stroma. The nodules exhibited papillary fronds with epithelial hyperplasia of monotonous low-grade cells, and scattered mitoses, forming relatively rigid/luminal structures with polarization. No desmoplasia or conventional infiltrative pattern was seen. Immunohistochemical staining showed strong expression for estrogen receptor (ER). Cytokeratin 5/6, p63 and calponin did not highlight the myoepithelial layer in the papillary elements or around the round structures. A diagnosis of atypical papillary proliferation was rendered to warrant an excision. Subsequently, the patient underwent total mastectomy, which revealed conventional invasive ductal carcinoma with lymphovascular space invasion.

Results (if a Case Study enter NA)

NA

Conclusion

Atypical papillary lesions of the nipple are difficult to classify in a limited biopsy material. The loss of myoepithelial cell layer makes interpretation even more challenging. Extreme caution should be taken in assigning neoplastic nature to the lesions in biopsy which eventually guide the surgeon in making decision to preserve the nipple or not.

Maternal Human Papillomavirus and Preterm Premature Rupture of Membranes: A Retrospective Cohort Study

Introduction: To determine whether maternal human papillomavirus (HPV) infection is associated with preterm premature rupture of membranes (PPROM). Materials and Methods: We conducted a retrospective cohort study of singleton deliveries at our institution from 2010 to 2015. Women, ages 16-49, with HPV genotyping or cervical cytology results 3 years before delivery were included. Chi-squared and logistic regression analyses were used. Results: In our cohort of 2153 women, 38.5% were HPV positive. PPROM was observed in 2.88% of women. HPV infection (p = 0.02), history of PPROM (p < 0.001), history of cervical conization or loop electrical excision procedure (LEEP) (p < 0.05), parity (p = 0.001), maternal body mass index at delivery (p < 0.001), drug use or smoking (p < 0.001), and ethnicity (p = 0.01) were associated with PPROM. HPV infection (odds ratio [OR] = 2.07, 95% confidence interval [CI]: 1.03-4.14) remained associated with PPROM when adjusting for history of PPROM, cervical conization, drug use or smoking, parity, ethnicity, and insurance. PPROM was associated with preterm delivery (OR = 105.50, 95% CI: 29.49-377.46) when adjusting for HPV infection, pregnancy-related hypertension, diabetes, placenta previa and abruption, cervical conization, smoking or drug use, ethnicity, and history of PPROM. HPV infection was associated with preterm delivery (p = 0.04) in univariate analysis, but not after adjusting for PPROM (p = 0.13). HPV infection had a univariate association with newborn septicemia (p = 0.02), respiratory distress syndrome (RDS) (p = 0.01), neonatal intensive care unit (NICU) admission (p = 0.001), and low birthweight (p = 0.03). Conclusions: HPV infection was associated with an increased risk of PPROM in this cohort. However, maternal HPV infection does not increase the risk of preterm delivery beyond those caused by PPROM. The observed association between maternal HPV infection and neonatal morbidity is likely due to the relationship between PPROM and preterm delivery.

Evaluation of Fetal First and Second Cervical Vertebrae: Normal or Abnormal?

OBJECTIVES

To use 3-dimensional sonographic volumes to evaluate the variable appearance of the normal fetal cervical spine and craniocervical junction, which if unrecognized may lead to misdiagnosis of malalignment at the first and second cervical vertebrae (C1 and C2).

METHODS

Three-dimensional sonographic volumes of the fetal cervical spine were obtained from 24 fetuses at gestational ages between 12 weeks 6 days and 35 weeks 1 day. The volumes were reviewed on 4-dimensional software, and the vertebral level was determined by labeling the first rib-bearing vertebra as the first thoracic vertebra. The ossification centers of the cervical spine and occipital condyles were then labeled accordingly and evaluated for alignment and structure by rotating the volumes in oblique planes. The appearance on multiplanar images was assessed for possible perceived anomalies, including malalignment, particularly at the C1 and C2 levels. Evidence of head rotation was correlated with the presence of possible malalignment at C1-C2. Head rotation was identified in the axial plane by measuring the angle of the anteroposterior axis of C1 to the anteroposterior axis of C2.

RESULTS

Of the 24 fetuses, 16 had adequate quality to assess the entire cervical spine and craniocervical junction. All 16 cases showed an osseous component of C1 that did not align directly with C2 on some of the multiplanar images when the volumes were rotated, which could lead to suspected diagnosis of spinal malalignment or a segmental abnormality, as occurred in 2 clinical cases in our practice. All 16 cases showed at least some degree of head rotation, ranging from 2° to 36°, which may possibly explain the apparent malalignment. The lateral offset from C1 to C2 ranged from 0.0 to 3.3 mm.

CONCLUSIONS

The normal C1 and C2 ossification centers may appear to be malaligned due to normal offsetting (lateral displacement) of C1 on C2. An understanding of the normal development of the cervical spine is important in assessing spinal anatomy.

The effect of oral contraceptives on bone mass and stress fractures in female runners

PURPOSE

To determine the effect of oral contraceptives (OC) on bone mass and stress fracture incidence in young female distance runners.

METHODS

One hundred fifty competitive female runners ages 18-26 yr were randomly assigned to OC (30 microg of ethinyl estradiol and 0.3 mg of norgestrel) or control (no intervention) for 2 yr. Bone mineral density (BMD) and content (BMC) were measured yearly by dual x-ray absorptiometry. Stress fractures were confirmed by x-ray, magnetic resonance imaging, or bone scan.

RESULTS

Randomization to OC was unrelated to changes in BMD or BMC in oligo/amenorrheic (N=50) or eumenorrheic runners (N=100). However, treatment-received analyses (which considered actual OC use) showed that oligo/amenorrheic runners who used OC gained about 1% per year in spine BMD (P<0.005) and whole-body BMC (P<0.005), amounts similar to those for runners who regained periods spontaneously and significantly greater than those for runners who remained oligo/amenorrheic (P<0.05). Dietary calcium intake and weight gain independently predicted bone mass gains in oligo/amenorrheic runners. Randomization to OC was not significantly related to stress fracture incidence, but the direction of the effect was protective in both menstrual groups (hazard ratio [95% CI]: 0.57 [0.18, 1.83]), and the effect became stronger in treatment-received analyses. The trial's statistical power was reduced by higher-than-anticipated noncompliance.

CONCLUSION

OC may reduce the risk for stress fractures in female runners, but our data are inconclusive. Oligo/amenorrheic athletes with low bone mass should be advised to increase dietary calcium and take steps to resume normal menses, including weight gain; they may benefit from OC, but the evidence is inconclusive.

Cost-effectiveness of combination peginterferon alpha-2a and ribavirin compared with interferon alpha-2b and ribavirin in patients with chronic hepatitis C

BACKGROUND

Sustained virological response (SVR) is the primary objective in the treatment of chronic hepatitis C (CHC). Results from a recent clinical trial of patients with previously untreated CHC demonstrate that the combination of peginterferon alpha-2a and ribavirin produces a greater SVR than interferon alpha-2b and ribavirin combination therapy. However, the cost-effectiveness of peginterferon alpha-2a plus ribavirin in the U.S. setting has not been investigated.

METHODS

A Markov model was developed to investigate cost-effectiveness in patients with CHC using genotype to guide treatment duration. SVR and disease progression parameters were derived from the clinical trials and epidemiologic studies. The impact of treatment on life expectancy and costs were projected for a lifetime. Patients who had an SVR were assumed to remain virus-free for the rest of their lives. In genotype 1 patients, the SVRs were 46% for peginterferon alpha-2a plus ribavirin and 36% for interferon alpha-2b plus ribavirin. In genotype 2/3 patients, the SVRs were 76% for peginterferon alpha-2a plus ribavirin and 61% for interferon alpha-2b plus ribavirin. Quality of life and costs were based on estimates from the literature. All costs were based on published U.S. medical care costs and were adjusted to 2003 U.S. dollars. Costs and benefits beyond the first year were discounted at 3%.

RESULTS

In genotype 1, peginterferon alpha-2a plus ribavirin increases quality-adjusted life expectancy (QALY) by 0.70 yr compared to interferon alpha-2b plus ribavirin, producing a cost-effectiveness ratio of $2,600 per QALY gained. In genotype 2/3 patients, peginterferon alpha-2a plus ribavirin increases QALY by 1.05 yr in comparison to interferon alpha-2b plus ribavirin. Peginterferon alpha-2a combination therapy in patients with HCV genotype 2 or 3 is dominant (more effective and cost saving) compared to interferon alpha-2b plus ribavirin. Results weighted by genotype prevalence (75% genotype 1; 25% genotype 2 or 3) also show that peginterferon alpha-2a plus ribavirin is dominant. Peginterferon alpha-2a and ribavirin remained cost-effective (below $16,500 per QALY gained) under sensitivity analyses on key clinical and cost parameters.

CONCLUSION

Peginterferon alpha-2a in combination with ribavirin with duration of therapy based on genotype, is cost-effective compared with conventional interferon alpha-2b in combination with ribavirin when given to treatment-naïve adults with CHC.

Establishing an in-house journal

Articles in journals such as Nursing Standard offer nurses a valuable means to keep their knowledge updated, but how many people do you know who have written an article? The majority of research undertaken by nurses remains unpublished (Humphris 1999), so much potentially useful experience, knowledge, ideas and research are lost. This article describes how the School of Health, Biological and Environmental Sciences (HeBES) at Middlesex University established an in-house journal to encourage nurses to develop their skills of writing for publication.

Polychlorinated dibenzo-p-dioxins (PCDDs) and furans (PCDFs) in urban air and deposition in the United Kingdom

Polychlorinated dibenzo-p-dioxins and furans (PCDD/Fs) have been monitored in air and deposition at four UK urban sites (London, Cardiff, Manchester and Stevenage) since the beginning of 1991; data from the first 2 years are presented here. Median Σ2,3,7,8-substituted PCDD/F concentrations in air were 3.2, 4.0, 3.5 and 2.6 pg/m(3) respectively for London, Cardiff, Manchester and Stevenage. Median Σ2,3,7,8-substituted PCDD/F deposition fluxes were 1.5 ng/m(2)/day in London, 1.4 ng/m(2)/day in Cardiff and Manchester and 0.79 ng/m(2)/day in Stevenage. Seasonal variations in the PCDD/F concentrations were observed at all sites for both air and deposition, with concentrations/fluxes generally elevated during the winter.

Comparative evaluation of detection assays for Chlamydia trachomatis

The performances of a commercial nucleic acid hybridization test (Gen-Probe Pace 2 Chlamydia trachomatis) and two commercial enzyme immunoassays (EIAs) (Abbott Chlamydiazyme and Pharmacia Chlamydia EIA) were evaluated against cell culture for the detection of C. trachomatis infection, with cervical swabs obtained from 1,037 women visiting a public sexual health center. The positivity rate by cell culture was 4.7%. Sensitivity and specificity for each test were as follows: Gen-Probe, 95.8 and 98.3%; Chlamydiazyme, 80.4 and 99.3%; Pharmacia EIA, 80.8 and 99.1%. Analysis of discrepant results with probe confirmation assay (Gen-Probe) and direct immunofluorescence (Syva Microtrak) revealed 12 cases of C. trachomatis infection for which culture was negative, resulting in the definition of a true-positive case as opposed to a culture positive. The positivity rate by true-positive definition was 5.9%, and sensitivity and specificity for each test were as follows: Gen-Probe, 96.7 and 99.6%; Chlamydiazyme, 77.5 and 100%; Pharmacia EIA, 77.0 and 100%; cell culture, 80.0 and 100%. We conclude that the Gen-Probe Pace 2 C. trachomatis test is a sensitive and specific alternative to cell culture for the detection of C. trachomatis.