POS0689 A 6-MONTH OPEN-LABEL EXTENSION STUDY OF THE SAFETY AND EFFICACY OF INTRAVENOUS BELIMUMAB IN PATIENTS WITH LUPUS NEPHRITIS

Background:

BLISS-LN (GSK Study BEL114054; NCT01639339), the largest lupus nephritis (LN) study to date, showed that intravenous (IV) belimumab (BEL) + standard therapy (ST) improved outcomes compared with ST alone in patients (pts) with active LN.1

Objectives:

To assess additional safety and efficacy data of BEL + ST in pts with LN in a 6-month open-label (OL) phase beyond 2 years of double-blind (DB) treatment in BLISS-LN.

Methods:

In this OL phase, eligible completers of the DB phase received monthly BEL 10 mg/kg IV + ST for 6 months. Endpoints: safety; Primary Efficacy Renal Response (PERR; uPCR ≤0.7; eGFR no worse than 20% below OL baseline eGFR or ≥60 ml/min/1.73 m2; no prohibited medications) and Complete Renal Response (CRR; uPCR <0.5; eGFR no worse than 10% below OL baseline eGFR or ≥90 ml/min/1.73 m2; no prohibited medications) at OL Week 28; proportion of pts with SLEDAI score <4; corticosteroid use; biomarkers. Analyses were based on observed data and summarised relative to the OL baseline (last value measured prior to the first dose of OL treatment).

Results:

We enrolled 257 pts (57.4% of pts in BEL114054) and treated 255 pts. All treated pts were included in the safety population (123 pts switched from placebo [PBO] to BEL; 132 pts remained on BEL). Efficacy was assessed in the safety population, excluding 1 pt due to non-compliance (mITT population; PBO to BEL: 122 pts; BEL to BEL: 132 pts). 96.5% of pts completed the OL phase; 3.5% withdrew, mainly due to adverse events (AE; 2.0%).

Overall, 168/255 (65.9%) pts had ≥1 AE (76/123 [61.8%] PBO to BEL pts; 92/132 [69.7%] BEL to BEL pts); 15/255 (5.9%) pts had ≥1 serious AE (5/123 [4.1%] PBO to BEL pts; 10/132 [7.6%] BEL to BEL pts); 1 (0.8%) pt died in the PBO to BEL group.

Proportions of PERR and CRR responders increased from OL baseline to OL Week 28 (Table 1. below)

Proportions of pts who attained SLEDAI scores <4 increased from OL baseline to OL Week 28 in the BEL to BEL group and decreased in the PBO to BEL group. Among pts receiving average daily prednisone-equivalent doses of ≤5 mg or ≤7.5 mg dose was maintained from OL baseline to OL Week 28 (Table 1. below)

In pts with autoantibodies at OL baseline, anti-dsDNA and anti-C1q levels decreased from OL baseline to OL Week 28 in both groups. Among pts with low C3/C4 levels at OL baseline, C3/C4 levels increased from OL baseline to OL Week 28 in both groups (Table 1. below)

Conclusion:

In this OL phase of BLISS-LN, proportions of PERR and CRR responders increased in both the BEL-naïve and BEL-experienced groups; and no new safety signals were observed. Improvements in biomarker levels were observed, especially in pts who switched from PBO to BEL.

Funding:

GSK.

References:

[1]Furie R, et al. N Engl J Med. 2020;383(12):1117-28.

Table 1.

Responses at OL baseline and OL Week 28 (mITT population, N=254)

OL baseline*OL Week 28PBO to BEL(n=122)BEL to BEL(n=132)PBO to BEL(n=122)BEL to BEL(n=132)n122132118122PERR, n (%)73 (59.8)†93 (70.5)†79 (66.9)91 (74.6)CRR, n (%)44 (36.1)†63 (47.7)†57 (48.3)76 (62.3)SLEDAI score <4n122132120122Responders, n (%)44 (36.1)†64 (48.5)†40 (33.3)64 (52.5)Prednisone-equivalent dosen122132121128≤5 mg, n (%)59 (48.4)78 (59.1)60 (49.6)75 (58.6)≤7.5 mg, n (%)62 (50.8)85 (64.4)66 (54.5)83 (64.8)Anti-dsDNA (IU/ml)‡n85648161Median (IQR) levels107.0 (49.0, 212.0)65.5 (42.5, 126.5)--Median (IQR) % change from baseline---30.2 (-46.3, -6.8)-10.7 (-27.2, 9.1)Anti-C1q (U/ml)§n64605854Median (IQR) levels71.7 (36.6, 167.5)47.1 (33.0, 75.7)--Median (IQR) % change from baseline---23.0 (-41.5, 0.5)-16.5 (-33.0, 6.1)C3 (mg/dl)‖n45374435Median (IQR) levels78.0 (72.0, 83.0)80.0 (71.0, 84.0)--Median (IQR) % change from baseline--6.2 (-4.2, 14.6)4.7 (-4.8, 16.9)C4 (mg/dl)‖n18121811Median (IQR) levels7.5 (6.0, 8.0)7.0 (7.0, 8.5)--Median (IQR) % change from baseline--23.6 (11.1, 37.5)11.1 (0.0, 57.1)

*DB Week 104 visit and the OL baseline visit were the same visit; †Post hoc analyses; ‡Among anti-dsDNA positive pts at OL baseline (≥30 IU/ml); §Among anti-C1q positive pts at OL baseline (≥22.2 U/ml); ‖Among pts with low C3 (<90 mg/dl)/C4 (<10 mg/dl) levels at OL baseline.

Acknowledgements:

Medical writing assistance was provided by Olga Conn, PhD, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Richard Furie Consultant of: GSK, Grant/research support from: GSK, Brad H Rovin Consultant of: GSK, Frederic Houssiau Consultant of: GSK, Grant/research support from: UCB, Gabriel Contreras Consultant of: Genentech, Merck, Grant/research support from: Genentech, Merck, Paula Curtis Shareholder of: GSK, Employee of: GSK, Anuradha Madan Shareholder of: GSK, Employee of: GSK, Angela Jones-Leone Shareholder of: GSK, Employee of: GSK, Mohamed Okily Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

SAT0193 A PHASE 3, OPEN-LABEL, CONTINUATION STUDY EVALUATING LONG-TERM SAFETY AND EFFICACY OF BELIMUMAB IN PATIENTS FROM JAPAN AND KOREA WITH SYSTEMIC LUPUS ERYTHEMATOSUS, FOR UP TO 7 YEARS

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disorder more prevalent in the Asian population vs Caucasians. Belimumab (BEL), a monoclonal antibody targeting B-lymphocyte stimulator, is approved in patients (pts) ≥5 years with active, autoantibody-positive SLE.

Objectives:

Evaluate long-term safety and efficacy of intravenous (IV) BEL + standard SLE therapy (SST) in pts with SLE in Japan/Korea.

Methods:

In this Phase 3, multicentre, open-label (OL) study (BEL114333;NCT01597622), eligible (≥18 years of age) completers of the double-blind phase of GSK study BEL113750 in Japan and South Korea or the subcutaneous OL phase of GSK Study BEL112341 in Japan, received monthly BEL 10 mg/kg IV plus SST. Primary endpoints: safety assessments. Key secondary endpoints: SRI4 response rate at each scheduled visit (observed data), defined as a ≥4-point reduction from baseline in SELENA-SLEDAI score, no worsening in PGA (<0.3-point increase from baseline) and no new BILAG 1A/2B organ domain scores; time to first severe SFI flare over time. Endpoints were analysed relative to first BEL dose (parent or current study). No follow-up data were collected after study withdrawal.

Results:

Overall, 142 pts were enrolled (Japan n=72; Korea n=70), 104 (73.2%) completed the study, 1 (0.7%) died and 37 (26.1%) withdrew.

Overall, 139 (97.9%) pts had ≥1 adverse event (AE) (Table). Most frequent AEs included: nasopharyngitis (60.6%); headache (28.2%); cough, herpes zoster and viral upper respiratory tract infection (18.3% each). Serious AEs (SAEs) occurred in 48 (33.8%) pts. Most common SAEs were infections and infestations, reported in 24 (16.9%) pts (Table). During this study, the annual incidence of AEs, including SAEs and AESI, remained stable or declined, with no trends of clinical concerns regarding the incidence of Grade 3 or 4 values for laboratory parameters. There was 1 transient positive immunogenicity result of no clinical concern.

Table.

The proportion of SRI4 responders was 47.8% at Year 1 (Week 24) and tended to increase numerically up to 84.6% at Year 7 (Week 48). The proportion of pts with a ≥4-point decrease from baseline in SELENA-SLEDAI score numerically increased from 51.5% at Year 1 (Week 24) to 84.6% at Year 7 (Week 48). Proportion of pts with no PGA worsening was 91.3-100% and the proportion with no new BILAG 1A/2B organ domain scores was 93.3-100% up to Year 7 (Week 48). A total of 21 (14.8%) pts had 24 severe SFI flares.

Conclusion:

BEL was well tolerated as add-on therapy to SST for ≤7 years in pts with SLE from Japan/Korea. Safety results were consistent with the known BEL safety profile.

Study funding: GSK.

Disclosure of Interests:

Yoshiya Tanaka Grant/research support from: Received research grants from Asahi-Kasei, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Ono, Speakers bureau: Received speaking fees and/or honoraria from Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Sang-Cheol Bae: None declared, Damon Bass Shareholder of: GSK, Employee of: GSK, Myron Chu Shareholder of: GSK, Employee of: GSK, Paula Curtis Shareholder of: GSK, Employee of: GSK, Kathleen DeRose Shareholder of: GSK, Employee of: GSK, Beulah Ji Shareholder of: GSK, Employee of: GSK, Regina Kurrasch Shareholder of: GSK, Employee of: GSK, Jenny Lowe Shareholder of: GSK, Employee of: GSK, Paige Meizlik Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

Red oak seedlings as indicators of deer browse pressure: Gauging the outcome of different white-tailed deer management approaches

After decades of high deer populations, North American forests have lost much of their previous biodiversity. Any landscape-level recovery requires substantial reductions in deer herds, but modern societies and wildlife management agencies appear unable to devise appropriate solutions to this chronic ecological and human health crisis. We evaluated the effectiveness of fertility control and hunting in reducing deer impacts at Cornell University. We estimated spring deer populations and planted Quercus rubra seedlings to assess deer browse pressure, rodent attack, and other factors compromising seedling performance. Oak seedlings protected in cages grew well, but deer annually browsed ≥60% of unprotected seedlings. Despite female sterilization rates of >90%, the deer population remained stable. Neither sterilization nor recreational hunting reduced deer browse rates and neither appears able to achieve reductions in deer populations or their impacts. We eliminated deer sterilization and recreational hunting in a core management area in favor of allowing volunteer archers to shoot deer over bait, including at night. This resulted in a substantial reduction in the deer population and a linear decline in browse rates as a function of spring deer abundance. Public trust stewardship of North American landscapes will require a fundamental overhaul in deer management to provide for a brighter future, and oak seedlings may be a promising metric to assess success. These changes will require intense public debate and may require new approaches such as regulated commercial hunting, natural dispersal, or intentional release of important deer predators (e.g., wolves and mountain lions). Such drastic changes in deer management will be highly controversial, and at present, likely difficult to implement in North America. However, the future of our forest ecosystems and their associated biodiversity will depend on evidence to guide change in landscape management and stewardship.

Migrant children within Europe: a systematic review of children's perspectives on their health experiences

OBJECTIVES

To review the extant literature to explore what is known about children's own perspectives on their health experiences, focussing on children and young people who have migrated into, and within, Europe.

STUDY DESIGN

A systematic review with narrative synthesis.

METHODS

A review of English language articles was performed in June 2016 using the following databases: MEDLINE, CINAHL, Cochrane and Web of Science. Included articles had to report data generated directly with children, up to 18 years of age, who had migrated across national borders into, or within, Europe during their own lifetimes. Extraction from articles was undertaken by all authors, and quality assessment of included reviews was performed using the Mixed Methods Appraisal Tool.

RESULTS

The articles in the final data set included research based on four broad areas: alcohol, smoking and substance use; diet, eating disorders and overweight; emotional, psychological and mental health issues; and children's views and experiences of health and health services. Most studies were cross-sectional analytic or incidence or prevalence studies.

CONCLUSION

There is a general lack of clarity in the literature regarding the reporting of children's own migration status. Children's voices are often subsumed within those of their adult parents or carers. There is a need to promote more child-focussed research which gives voice to migrant children to better understand the complex and multidimensional factors that contribute to their (ill)health.

The absence of wild game and fish species from the USDA National Nutrient Database for standard reference: addressing information gaps in wild caught foods

We highlighted gaps in nutritional data for wild game meat and wild caught fish that have a regulated harvesting season in New York State, and examined the possible role that wild game and fish play in current trends towards consumption of local, healthy meat sources. This project is part of larger study that examines family food decision-making, and explores possibilities for leveraging the locavore movement in support of consumption of wild game and fish.

Jordanian perspectives on advanced nursing practice: an ethnography

AIM

This study aimed to explore how different groups of participants perceived the concept of advanced nursing practice in Jordan.

BACKGROUND

In Jordan, there are postgraduate educational programmes offering a Master's degree in clinical nursing for registered nurses. Intended to prepare nurses to practise at an advanced level as potential clinical nurse specialists in critical care, community health nursing and maternal newborn nursing, little was known prior to this study about the development of advanced nursing roles for nurses in Jordan and the drivers behind their establishment.

METHODS

Using ethnographic design, narratives from semi-structured interviews and non-participant observation with participants from five Jordanian hospitals and two public universities were collected and analysed according to thematic analysis.

FINDINGS AND DISCUSSION

Four themes emerged from the data: core competencies, specific practice area vs. generic practice, beneficiaries of advanced nursing practice and drivers for educational change. The findings are similar to those found in other countries and highlight the need for a consensual understanding between nurse educationalists, professional bodies and employers about what advanced nursing practice in Jordan should be, so that a common framework can be identified.

CONCLUSION

Paralleling the lack of consistency in understanding of advanced nursing practice in the broader literature, participants described a number of different elements of advanced practice that are relevant to the specific context of contemporary Jordanian nursing.

Rosiglitazone RECORD study: glucose control outcomes at 18 months

AIMS

To compare glucose control over 18 months between rosiglitazone oral combination therapy and combination metformin and sulphonylurea in people with Type 2 diabetes.

METHODS

RECORD, a multicentre, parallel-group study of cardiovascular outcomes, enrolled people with an HbA(1c) of 7.1-9.0% on maximum doses of metformin or sulphonylurea. If on metformin they were randomized to add-on rosiglitazone or sulphonylurea (open label) and if on sulphonylurea to rosiglitazone or metformin. HbA(1c) was managed to < or = 7.0% by dose titration. A prospectively defined analysis of glycaemic control on the first 1122 participants is reported here, with a primary outcome assessed against a non-inferiority margin for HbA(1c) of 0.4%.

RESULTS

At 18 months, HbA(1c) reduction on background metformin was similar with rosiglitazone and sulphonylurea [difference 0.07 (95% CI -0.09, 0.23)%], as was the change when rosiglitazone or metformin was added to sulphonylurea [0.06 (-0.09, 0.20)%]. At 6 months, the effect on HbA(1c) was greater with add-on sulphonylurea, but was similar whether sulphonylurea was added to rosiglitazone or metformin. Differences in fasting plasma glucose were not statistically significant at 18 months [rosiglitazone vs. sulphonylurea -0.36 (-0.74, 0.02) mmol/l, rosiglitazone vs. metformin -0.34 (-0.73, 0.05) mmol/l]. Increased homeostasis model assessment insulin sensitivity and reduced C-reactive protein were greater with rosiglitazone than metformin or sulphonylurea (all P < or = 0.001). Body weight was significantly increased with rosiglitazone compared with sulphonylurea [difference 1.2 (0.4, 2.0) kg, P = 0.003] and metformin [difference 4.3 (3.6, 5.1) kg, P < 0.001].

CONCLUSIONS

In people with diabetes, rosiglitazone in combination with metformin or sulphonylurea was demonstrated to be non-inferior to the standard combination of metformin + sulphonylurea in lowering HbA(1c) over 18 months, and produces greater improvements in C-reactive protein and basal insulin sensitivity but is also associated with greater weight gain.

Limited impact of tamoxifen following dose-intensive L-FAC multimodality therapy of breast cancer

10741

Background: Front-line dose-intensive L-FAC has demonstrated a favorable 5-year relapse free survival pattern (ASCO 2004 #739). Tamoxifen was given for 5 years to ER+ patients after L-FAC completion. We evaluated the impact of adding tamoxifen to L-FAC. By design, this pilot study excluded low-risk patients not candidates for chemotherapy. Methods: 109 breast cancer patients were enrolled (4 excluded due to treatment violations) from 6/1989 to 1/2003: 20 Stage I (S), 52 S-II, 22 S-III, for a total of 94 patients. 11 S-IV patients were excluded from survival analysis. Adverse tumor presentations included: ER- 49, PgR- 60, P53+ 24, non-diploid 39, histological grade III 37, CerbB2+ 33. L-FAC included 72 hour (h) iv infusion 400mg/m2/day (d) 5-fluorouracil (F) modulated by iv bolus 200mg/m2/d X3 leucovorin (L), concomitantly with 24h iv d1 600–1000mg/m2 cyclophosphamide (C), 48h iv d2 + d3 60mg/m2 doxorubicin (A). S-I and S-II were given 6 courses and 8 for S-III. Increasing A + C dose level and/or shortening treatment intervals < 3 weeks with growth factors provided intensification. 40 patients received tamoxifen. Results: At a median follow-up of 74 months (range 9–214), 73 (78%) are alive (1 with relapse). Relapse free survival was: S-I 95%, S-II 81%, S-III 78%. At average course intervals of 18 days, dose intensity A/C mg/m2/wk was 24.2 / 335.4 with evidence of WHO grade III/IV stomatitis in 43%, neutropenia 59%, cumulative thrombocytopenia 50%, hand-foot syndrome 32% of patients. Aside from delayed relapse associated with tamoxifen, relapse-free survival >82 months was similar with and without tamoxifen. No relapse was observed after >53 months in ER- tumors despite showing higher frequency of adverse tumor risk factors. Conclusion: The impact of adding tamoxifen appears quite limited in a patient population with adverse tumor presentation treated with dose-intensive L-FAC.

No significant financial relationships to disclose.

An elemental diet for bowel obstruction in pregnancy: a case study

Bowel obstruction is a recognised complication in pregnancy, especially in those with adhesions from previous surgery. We report a case where the use of an elemental diet was successful in avoiding surgery in a pregnant patient with recurrent conservatively managed small bowel obstruction.

A double-blind, randomised, parallel group, multinational, multicentre study comparing a single dose of ondansetron 24 mg p.o. with placebo and metoclopramide 10 mg t.d.s. p.o. in the treatment of opioid-induced nausea and emesis in cancer patients

Nausea and emesis are common side effects of opioid drugs administered for pain relief in cancer patients. The aim of this study was to compare the anti-emetic efficacy and safety of ondansetron, placebo and metoclopramide in the treatment of opioid-induced nausea and emesis (OIE) in cancer patients. This was a multinational, multicentre, double-blind, parallel group study in which cancer patients who were receiving a full opioid agonist for cancer pain were randomised to receive one of oral ondansetron 24 mg once daily, metoclopramide 10 mg three times daily, or placebo. Study medication was started only if the patient experienced nausea and/or emesis following opioid administration. Efficacy and safety assessments were made over a study period of 24 h from the time of the first dose of anti-emetics/placebo. The study was terminated prematurely because of the difficulties in recruiting patients satisfying the stringent entry criteria. Ninety-two patients were included in the intent-to-treat population: 30 patients received placebo, 29 patients ondansetron and 33 patients metoclopramide. There was no statistically significant difference between the groups in the proportion achieving complete control of emesis (33% of patients on placebo, 48% on ondansetron and 52% on metoclopramide) or complete control of nausea (23% of patients on placebo, 17% on ondansetron and 36% on metoclopramide). Rescue anti-emetics were required in 8 of 33 patients on metoclopramide, 4 of 29 on ondansetron, and 3 of 30 on placebo. The incidence of adverse events was very low and similar in all treatment groups. Neither ondansetron 24 mg once daily nor metoclopromide 10 mg t.d.s. given orally was significantly more effective than placebo in the control of OIE in cancer patients.

Training primary care physicians to give limited manual therapy for low back pain: patient outcomes

STUDY DESIGN

Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice.

OBJECTIVES

To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain.

SUMMARY OF BACKGROUND DATA

Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training.

METHODS

Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care.

RESULTS

No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02).

CONCLUSION

Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Training in back care to improve outcome and patient satisfaction. Teaching old docs new tricks

BACKGROUND

We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques.

METHODS

From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson's chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time.

RESULTS

Characteristics of the 13 physicians' patients in the cohort group and the manual therapy trial showed some differences in income, workers' compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities.

CONCLUSIONS

A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.

Treatment of low back pain associated with ;;back mice'': a case series

Back mice are subcutaneous fibroadenomatous nodules that cause low back symptoms. Previous case reports do not provide systematic descriptions of the clinical presentation or long-term follow-up of this problem. This retrospective case series reports syndrome characteristics and treatment outcomes for injection therapy for "back mice." We completed telephone interviews, chart reviews, and written questionnaires for a convenience sample of 35 participants. Participants reported the following symptoms: pain radiating to the lower leg (37%), leg numbness or paresthesias (14%), and a median of 8 weeks of pain before treatment (range 3 weeks to 10 years). Thirty-one participants (89%) received lasting relief from injection of local anesthetic and corticosteroid. Injection therapy relieved both local and radiating symptoms but often did not eliminate the nodules. Thirty participants (86%) were "satisfied" or "very satisfied" with the treatment. There were no adverse events reported. Back mice can cause radiating pain that can be confused with other low back or leg syndromes. Injection treatment seems to be effective, long lasting, and well tolerated. Physicians should search for these nodules in patients with unexplained low back pain and try injection therapy before initiating expensive therapy.

Fibro-fatty nodules and low back pain. The back mouse masquerade

BACKGROUND

Few useful interventions exist for patients with persistent low back pain. We suggest that a fibro-fatty nodule ("back mouse") may be an identifiable and treatable cause of this and other types of pain.

METHODS

We describe 2 patients with painful nodules in the lower back and lateral iliac crest areas. In both cases, the signs and symptoms were unusual and presented at locations distant from the nodule. One patient complained of severe acute lower abdominal pain, and the other had been treated for chronic recurrent trochanteric bursitis for several years.

RESULTS

In both patients, symptoms appeared to be relieved by multiple injection of the nodule.

DISCUSSION

There is agreement that back mice exist. Referred pain from the nodules might explain the distant symptoms and signs in these cases. Multiple puncture may be an effective treatment because it lessens the tension of a fibro-fatty nodule.

CONCLUSIONS

Randomized trials on this subject are needed. In the meantime, physicians should keep back mice in mind when presented with atypical and unaccountable symptoms in the lower abdomen, inguinal region, or legs.

Program directors' perspectives on federally funded fellowship training in primary care research

PURPOSE

To describe the organization, models of training, and institutional impact of National Research Service Award fellowship programs in primary care research.

METHOD

Survey of 25 directors of currently-funded and former training sites.

RESULTS

Twenty-four program directors (96%) completed the survey. Programs allocated 39% of fellows' time to course work leading to an advanced degree or other didactic instruction, and 40% of time to the conduct of research. Collaborations with other training programs within the institution occurred at 83% of sites. Programs commonly (54%) or exclusively (42%) relied on a research model of "early research independence" in which the fellow defined an area of research interest, rather than an "apprenticeship" model in which the fellow worked in a senior investigator's research area. These programs enriched the local academic environment, but required extensive financial subsidies. The high costs of training often had adverse impacts on recruitment and other components of the training process.

CONCLUSION

Research training programs in primary care often substitute acquisition of advanced degrees for early immersion in research. The "early independence" model of research differs from fellowships in the medical specialties, and requires further study to assess its effectiveness. The need to subsidize training costs poses substantial problems for the institutions that host these fellowship programs.

Ondansetron is more effective than metoclopramide for the treatment of opioid-induced emesis in post-surgical adult patients. Ondansetron OIE Post-Surgical Study Group

Nausea and vomiting are common side effects of opioids administered for pain control. This double-blind, randomized, parallel-group study evaluated the anti-emetic efficacy and tolerability of single intravenous (i.v.) doses of ondansetron 8 mg, ondansetron 16 mg and metoclopramide 10 mg in the treatment of opioid-induced emesis. Adult patients undergoing low emetogenic surgical procedures, using a standardized anaesthesia regimen were assessed for 24 h following administration of study anti-emetic to treat established post-surgical opioid-induced emesis. A total of 4511 patients were enrolled of whom 1366 experienced opioid-induced emesis and received randomized study medication. Ondansetron 8 mg and 16 mg were significantly better than metoclopramide 10 mg (P < 0.05) for both complete control of emesis, complete control of nausea and other efficacy measures. There were no significant differences between the two ondansetron groups. All three treatments were well tolerated. In conclusion, this large, multicentre study demonstrates that ondansetron is more effective than metoclopramide in the treatment of opioid-induced emesis following administration of post-surgical opioids to control pain.

Characteristics and quality of Papanicolaou smears obtained by primary care clinicians using a single commercial laboratory

BACKGROUND

Few data are available on factors associated with the quality of Papanicolaou smears performed in primary care.

OBJECTIVE

To identify the patterns and proficiency of cervical cancer screening among different primary care specialties.

MATERIALS AND METHODS

Clinical and cytologic data from 21,833 Papanicolaou smears, submitted to a single large commercial laboratory by 176 clinicians during a 7-month period, were correlated with individual clinician and specialty characteristics according to indexes of specimen quality.

RESULTS

Obstetrician-gynecologists, nurse practitioners, and physician assistants provided screening to a younger population of women compared with family physicians, internists, and general practitioners. Factors positively associated with a greater probability of a "satisfactory" smear or the presence of endocervical cells (as a marker of adequate sampling) were increasing patient age, use of the cytobrush, and the specialty of the obstetrician-gynecologist. Satisfactory smears were not associated with any increased identification of cytologic abnormalities compared with "limited" smears. In contrast, smears with endocervical cells showed a higher proportion of abnormalities compared with specimens without such cells.

CONCLUSIONS

Differences in the performance of obtaining Papanicolaou smears exist between primary care specialties, but need further clarification. The use of the cytobrush and the presence of endocervical cells are criteria that reflect clinician proficiency more realistically than the laboratory criterion of satisfactory smear.

The effect of the quality of Papanicolaou smears on the detection of cytologic abnormalities

BACKGROUND

Controversy continues regarding the relation between the quality of Papanicolaou (Pap) smears, especially the presence of endocervical cells (ECC), with the finding of cytologic abnormalities.

METHODS

As part of a study regarding performance feedback on the quality of Pap smears, data from 56,475 Pap smears obtained by 176 participating clinicians over a 20-month period were analyzed to assess the relation between the presence of ECC, the categorization of global specimen adequacy as "satisfactory" or "satisfactory with limitations," and the prevalence of atypia and squamous intraepithelial lesions (SILs).

RESULTS

Atypia was less likely to be found in "satisfactory" Pap smears than in "satisfactory with limitations" quality Pap smears (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.5-0.6; P < 0.001), even though the latter could contain ECC. No association was found between satisfactory Pap smears and cytologic abnormalities. Compared with specimens with no ECC, an ECC count of > or = 50 on a slide was associated positively with the detection of atypia (OR, 2.1; 95% CI, 1.8-2.4; P < 0.001) or SILs (OR, 1.7; 95% CI, 1.3-2.2; P < 0.001). A similar relation existed between ECC counts of 25-50 (OR, 1.9; 95% CI, 1.1-2.2; P = 0.01) and the detection of SILs. No relation was found between specimens with < 25 ECC and the presence of atypia or abnormalities.

CONCLUSIONS

The global adequacy criterion of "satisfactory" assigned to a Pap smear does not indicate that there is a greater likelihood of detecting cytologic abnormalities compared with lower quality Pap smears. To the authors' knowledge, previous studies regarding the link between ECC in the Pap smear and cytologic abnormalities have not addressed the relevance of how many ECC are needed to maximize the identification of abnormalities. The data from the current study support the value of obtaining at least 25 ECC as a quality indicator of sampling.

Breast stimulation to augment labor: history, mystery, and culture

This paper describes the development of a researchable project, arising from the clinical observation of a physiologic phenomenon during labor. Augmentation of labor by breast stimulation has been used in a variety of cultures for centuries. The process of developing a clinical study of augmentation in the modern obstetric environment is discussed, with reference to cultural attitudes of patients and health care workers.

A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor

BACKGROUND

Breast stimulation to augment labor has been used for centuries in tribal societies and by midwives. In recent years it has been shown to be effective in ripening the cervix, inducing labor, and as an alternative to oxytocin for the contraction stress test. This study compared the effectiveness of breast stimulation with oxytocin infusion in augmenting labor.

METHODS

Women admitted to the labor ward were eligible for the study if they had inadequate labor with premature rupture of the membranes and met inclusion criteria. They were assigned to oxytocin augmentation or breast stimulation (manual or pump), and were switched to oxytocin in the event of method failure. Outcomes included time to delivery, intervention to delivery, proportion of spontaneous deliveries, and Apgar scores. One hundred participants were needed in each arm of the study to demonstrate a 2- to 3-hour difference in delivery time, with a power of 80 percent.

RESULTS

Analysis was performed on 79 women, of whom 49 were in the breast stimulation group and 30 in the oxytocin group. Sixty-five percent of the participants failed breast stimulation and were switched to oxytocin infusion. Although augmentation start to delivery was shorter for the oxytocin group (p < 0.001), no differences in total labor time occurred between the groups. Nulliparas receiving breast stimulation had more spontaneous (relative risk 1.7, p = 0.04), and fewer instrumental deliveries than those receiving oxytocin (relative risk 0.2, p = 0.02). No significant differences in adverse fetal outcomes occurred between the study groups.

CONCLUSIONS

The small number of participants and a variety of problems with the conduct of the study prevented the formulation of reliable conclusions from the results. However, the study provided important insights into the feasibility and problems of developing a high-quality randomized trial of augmentation by breast stimulation.

Comparison of an orally disintegrating ondansetron tablet with the conventional ondansetron tablet for cyclophosphamide-induced emesis in cancer patients: a multicenter, double-masked study. Ondansetron Orally Disintegrating Tablet Emesis Study Group

A total of 427 cancer patients receiving cyclophosphamide chemotherapy participated in this multicenter, double-masked, double-dummy, parallel-group, randomized study comparing the antiemetic efficacy and safety of an 8-mg conventional ondansetron tablet (OT, n = 212) taken twice daily with an 8-mg orally disintegrating ondansetron tablet (ODT, n = 215) taken twice daily for 3 days. In the primary efficacy analysis, complete or major control of emesis (0 to 2 emetic episodes) between days 1 and 3 was seen in 80% of OT and 78% of ODT patients. The 90% confidence interval for the differences between treatments was -8.6% to 4.4% (defined interval of equivalence, +/-15%), showing that the formulations were equivalent. In the secondary efficacy analysis, no significant differences were observed in the rates of complete control of emesis (no episodes of emesis) over 3 days (63% and 64% of the respective groups) and on day 1 (84% and 81%, respectively) and in the complete control of nausea over 3 days (37% and 43%, respectively) and on day 1 (59% and 61% of patients, respectively). The taste of ODT was acceptable to the majority of patients (89%) who received it. OT and ODT were both well tolerated. Thus 8 mg ODT twice daily represents a palatable, well-tolerated, and effective antiemetic treatment for the control of cyclophosphamide-induced emesis and nausea and provides equivalent treatment to OT 8 mg twice daily.

Practitioner self-confidence and patient outcomes in acute low back pain

OBJECTIVE

To compare outcomes for patients with acute low back pain who received care from practitioners with different self-confidence scores on a 4-item scale.

DESIGN

Cross-sectional survey of practitioners. Prospective cohort study of patient outcomes.

SETTING

Private practices and a group model health maintenance organization.

PARTICIPANTS

One hundred eighty-nine practitioners, including private practice traditionally trained medical physicians, chiropractors, and physicians in a group model health maintenance organization, who were randomly chosen from practices across the state of North Carolina. These practitioners enrolled 1633 patients with acute low back pain into a prospective cohort study.

METHODS

The practitioner survey contained 10 questionnaire items that measured aspects of practitioner confidence and attitudes in assessing and treating patients with low back pain. Patients were interviewed by telephone after the initial office visit and at 2, 4, 8, 12, and 24 weeks, or until complete recovery, whichever came first.

RESULTS

Of 189 study practitioners, 95% responded to the survey. A 4-item scale, shown by factor analysis to describe practitioners' self-confidence, demonstrated good internal consistency among physicians and chiropractors. Chiropractors had significantly stronger self-confidence scores than physicians. Among patients of primary care physicians and chiropractors, those who received care from practitioners with stronger self-confidence scores did not differ in the time to functional improvement, overall patient satisfaction, or their perception of the completeness of care.

CONCLUSION

The level of practitioner self-confidence, as measured by a 4-item scale, did not predict patient outcomes in the treatment of acute low back pain.

Does training location influence the clinical skills of medical students?

PURPOSE

To examine the benefits of the shift of medical education into ambulatory primary care settings by investigating whether medical students exposed to a common primary care problem (low back pain) in ambulatory care settings develop better clinical skills.

METHOD

In 1995, the authors categorized 420 students from all four North-Carolina medical schools into groups that had previously encountered patients with low back pain in ambulatory primary care settings, tertiary care settings, both, or neither. The clinical skills of the groups were determined using data collected during standardized-patient examination in which students took the history of, physically examined, and chose a diagnostic strategy for patients with acute, uncomplicated low back pain.

RESULTS

In general, there was no difference between the performances of the student groups associated with the settings of their previous encounters with low back pain. On average, the students failed to ask 35% of the history items and failed to perform 35% of the physical examination items. Many students chose inappropriate diagnostic strategies.

CONCLUSION

The lack of difference between the groups' clinical performances indicates a need to more rigorously define and evaluate outcomes of education in ambulatory care settings. The generally poor clinical performance of all groups suggests that the current curriculum inadequately teaches clinical skills needed to assess and manage common problems. Clearer expectations of competencies and assurances that preceptors in ambulatory care settings will help students meet those learning objectives might lead to better outcomes.

Heritable variation in stomatal responses to elevated CO2 in wild radish, Raphanus raphanistrum (Brassicaceae)

Rising atmospheric carbon dioxide may affect plant populations in the short term through effects on photosynthesis and carbon allocation, and over the long term as an agent of natural selection. To test for heritable effects of elevated CO2 on stomatal responses and plant fecundity in Raphanus raphanistrum, we grew plants from 12 paternal families in outdoor open-top chambers at ambient (35 Pa) or elevated (67 Pa) CO2. Contrary to results from a previous study of this species, total flower and fruit production were marginally lower under elevated CO2. Across families, stomatal index and guard cell length showed little response to CO2 enrichment, but these characters varied significantly among paternal families in both the direction and magnitude of their response to changing CO2. Although these family-by-CO2 interactions suggest that natural selection might affect stomatal characters when ambient CO2 levels increase, we found no significant correlation between either character and flower or fruit production. Therefore, our data suggest that while heritable variation for stomatal index and guard cell length exists in this population, selection due to increasing CO2 is not likely to act on these traits because they had no detectable effect on lifetime fecundity.