The complete genome sequence of the gram-positive bacterium Bacillus subtilis

Bacillus subtilis is the best-characterized member of the Gram-positive bacteria. Its genome of 4,214,810 base pairs comprises 4,100 protein-coding genes. Of these protein-coding genes, 53% are represented once, while a quarter of the genome corresponds to several gene families that have been greatly expanded by gene duplication, the largest family containing 77 putative ATP-binding transport proteins. In addition, a large proportion of the genetic capacity is devoted to the utilization of a variety of carbon sources, including many plant-derived molecules. The identification of five signal peptidase genes, as well as several genes for components of the secretion apparatus, is important given the capacity of Bacillus strains to secrete large amounts of industrially important enzymes. Many of the genes are involved in the synthesis of secondary metabolites, including antibiotics, that are more typically associated with Streptomyces species. The genome contains at least ten prophages or remnants of prophages, indicating that bacteriophage infection has played an important evolutionary role in horizontal gene transfer, in particular in the propagation of bacterial pathogenesis.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No. 18

OBJECTIVES

To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy vs enucleation for treatment of choroidal melanoma.

METHODS

Patients were evaluated for eligibility at 43 participating clinical centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to enucleation or 125I brachytherapy. Patients were examined at specified intervals after enrollment for data collection purposes. Findings presented herein are based on data received by September 30, 2000. Data for each patient were analyzed with the treatment group to which the patient was assigned randomly at the time of enrollment.

RESULTS

During the 11(1/2)-year accrual period, 1317 patients enrolled; 660 were assigned randomly to enucleation and 657 to 125I brachytherapy. Only 2 patients in the enucleation arm were found to have been misdiagnosed when histopathology was reviewed centrally. All but 17 patients (1.3%) received the assigned treatment. Adherence to the brachytherapy protocol was excellent, with 91% of patients treated per protocol. Based on time since enrollment, 1072 patients (81%) had been followed for mortality for 5 years and 416 (32%) for 10 years. A total of 364 patients had died: 188 (28%) of 660 patients in the enucleation arm and 176 (27%) of 657 patients in the brachytherapy arm. The unadjusted estimated 5-year survival rates were 81% and 82%, respectively; there was no clinically or statistically significant difference in survival rates overall (P =.48, log-rank test). The adjusted estimated risk ratio for 125I brachytherapy vs enucleation was 0.99 (95% confidence interval [CI], 0.80-1.22). Five-year rates of death with histopathologically confirmed melanoma metastasis were 11% and 9% following enucleation and brachytherapy, respectively; after adjustment, the estimated risk ratio was 0.91 (95% CI, 0.66-1.24).

CONCLUSIONS

Mortality rates following 125I brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment of patients with choroidal melanoma who enrolled in this COMS trial. The power of the study was sufficient to indicate that neither treatment is likely to increase or decrease mortality rates by as much as 25% relative to the other.

Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy

A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of manualized treatment, either cognitive-behavioral psychotherapy (CB) or psychodynamic-interpersonal psychotherapy (PI). Each of 5 clinician-investigators treated clients in all 4 treatment conditions. On most measures, CB and PI were equally effective, irrespective of the severity of depression or the duration of treatment. However, there was evidence of some advantage to CB on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CB's effects were more rapid than those of PI, nor did the effects of each treatment method vary according to the severity of depression. There was no overall advantage to 16-session treatment over 8-session treatment. However, those presenting with relatively severe depression improved substantially more after 16 than after 8 sessions.

In vivo expression of alternatively spliced forms of integrin-associated protein (CD47)

Integrin-associated protein (IAP) is a 50 kDa plasma membrane protein physically and functionally associated with beta 3 integrins in a variety of cells. IAP has an extracellular immunoglobulin domain, five transmembrane domains and a short intracytoplasmic tail. IAP is recognized by anti-CD47 antibodies and is expressed on cells, such as erythrocytes and lymphocytes, which do not express beta 3 integrins. To learn more about potential functions of IAP we examined its expression in vivo. Using the polymerase chain reaction, we detected 4 alternatively splice forms of IAP which differ from each other only at their intracytoplasmic carboxy termini. These alternatively spliced forms are generated by inclusion or exclusion of three short exons within 5 kb in the genome and are highly conserved between mouse and man. There is tissue specificity of expression of the alternatively spliced forms of IAP mRNA, with bone marrow-derived cells expressing predominantly one form and neural tissue another. Using polyclonal antibodies which recognize the alternatively spliced bone marrow (form 2) and neural (form 4) forms of IAP, we found that in accord with the mRNA, form 2 protein was expressed in all tissues primarily on bone marrow-derived cells and endothelia, while form 4 was highly expressed in the brain and peripheral nervous system. The evolutionary conservation of IAP isoforms and their tissue-specific expression suggest an important role for these intracytoplasmic domains in IAP function.

Purpura and dermal thinning associated with high dose inhaled corticosteroids

OBJECTIVE

To assess the effect of high dose inhaled corticosteroids on skin.

DESIGN

Cross sectional study of patients receiving treatment for chest diseases.

SETTING

Outpatient chest clinic in a teaching hospital.

PATIENTS

68 Patients divided into four groups of similar age--namely, 15 receiving long term oral prednisolone, 21 receiving high dose inhaled corticosteroids, 15 receiving low dose inhaled corticosteroids, and 17 controls.

MAIN OUTCOME MEASURES

Skin thickness at three sites measured by A scan ultrasound and clinical assessment of purpura.

RESULTS

Compared with controls patients in both the oral prednisolone treated group and the high dose inhaled corticosteroid treated group had significantly thinner skin at all three sites (group median thicknesses: prednisolone treated group 28-33% less than controls; high dose inhaled corticosteroid treated group 15-19% less than controls). Differences in skin thicknesses between the low dose inhaled corticosteroid treated group and the controls were trivial. The prevalence of purpura was significantly greater in patients receiving oral prednisolone (12/15 patients) and high dose inhaled corticosteroids (10/21) than in controls (2/17).

CONCLUSION

Skin thinning and purpura represent further evidence of systemic effects of high dose inhaled corticosteroids.

A randomized trial of two treatments for mild traumatic brain injury: 1 year follow-up

The purpose of this study was to provide 1 year follow-up data to a previous paper that compared single-session (SS) treatment to treatment-as-needed (TAN) outcomes for mild traumatic brain injury (MTBI) survivors at 3 months post-injury. Participants were 105 adults with MTBI who were recruited from consecutive admissions to two hospital emergency wards, and randomly assigned to either the SS or TAN modality. No group differences in outcome were evident at 12 months post-injury. As well, improvements seen in the groups after 3 months were maintained at 12 months. As improvements between 3 and 12 months were negligible, self-reported improvement after a treated MTBI typically occurred within the first 3 months. Brief educational intervention given soon after MTBI appears to be as helpful as more intensive treatment for most MTBI survivors for at least 12 months post-injury.

Analysis of preventable trauma deaths and inappropriate trauma care in a rural state

OBJECTIVE

The goal of this study was to determine the rate of preventable mortality and inappropriate care in cases of traumatic death occurring in a rural state.

DESIGN

This is a retrospective case review.

MATERIALS AND METHODS

Deaths attributed to mechanical trauma throughout the state and occurring between October 1, 1990 and September 30, 1991 were examined. All cases meeting inclusion criteria were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital as well as hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines.

MEASUREMENTS AND MAIN RESULTS

The overall preventable death rate was 13%. Among those patients treated at a hospital, the preventable death rate was 27%. The rate of inappropriate care was 33% overall and 60% in-hospital. The majority of inappropriate care occurred in the emergency department phase and was rendered by one or more members of the resuscitation team, including primary contact physicians and surgeons. Deficiencies were predominantly related to the management of the airway and chest injuries.

CONCLUSIONS

The rural preventable death rate from trauma is not dissimilar to that found in urban areas before the implementation of a trauma care system. Inappropriate care rendered in the emergency department related to airway and chest injury management occurs at a high rate. This seems to be the major contributor to preventable trauma deaths in rural locations. Education of emergency department primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in the rural setting.

Dose-effect relations in time-limited psychotherapy for depression

Criteria for reliable and clinically significant improvement were applied to standard and individually tailored outcome measures data from 212 depressed clients who had been randomly assigned to receive either 8 or 16 sessions of time-limiting psychotherapy. The data were used to address 2 questions: (a) Is the dose-effect curve for psychological symptoms negatively accelerated? and (b) is there a differential rate of response for acute, chronic, and characterological/interpersonal components of depression? The results supported the differential rate of response of different components of depression and suggested qualifications to the acute, chronic, and characterological/interpersonal components and evidence that both supported and qualified previous suggestions that the dose-effect curve is negatively accelerated.

Associations of sleep with everyday mood, minor symptoms and social interaction experience

Although there are strong popular beliefs about the value of a good night's sleep, there is very little documented evidence of day-to-day relations between sleep and well-being. In this study, covariations between sleep and both prior and subsequent daily states of well-being were studied in a healthy, employed sample. Thirty volunteers used pocket computers to complete a daily sleep diary and self-rating scales of mood, minor symptoms and social interaction experience. These were recorded every 2 hours for 14 days except during sleep periods. A pooled regression analysis showed small but significant relationships between many of the sleep and well-being measures. Sleep appeared to be more strongly related to subsequent well-being than prior well-being. An earlier onset of sleep was associated with better mood and social interaction experience the following day and was a better predictor than sleep duration. This result was interpreted to be consistent with the phase angle model of chronobiologic mood disorders. In general, the results suggest that the sleep disturbances found in affective disorders may not be pathological but instead represent the extremes of normal relationships between sleep and well-being.

Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema

We compared four treatment protocols in 57 patients with presumed pre-hospital pulmonary edema. Group A patients were treated with nitroglycerin and furosemide, group B patients with morphine sulfate and furosemide, group C with all three agents, and group D with nitroglycerin and morphine, but without furosemide. Twenty-three percent of our patients were ultimately found not to have pulmonary edema, with pneumonia and/or exacerbations of chronic lung disease the most frequent alternate diagnoses. Group A patients had significantly greater improvement, both subjectively and objectively, than group B patients, a substantial number of whom failed to improve, or even worsened. There was no evident synergistic effect of any of the drugs, and some indication that furosemide might have caused clinically important problems with fluid and electrolyte management in some of the patients. Our data suggest that nitroglycerin is beneficial in the management of presumed pre-hospital pulmonary edema, while morphine and furosemide may not add anything to its efficacy, and may be potentially deleterious in some of these patients.

Debt, social disadvantage and maternal depression

Depression is common among women with young children, and is strongly associated with financial adversity. Debt is a common feature of such adversity, yet its relationship with depression has not been examined before. We have used longitudinal data, collected over six months, on 271 families with young children, to examine this relationship. Multiple regression was used to identify independent predictors of the total Edinburgh Post-natal Depression Scale score from a range of socioeconomic, demographic, social support and child health related variables. Worry about debt was the strongest independent socioeconomic predictor of the depression score at both initial and follow-up occasions. To account for the possibility of reverse causation, i.e. depression causing worry about debt, alternative regression models are reported which show that owing money by itself predicts depression and earlier debt worries predicts depression six months later. We were unable to show that earlier debt worries independently predicted subsequent depression scores after the initial depression score had been taken into account in the analysis. Although debt has not been shown to be an independent prospective predictor of depression, our results suggest it has a central place in the association between socioeconomic hardship and maternal depression. Evidence from qualitative studies on poverty and from studies on the causes of depression support this hypothesis. The implications for policy are that strategies to enable families to control debt should be an explicit part of wider antipoverty measures which are designed to reduce depression and psychological distress among mothers of young children.

Women's interest in genetic testing for breast cancer susceptibility may be based on unrealistic expectations

We report on results of an interview study assessing women's attitudes toward and hypothetical interest in genetic susceptibility testing for breast cancer. Data are from 246 interviews with women of varying ethnicity (African American, European American, Native American, and Ashkenazi Jewish), family history of breast cancer (negative, positive, and borderline), and educational level. Semistructured interviews included questions on general health beliefs; attitudes, experiences, and concerns about breast cancer; and hypothetical interest in genetic testing. Influence of specific test characteristics was assessed with 14 Likert scales varying negative and positive predictive value, timing of disease, possible medical interventions following a positive result. Results reported include both statistical and qualitative analysis. We found that women had a high level of interest in testing which, in general, did not vary by ethnicity, level of education, or family history. Interest in testing appeared to be shaped by an exaggerated sense of vulnerability to breast cancer, limited knowledge about genetic susceptibility testing, and generally positive views about information provided through medical screening. However, study participants were most interested in a test that didn't exist (high positive predictive value followed by effective, noninvasive, preventive therapy) and least interested in the test that does exist (less than certain positive predictive value, low negative predictive value, and limited, invasive, and objectionable therapeutic options). Our data suggest that without a careful counseling process, women could easily be motivated toward interest in a test which will not lead to the disease prevention they are seeking.

Effects of treatment duration and severity of depression on the maintenance of gains after cognitive-behavioral and psychodynamic-interpersonal psychotherapy

One hundred four clients completed a mailed follow-up 1 year after completing 8 of 16 sessions of treatment, either cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. Although mean scores on outcome measures at 1 year suggested that gains were, in general, well maintained, only 29% of clients were asymptomatic on all 3 occasions of testing (end of treatment, 3 months and 1 year later) without recourse to further treatment. However, only 11% of those asymptomatic at end of treatment experienced relapse or recurrence of depression, albeit on the limited evidence of just two follow-up assessments. The results of comparisons among treatment conditions at 1 year differed substantially from those obtained earlier: Eight-session PI treatment now appeared less efficacious than the other 3 treatment conditions, and there was now no measurable benefit of 16-session over 8-session CB, irrespective of initial severity of depression. These findings confirm the importance of follow-up in evaluation of psychotherapies for depression.

Impact of Cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression

Twenty-seven of 114 depressed clients, stratified for severity of depression, obtained a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) diagnosis of Cluster C personality disorder--that is, avoidant, obsessive-compulsive or dependent personality disorder (PD clients)--whereas the remaining 87 did not (non-personality-disorder [NPD] clients). All clients completed either 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. On most measures, PD clients began with more severe symptomatology than NPD clients. Among those who received PI therapy, PD clients maintained this difference posttreatment and at 1-year follow-up. Among those who received CB therapy, posttreatment differences between PD and NPD groups were not significant. Treatment length did not influence outcome for PD clients. PD clients whose depression was also relatively severe showed significantly less improvement after treatment than either PD clients with less severe depression or NPD clients.

The Iowa Personality Disorder Screen: development and preliminary validation of a brief screening interview

The length and expense of comprehensive personality disorder interviews makes them unwieldy for routine use. A brief but sensitive screen could eliminate administration of longer instruments in many instances. We describe the development of the Iowa Personality Disorder Screen (IPDS)--a mini-structured interview which can be completed in less than 5 minutes. Retrospective analyses using 1,203 SIDP-R interviews suggested that the IPDS items should provide good sensitivity and specificity. We present results from a prospective validation study, using a mixed group of 52 nonpsychotic inpatients and outpatients who were diagnosed using the SIDP-IV. Blind administration of the IPDS yielded excellent sensitivity (92%) and good specificity (79%), using a subset of five screening items. Addition of two more items leads to an estimated sensitivity of 79% and specificity of 86%. The IPDS shows promise as a quick personality disorder screen for use in research settings or standard clinical interviews.

Social domain dysfunction and disorganization in borderline personality disorder

BACKGROUND

Social dysfunction in personality disorder is commonly ascribed to abnormal temperamental traits but may also reflect deficits in social processing. In this study, we examined whether borderline and avoidant personality disorders (BPD, APD) may be differentiated by deficits in different social domains and whether disorganization of social domain functioning uniquely characterizes BPD.

METHOD

Patients were recruited from psychiatric clinics in Pittsburgh, USA, to provide a sample with BPD, APD and a no-personality disorder (no-PD) comparison group. Standardized assessments of Axis I and Axis II disorders and social domain dysfunction were conducted, including a new scale of 'domain disorganization' (DD).

RESULTS

Pervasive social dysfunction was associated with a 16-fold increase in the odds of an Axis II disorder. Both APD and BPD were associated with elevated social dysfunction. Romantic relationship dysfunction was associated specifically with BPD symptoms and diagnosis. DD was associated specifically with a categorical BPD diagnosis and with a dimensional BPD symptom count.

CONCLUSIONS

A focus on the inherently interpersonal properties of personality disorders suggests specific mechanisms (within and across interpersonal domains) that may help to account for the origins and maintenance of some disorders. In particular, BPD reflects disturbances in romantic relationships, consistent with a role for attachment processes, and in the organization of functioning across social domains.

Limited inferior macular translocation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To review a series of patients with age-related macular degeneration undergoing limited macular translocation for the treatment of subfoveal choroidal neovascularization, to determine short-term visual acuity outcomes, to measure amounts of attainable retinal movement, and to identify prognostic factors.

METHODS

A retrospective review was conducted on a consecutive series of patients undergoing inferior limited macular translocation with scleral imbrication for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. The main outcome measures investigated were distance of macular translocation, visual acuity at 3 and 6 months after surgery, change in visual acuity from baseline, and the development of intraoperative and postoperative complications. Univariate and multivariate analyses of a number of potential prognostic factors were undertaken.

RESULTS

Macular translocation was achieved in all 102 eyes (101 patients) included in this study. The range of movement varied from 200 to 2,800 microm with a median movement of 1, 200 microm. Nearly 33% of the study group achieved a visual acuity better than 20/100 at 3 months, and 49% achieved this vision at 6 months. At 3 and 6 months, 37% and 48% of the study group, respectively, experienced 2 or more lines of improvement on visual acuity testing, and by 6 months 16% experienced greater than 6 lines of visual improvement. Good baseline vision, achieving the desired amount of macular translocation, a greater amount of macular translocation, and recurrent choroidal neovascularization at baseline were associated with better visual acuities at 3 and 6 months. Poor preoperative vision and the development of complications were associated with worse vision at 3 and 6 months.

CONCLUSIONS

Limited macular translocation is a technically feasible procedure that can lead to significant visual improvement and good visual acuity in some patients presenting with subfoveal choroidal neovascularization associated with age-related macular degeneration. A randomized prospective clinical trial of this surgical technique is warranted.

The MicroRNA pathway plays a regulatory role in stem cell division

One of the key characteristics of stem cells is their capacity for self-renewal for long periods of time. In this respect, stem cells are similar to cancer cells, which also have the ability to escape cell cycle stop signals. Therefore, a critical question in stem cell and cancer biology is how cell division is regulated in these cell types. In this review, we summarize recent progress and describe future challenges to understanding the role the microRNA pathway plays in regulating mechanisms controlling stem cell division.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, II: characteristics of patients enrolled and not enrolled. COMS Report No. 17

OBJECTIVES

To describe characteristics of patients evaluated for the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy for choroidal melanoma by enrollment status, and to compare characteristics of patients enrolled with those of patients with tumors of eligible size who did not enroll in order to assess the extent to which findings from the clinical trial can be generalized to future patients.

METHODS

For all patients diagnosed with choroidal melanoma and evaluated for the clinical trial at COMS centers from November 1986 through July 31, 1998, selected data were transmitted to the COMS Coordinating Center, Baltimore, Md, where they were integrated and analyzed. Data included ophthalmic and medical history, examination findings, and visual acuity measurements recorded prior to enrollment; standardized A- and B-scan echographic examination findings; and wide-angle fundus photographs and fluorescein angiograms.

RESULTS

Of 8712 patients with choroidal melanoma, 5046 had tumors of eligible size; of these, 2882 (57%) were eligible for enrollment, and 1317 (46% of eligible patients, 26% of patients with tumors of eligible size) enrolled. Most differences between eligible and ineligible patients corresponded to eligibility and exclusion criteria. However, ineligible patients were older and had thicker tumors than eligible patients. Eligible patients who enrolled were slightly older and had larger tumors than those who did not enroll. Nearly half (48%) of enrolled patients had choroidal melanoma with the apex located temporal to the fovea, compared with 40% of eligible patients not enrolled and 29% of ineligible patients.

CONCLUSIONS

This trial was designed to yield internally valid treatment comparisons through random assignment to treatment at time of enrollment. Information from this and other studies document that enrolled patients were similar to other patients with choroidal melanoma who were treated with 125I brachytherapy. These findings support the external validity of the trial and applicability of treatment findings to all patients who meet the criteria used to judge eligibility for the trial.

Multiple mechanisms of reflex bronchospasm in guinea pigs

The mechanisms of histamine- and bradykinin-induced reflex bronchospasm were determined in anesthetized guinea pigs. With intravenous administration, both autacoids evoked dose-dependent increases in tracheal cholinergic tone. Vagotomy or atropine prevented these tracheal reflexes. When delivered as an aerosol, bradykinin readily increased tracheal cholinergic tone, whereas histamine aerosols were much less effective at inducing tracheal reflexes. Also, unlike histamine, bradykinin could evoke profound increases in cholinergic tone without directly or indirectly (e.g., prostanoid dependent) inducing measurable airway smooth muscle contraction resulting in bronchospasm. Neither autacoid required de novo synthesis of prostanoids or nitric oxide to induce reflex tracheal contractions. Combined cyclooxygenase inhibition and tachykinin-receptor antagonism did, however, abolish all effects of bradykinin in the airways, whereas responses to histamine were unaffected by these pretreatments. The data indicate that histamine and bradykinin initiate reflex bronchospasm by differential activation of vagal afferent nerve subtypes. We speculate that selective activation of either airway C fibers or airway rapid adapting receptors can initiate reflex bronchospasm.

Stability of the mandible following advancement: a comparison of three postsurgical fixation techniques

This study examines short-term stability of the mandible following mandibular advancement surgery by means of three standard techniques of postsurgical fixation. Twenty-two adult female rhesus monkeys (Macaca mulatta) underwent sagittal ramus advancement osteotomy of approximately 4 to 6 mm. Six animals had dental maxillomandibular fixation alone. Six animals had dental plus skeletal maxillomandibular fixation with circummandibular wires connected to pyriform aperture wires. Ten animals had rigid internal fixation with bicortical bone screws between the proximal and distal segments without maxillomandibular fixation. Radiographic cephalograms with the aid of tantalum bone markers and dental amalgams were analyzed during the first 6 postoperative weeks to evaluate skeletal and dental stability. Rigid internal fixation and the use of dental plus skeletal maxillomandibular fixation were both equally effective in the prevention of postsurgical relapse. However, in the animals in which only dental maxillomandibular fixation was used, statistically significant changes (relapse) occurred when compared with either of the other groups.

Do medical conditions affect cognition in older adults?

Analyses of a nationally representative sample who completed a list recall task (weighted n = 6,446) and 2 mental status tasks (weighted n = 6,646) were conducted to determine whether specific medical conditions such as high blood pressure and diabetes as well as general health ratings predict cognitive performance in adults aged 70 to 103. Presence of stroke and poorer health ratings predicted poorer performance on the 3 tasks. Presence of diabetes predicted poorer performance on recall and 1 mental status task. Age interacted with medical conditions including high blood pressure and diabetes in predicting mental status, with condition-related deficits confined to the younger end of the age continuum. Global health ratings interacted with age, with poorer ratings associated with worse mental status in the younger participants. Findings suggest that stroke and diabetes are associated with cognitive deficits. Some deficits are more pronounced in younger old adults with high blood pressure and poorer health ratings.

Thiopurine withdrawal during sustained clinical remission in inflammatory bowel disease: relapse and recapture rates, with predictive factors in 237 patients

BACKGROUND

Thiopurines (azathioprine and mercaptopurine) remain integral to most medical strategies for maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). Indefinite use of these drugs is tempered by long-term risks. While clinical relapse is noted frequently following drug withdrawal, there are few published data on predictive factors.

AIM

To investigate the success of planned thiopurine withdrawal in patients in sustained clinical remission to identify rates and predictors of relapse.

METHODS

This was a multicentre retrospective cohort study from 11 centres across the UK. Patients included had a definitive diagnosis of IBD, continuous thiopurine use ≥3 years and withdrawal when in sustained clinical remission. All patients had a minimum of 12 months follow-up post drug withdrawal. Primary and secondary end points were relapse at 12 and 24 months respectively.

RESULTS

237 patients were included in the study (129 CD; 108 UC). Median duration of thiopurine use prior to withdrawal was 6.0 years (interquartile range 4.4-8.4). At follow-up, moderate/severe relapse was observed in 23% CD and 12% UC patients at 12 months, 39% CD and 26% UC at 24 months. Relapse rate at 12 months was significantly higher in CD than UC (P = 0.035). Elevated CRP at withdrawal was associated with higher relapse rates at 12 months for CD (P = 0.005), while an elevated white cell count was predictive at 12 months for UC (P = 0.007).

CONCLUSION

Thiopurine withdrawal in the context of sustained remission is associated with a 1-year moderate-to-severe relapse rate of 23% in Crohn's disease and 12% in ulcerative colitis.