'This is silent murder' - are we medicalising human distress caused by the reality of life as an asylum seeker in the UK?

The number of displaced people, including asylum seekers and refugees, in the UK continues to rise. This article highlights findings from two participatory community listening exercises on the topic of health of displaced people.

Sex differences in visceral sensitivity and brain activity in a rat model of comorbid pain: a longitudinal study

ABSTRACT

Temporomandibular disorder (TMD) and irritable bowel syndrome (IBS) are 2 chronic overlapping pain conditions (COPCs) that present with significant comorbidity. Both conditions are more prevalent in women and are exacerbated by stress. While peripheral mechanisms might contribute to pain hypersensitivity for each individual condition, mechanisms underlying the comorbidity are poorly understood, complicating pain management when multiple conditions are involved. In this study, longitudinal behavioral and functional MRI-based brain changes have been identified in an animal model of TMD-like pain (masseter muscle inflammation followed by stress) that induces de novo IBS-like comorbid visceral pain hypersensitivity in rats. In particular, data indicate that increased activity in the insula and regions of the reward and limbic systems are associated with more pronounced and longer-lasting visceral pain behaviors in female rats, while the faster pain resolution in male rats may be due to increased activity in descending pain inhibitory pathways. These findings suggest the critical role of brain mechanisms in chronic pain conditions and that sex may be a risk factor of developing COPCs.

Avelumab first-line maintenance treatment for advanced urothelial carcinoma: review of evidence to guide clinical practice

The JAVELIN Bladder 100 phase III trial led to the incorporation of avelumab first-line (1L) maintenance treatment into international guidelines as a standard of care for patients with advanced urothelial carcinoma (UC) without progression after 1L platinum-based chemotherapy. JAVELIN Bladder 100 showed that avelumab 1L maintenance significantly prolonged overall survival (OS) and progression-free survival in this population compared with a 'watch-and-wait' approach. The aim of this manuscript is to review clinical studies of avelumab 1L maintenance in patients with advanced UC, including long-term efficacy and safety data from JAVELIN Bladder 100, subgroup analyses in clinically relevant subpopulations, and 'real-world' data obtained outside of clinical trials, providing a comprehensive resource to support patient management. Extended follow-up from JAVELIN Bladder 100 has shown that avelumab provides a long-term efficacy benefit, with a median OS of 23.8 months measured from start of maintenance treatment, and 29.7 months measured from start of 1L chemotherapy. Longer OS was observed across subgroups, including patients who received 1L cisplatin + gemcitabine, patients who received four or six cycles of 1L chemotherapy, and patients with complete response, partial response, or stable disease as best response to 1L induction chemotherapy. No new safety signals were seen in patients who received ≥1 year of avelumab treatment, and toxicity was similar in those who had received cisplatin or carboplatin with gemcitabine. Other clinical datasets, including noninterventional studies conducted in Europe, USA, and Asia, have confirmed the efficacy of avelumab 1L maintenance. Potential subsequent treatment options after avelumab maintenance include antibody-drug conjugates (enfortumab vedotin or sacituzumab govitecan), erdafitinib in biomarker-selected patients, platinum rechallenge in suitable patients, nonplatinum chemotherapy, and clinical trial participation; however, evidence to determine optimal treatment sequences is needed. Ongoing trials of avelumab-based combination regimens as maintenance treatment have the potential to evolve the treatment landscape for patients with advanced UC.

Lest we forget. Illuminating lived experience of the Covid-19 pandemic and lockdown

The COVID-19 pandemic and associated 'lockdowns' profoundly impacted people's lives in 2020-2021 and beyond. This study sought to understand unique person-centred insights into health and wellbeing during the restrictive measures in the United Kingdom and to enable us to remember and give testimony to these lived experiences. Using photo-methods, participants from a larger cohort study which tracked people's behaviours during the pandemic were invited to share photographs and short text to visually illustrate their ephemeral and unique COVID-19 experiences. In total 197 participants shared 398 photographs. Using a critical realist approach in our design and analysis, we sought to gain an alternative viewpoint on what 'lockdown' and the pandemic meant. Our major findings revealed starkly contrasting experiences illustrated in our two major themes. Firstly loss, including ambiguous losses and a sense of loss, loss of freedoms and death. Secondly, salutogenesis (what makes us well) whereby participants were able to draw on assets which helped to keep them well by maintaining social connection, 'making the best of it', reconnecting with nature and appreciating the outdoors, creativity for pleasure and faith. Our findings illuminate widely differing experiences and indicate the powerful effect of assets that were perceived by our participants to protect their wellbeing. Understanding differential vulnerability will be essential going forward to target resources appropriately to those who have the least control over their lives, those with the greatest vulnerabilities and least assets which in turn could support a self-perpetuating recovery.

We care but we're not carers: perceptions and experiences of social prescribing in a UK national community organisation

AIMS

(1) To explore how social prescribing referrals impact experiences of existing members of a voluntary and community-based organisation and (2) to describe the processes and relationships associated with joining community and voluntary organisations.

METHODS

Online survey and qualitative interviews with members of Men's Sheds, a global volunteer-led initiative to address loneliness and social isolation in men. 93 self-selecting Shed members (average age 67 years, 93% male) from across England and Scotland took part in the survey about demographics, joining the Shed, and free-text questions about experiences in the Shed. From the survey participants, 21 Shed members were purposively sampled and interviewed to explore the impact of social prescribing and referrals on the Sheds.

RESULTS

Participating in the Men's Shed was often associated with a significant change in personal circumstances, and Sheds provided a unique social support space, particularly valuable for men. Key factors around experiences of social prescribing and referral mechanisms were identified. We developed three themes: the experience of joining a Shed, success factors and risks of social prescribing, and 'we care but we're not carers'.

CONCLUSIONS

The results show that Men's Sheds are a caring organisation, but their members are not trained as professional carers, and men come to the Shed for their own personal reasons. They are concerned about the potential additional responsibilities associated with formal referrals. They encourage the development of relationships and local-level understanding of the essence of Sheds to enable social prescribing. As models of social prescribing grow nationally and internationally, collaboratively working with voluntary and community organisations to develop a mutually beneficial approach is essential for the effectiveness and sustainability of social prescribing in community health.

A qualitative exploration of a financial inclusion service in an English foodbank

AIMS

Foodbanks provide emergency food provision. This need can be triggered by a change in circumstance or a crisis. Failures in the social security safety net are the most significant driver for hunger in the UK. There is some evidence that an advisory service which runs alongside a foodbank is more effective in reducing emergency provision and the duration and severity of hunger. The 'Making a Difference' project at an English foodbank is a pilot scheme aiming to increase financial resilience in their service users. From summer 2022, they introduced new advice worker roles, in partnership with Shelter [Housing advice] and Citizen's Advice [General, debt and benefits advice], aiming to pre-empt the need for foodbank use, to triage the financial needs of service users and refer appropriately to reduce repeat visits to the foodbank.

METHODS

This qualitative study involved in-depth interviews with four staff and four volunteers to evaluate barriers, facilitators and potential friction points in referrals and partnership working.

FINDINGS

Our data were analysed thematically into four themes: Holistic needs assessment; Reaching seldom heard communities; Empowerment; The needs of staff and volunteers. Two case studies illustrate the complexity of people's needs.

CONCLUSION

A financial inclusion service operating within foodbanks giving housing, debt and benefits advice shows some promise in reaching people in crisis at the point of need. Based within the heart of a community, it appears to meet the complex needs of very vulnerable people who may have found mainstream support services inaccessible. This asset-based approach with the foodbank as a trusted provider enabled joined up, compassionate, holistic, and person-centred advice quickly cutting across multiple agencies, reaching underserved and socially excluded clients. We suggest that supportive services are needed for volunteers and staff who are vulnerable to vicarious trauma from listening and supporting people in crisis.

Differential Activation of Colonic Afferents and Dorsal Horn Neurons Underlie Stress-Induced and Comorbid Visceral Hypersensitivity in Female Rats

Chronic Overlapping Pain Conditions, including irritable bowel syndrome (IBS) and temporomandibular disorder (TMD), represent a group of idiopathic pain conditions that likely have peripheral and central mechanisms contributing to their pathology, but are poorly understood. These conditions are exacerbated by stress and have a female predominance. The presence of one condition predicts the presence or development of additional conditions, making this a significant pain management problem. The current study was designed to determine if the duration and magnitude of peripheral sensitization and spinal central sensitization differs between restraint stress-induced visceral hypersensitivity (SIH) and chronic comorbid pain hypersensitivity (CPH; stress during pre-existing orofacial pain). SIH in female rats, as determined by the visceromotor response, persisted at least four but resolved by seven weeks. In contrast, CPH persisted at least seven weeks. Surprisingly, colonic afferents in both SIH and CPH rats were sensitized at seven weeks. CPH rats also had referred pain through seven weeks, but locally anesthetizing the colon only attenuated the referred pain through four weeks, suggesting a transition to colonic afferent independent central sensitization. Different phenotypes of dorsal horn neurons were sensitized in the CPH rats seven weeks post stress compared to four weeks or SIH rats. The current study suggests differential processing of colonic afferent input to the lumbosacral spinal cord contributes to visceral hypersensitivity during comorbid chronic pain conditions. PERSPECTIVE: Chronic Overlapping Pain Conditions represent a unique challenge in pain management. The diverse nature of peripheral organs hinders a clear understanding of underlying mechanisms accounting for the comorbidity. This study highlights a mismatch between the condition-dependent behavior and peripheral and spinal mechanisms that contribute to visceral pain hypersensitivity.

Health status of fathead minnow (Pimephales promelas) populations in a municipal wastewater effluent-dominated stream in the Canadian prairies, Wascana Creek, Saskatchewan

Their unique hydrological and climatic conditions render surface water systems in the southern Canadian Prairies at an elevated risk from exposure to contaminants released from municipal wastewater effluents (MWWEs). The aim of this study was to characterize the potential health effects and their underlying molecular mechanisms in populations of fathead minnow (Pimephales promelas; FHM) in Wascana Creek, an effluent dominated stream in Southern Saskatchewan, Canada. Studies were conducted during the spawning season in 2014 and 2015 to assess responses in terms of overall health, reproductive functions, plasma sex steroid hormone levels, and expression of selected genes along the hypothalamus-pituitary-gonadal axis. FHM downstream of the effluent fallout had lower gonadosomatic indices and significantly greater hepatosomatic indices compared to upstream populations. In both male and female FHMs, significantly greater occurrence and severity of gonadal degradation and delayed maturation were observed in downstream fish compared to upstream fish. Downstream males also displayed lower scores of secondary sexual characteristics and a decreasing trend in plasma 11-ketotestosterone levels. Interestingly, no indications of exposure to estrogenic compounds, such as occurrence of testicular oocytes were observed, which was in accordance with the lack of presence of key biomarkers of estrogenic exposure, such as induction of vitellogenin. In general, expression of the majority of transcripts measured in FHMs downstream of the effluent fallout was significantly downregulated, which supports observations of the general deterioration of the health and reproductive status of these fish. Chemical analysis indicated that 10 pharmaceuticals and personal care products (PPCPs) were present at the downstream site, some at sufficiently great concentrations that may present a risk to aquatic organisms. With continuous exposure to a diverse number of stressors including high nutrient and ammonia levels, the presence of a variety of PPCPs and other contaminants, Wascana Creek should be considered as an ecosystem at risk.

Clinical thermography at extreme temperatures

Every day, emergency departments and acute medical units all over the world receive and assess thousands of patients. Most are stable, but a few require immediate stabilization. To identify these, all patients are routinely triaged and have vital signs measured. Our group has shown that thermographic images of the face can be an alternative method for identifying patients at increased risk of 30-day mortality. In our previous studies, the thermographic images were taken after the patients had been inside for at least 30 minutes. However, to identify patients at risk, the images have to be available as quickly as triage, i.e. at the door when the patient arrives. Therefore, we have performed a small study, with the aim of illustrating the effect of such heat-gradients on thermal images of the face.

Equivalence of Assurance® Gold Enzyme Immunoassay for Visual or Instrumental Detection of Motile and Nonmotile Salmonella in All Foods to AOAC Culture Method: Collaborative Study

Six foods representative of a wide variety of processed, dried powder processed, and raw food types were analyzed by the Assurance® Gold Salmonella Enzyme Immunoassay (EIA) and AOAC INTERNATIONAL culture method. Paired samples of each food type were simultaneously analyzed; one sample by the Assurance method and one by the AOAC culture method. The results for Assurance method were read visually and instrumentally with a microplate reader. A total of 24 laboratories representing federal government agencies and private industry, in the United States and Canada, participated in this collaborative study. Food types were inoculated with species of Salmonella with the exception of raw ground chicken, which was naturally contaminated. No statistical differences (p < 0.05) were observed between Assurance Gold Salmonella EIA with either visual or instrumental interpretation and the AOAC culture method for any inoculation level of any food type or naturally contaminated food. The Assurance visual and instrumental options of reading sample reactions produced the same results for 1277 of the 1296 sample and controls analyzed.

Abstract P6-18-08: Everolimus + exemestane for HR+ advanced breast cancer in routine clinical practice- Final results from the non-interventional trial, BRAWO

Background: In the pivotal BOLERO-2 trial, everolimus (EVE) + exemestane (EXE) more than doubled the median progression-free survival (PFS) vs EXE alone in hormone receptor positive (HR+), human epidermal growth factor-receptor 2-negative (HER2-) advanced breast cancer (ABC) recurring/progressing on/after prior non-steroidal aromatase inhibitors (NSAIs). BRAWO is a German non-interventional study conducted in patients (pts) with HR+, HER2–ABC receiving EVE + EXE, according to Summary of Product Characteristics (SmPC), in routine clinical practice. Here we report the final PFS and safety results.

Methods: This multicenter study documented 2100 pts between October 2012 and December 2017 across 341 sites in Germany. Postmenopausal women with HR+, HER2– ABC with recurrence or progression after a NSAI were included. Primary observation parameters included the evaluation of the effectiveness of EVE + EXE used in routine care for the entire pt group.

Results: In the final analysis, out of the 2100 documented pts, 2074 were included in the full analysis set. The median time since the primary diagnosis was 7.1 years and the median time from first sign of relapse (local recurrence or distant metastases) was 2.1 years. At baseline, 54.1% of pts presented with visceral metastases and 50.1% had an ECOG performance status of 0. Approximately, 63% of pts started with EVE 10 mg (median duration of exposure: 5.1 months; 95% CI, 4.6-5.4), while 34.1% started with EVE 5 mg (median duration of exposure: 4.6 months; 95% CI, 4.1-5.2).

The distribution of treatment lines was as follows: first line, 28.7% (n=595); second line, 31.9% (n=662); third line, 18.1% (n=376); fourth line, 10.7% (n=221) and, fifth line and later, 10.6% (n=220). Treatment was discontinued by 55.7% of pts (n=1170) due to progressive disease and 26% of pts (n=546) due to adverse events. The Kaplan-Meier estimate of the median PFS was 6.6 months (95% CI, 6.2-7.0). The best overall responses, based on clinical routine, were complete response, 0.8% (n=17), partial response, 7.4% (n=150), and stable disease, 41.3% (n=842). The general safety profile was consistent with the previously reported safety findings. The most common adverse events were stomatitis (any grade: 42.6%, grade 3: 3.8%, grade 4: <0.1%) and fatigue (any grade: 19.8%, grade 3: 1.5%).

Conclusions: Data from BRAWO support EVE + EXE as a suitable treatment option with a reasonable safety profile for HR+, HER2− ABC recurring or progressing on/after prior NSAIs.

Citation Format: Lüftner D, Schuetz F, Schneeweiss A, Grischke E-M, Bloch W, Decker T, Uleer C, Salat C, Förster F, Schmidt M, Mundhenke C, Tesch H, Jackisch C, Fischer T, Guderian G, Hanson S, Fasching P. Everolimus + exemestane for HR+ advanced breast cancer in routine clinical practice- Final results from the non-interventional trial, BRAWO [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-08.

Hypogammaglobulinaemia after rituximab treatment-incidence and outcomes

BACKGROUND

Rituximab, a chimeric monoclonal antibody against CD20, is increasingly used in the treatment of B-cell lymphomas and autoimmune conditions. Transient peripheral B-cell depletion is expected following rituximab therapy. Although initial clinical trials did not show significant hypogammaglobulinaemia, reports of this are now appearing in the literature.

METHODS

We performed a retrospective review of patients previously treated with rituximab that were referred to Clinical Immunology with symptomatic or severe hypogammaglobulinaemia. Patient clinical histories, immunological markers, length of rituximab treatment and need for intravenous immunoglobulin replacement therapy (IVIG) were evaluated. An audit of patients receiving rituximab for any condition in a 12-month period and frequency of hypogammaglobulinaemia was also carried out.

RESULTS

We identified 19 post-rituximab patients with persistent, symptomatic panhypogammaglobulinaemia. Mean IgG level was 3.42 ± 0.4 g/l (normal range 5.8-16.3 g/l). All patients had reduced or absent B-cells. Haemophilus Influenzae B, tetanus and Pneumococcal serotype-specific antibody levels were all reduced and patients failed to mount an immune response post-vaccination. Nearly all of them ultimately required IVIG. The mean interval from the last rituximab dose and need for IVIG was 36 months (range 7 months-7 years). Of note, 23.7% of 114 patients included in the audit had hypogammaglobulinaemia.

CONCLUSION

With the increasing use of rituximab, it is important for clinicians treating these patients to be aware of hypogammaglobulinaemia and serious infections occurring even years after completion of treatment and should be actively looked for during follow-up. Referral to clinical immunology services and, if indicated, initiation of IVIG should be considered.

Preventing obesity at weaning: parental views about the EMPOWER programme

BACKGROUND

Infant growth and lifestyle are now recognized as being critical determinants of later obesity. EMPOWER (Empowering Parents to Prevent Obesity at Weaning: Exploratory Research) was developed as an intervention for parents whose babies are at high risk. Delivered by specially trained health visitors, it is underpinned by the Family Partnership Model and uses a strengths-based, solution-focused way of working with families.

METHODS

Mothers of babies participating in the pilot of EMPOWER in Leeds were recruited to take part in a study to examine perceptions about the programme's acceptability and usefulness. Interviews were taped and transcribed, and thematic analysis undertaken.

RESULTS

Families talked positively about the approach of the EMPOWER health visitor with her emphasis on listening, partnership working and shared problem-solving. Parents particularly valued the use of a non-judgemental approach, which they felt had helped them to discuss openly, sensitive issues such as weight and diet. They identified a number of important benefits ranging from increased knowledge about the most appropriate types and amount of food to feed their toddler, to more far-reaching changes within the family as a whole, including modifications to their own diet and lifestyle. Programmes of this nature were perceived as more valuable than the standard help that is currently available.

CONCLUSION

The EMPOWER programme appears to be both acceptable and valued by targeted parents and a potentially effective means of supporting high-risk families to prevent their children from developing obesity. An exploratory randomized controlled trial is now underway to ascertain the feasibility of conducting a definitive phase 3 trial.

Preliminary progression free survival and SPARC tumor correlatives from a phase II neoadjuvant trial of gemcitabine, epirubicin, and nab paclitaxel

Abstract #5116

Background: Neoadjuvant combinations of gemcitabine (G), anthracyclines and taxanes have demonstrated significant activity with pCR rates of 20-25% albeit with significant myelosuppression. Secreted protein acidic rich in cysteine (SPARC) is an albumin binding protein that mediates intratumoral accumulation of nab-paclitaxel (nab-P) via a SPARC-albumin specific binding activity. This study was designed to evaluate a biweekly schedule of neoadjuvant nab paclitaxel (nab-P) with gemcitabine and epirubicin (E). SPARC tumor assessments were performed in consenting patients (pts) with subsequent pathologic and survival correlatives.
 Methods: Eligibility: Clinical T1c-T4d and/or N0-3, M0 breast cancer (T1N0M0 excluded), ECOG PS 0-2, normal LVEF. ER/PR/HER2 obtained for all pts. Treatment: 6 cycles neoadjuvant G 2000 mg/m2, E 50 mg/m2, and nab-P 175 mg/m2 q14 days followed by surgery. Post operative therapy: 4 cycles G 2000 mg/m2 and nab-P 220 mg/m2 q14 days. Myeloid growth factors were mandated with all cycles. 2 antibody reagents were used to probe for SPARC expressions. For this study, level 3 immunohistochemical (IHC) SPARC staining was considered positive. Results: 123 pts have enrolled with pathologic responses available for 106. 82 pts consented to SPARC testing. Median age 51 (29-72). Median tumor size 4.5 cm. Histology: 81% ductal, 10% lobular, 9% other. 42% ER and PR negative. 55% clinical T3/T4 and 66% lymph node positive at presentation. G3/4 toxicity present in >5% of pts: neutropenia 16% (febrile neutropenia 1 pt), thrombocytopenia 9% with arthralgias 11%, fatigue 10%, and infection 7%. 20 pts did not complete study treatment for the following reasons: disease progression 7, toxicity 3, pt/MD request 5, and other 5. pCR was noted in 23 pts (22%) with PRs in 76 pts (71%), and 6 SD. SPARC IHC staining was available for 76 tumors. SPARC level 3 IHC staining was noted in 65 tumors (86%); 65% were associated with a PR or pCR. Median PFS was 23 months and overall survival at 24 months is 77%. Pts who relapsed ≤16 months from diagnosis were more likely to be triple negative (p = 0.04), or ER negative (p = 0.001), or PR negative (p = 0.0006). Conclusions: Neoadjuvant dose dense GEA is active and better tolerated than other gemcitabine/anthracycline/taxane combinations. The pCR rate of 22% compares favorably with other comparable neoadjuvant regimens albeit with minimal toxicity. Pts with early relapse defined as ≤16 months from diagnosis were more likely to demonstrate a triple negative phenotype or demonstrate estrogen or progesterone receptor negativity. SPARC tumor correlatives with progression free and overall survival are on ongoing and will be presented.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5116.

Final results of a first line multicenter phase II metastatic breast cancer trial of vinflunine monotherapy and in combination with trastuzumab in HER2+ patients

Abstract #3148

Background: Vinflunine (VFL) is a novel microtubule inhibitor agent of the vinca alkaloid class that inhibits tubulin polymerization without stabilization, resulting in cell cycle arrest in mitosis and apoptosis. Weak tubulin binding at the vinca-binding site accounts for its reduced neurotoxicity. VFL has demonstrated activity in anthracycline and taxane pretreated patients (pts) and in combination with capecitabine. This trial evaluates the activity and safety of VFL monotherapy and in combination with trastuzumab (T) in HER2+ pts as 1st line therapy metastatic breast cancer (MBC).
 Methods: Eligibility: 0 prior regimens for MBC, > 6 mo from adjuvant therapy, RECIST criteria measurable disease, ECOG PS 0-2, adequate organ function, peripheral neuropathy < G2. Treatment: HER2 unspecified: VFL 320 mg/m2 IV q3 wks; FISH HER2+ pts: VFL 280 mg/m2 plus T 6 mg/kg q3 wks. Response evaluations q9 wks; treatment continued until disease progression or toxicity.
 Results: Due to termination of VFL licensing between BMS and Pierre Fabre Medicament, the study closed prematurely with only 31 evaluable pts of a planned 48 pts in each treatment arm of VFL monotherapy or VFL in combination with T. 10 pts received VFL and 21 pts were treated with VFL + T. Median age: 59 yrs (35-78). ECOG PS 0-18 pts, 1-11 pts, 2-2 pts. 48% were ER+. Prior adjuvant anthracyclines and taxanes noted in 17 and 19 pts respectively. 4 pts presented with de novo stage IV disease, all HER2 positive. 45% had 3 or more metastatic disease sites with bone (17 pts), liver (16 pts) and lung (15 pts) predominating. Median of # cycles: 4 (range 1-19). There were 10 PRs (32%), all in VFL + T, and 9 pts (29%) with PD (VFL-4 pts, VFL + T-5pts). SD was reported in 10 pts (32%). 2 pts (7%) were unevaluable, divided equally between the two arms. G3/4 neutropenia occurred in 11 pts (35%); none with fever. G3 nonhematologic toxicity consisted of pain, attributed to treatment in 5 pts (16%) (sites: abdomen-2, chest, back, and infusion site each in 1 pt), and GI toxicity characterized by N/V 3 pts (10%) as well as abdominal pain, diarrhea, constipation, occurring each in 2 pts (6%). There were no G4 events. 10 pts were hospitalized (GI -4 pts, pain 2 pts, pulmonary 2 pts, and other 2 pts). Median PFS was 3.5 months for VFL and 6.6 months for VFL + T. Median overall survival was 9 months for VFL and has not been reached for VFL + T.
 Conclusions: The combination of vinflunine and trastuzumab is active in the first line treatment of MBC, producing a 48% response rate. Adverse events were as expected, manageable and consisted primarily of neutropenia, pain and GI toxicity. This encouraging activity compares favorably with other trastuzumab combination regimens and merits further evaluation.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3148.

Intrathecal enzyme replacement therapy reduces lysosomal storage in the brain and meninges of the canine model of MPS I

Enzyme replacement therapy (ERT) has been developed for several lysosomal storage disorders, including mucopolysaccharidosis I (MPS I), and is effective at reducing lysosomal storage in many tissues and in ameliorating clinical disease. However, intravenous ERT does not adequately treat storage disease in the central nervous system (CNS), presumably due to effects of the blood-brain barrier on enzyme distribution. To circumvent this barrier, we studied whether intrathecal (IT) recombinant human alpha-L-iduronidase (rhIDU) could penetrate and treat the brain and meninges. An initial dose-response study showed that doses of 0.46-4.14 mg of IT rhIDU successfully penetrated the brain of normal dogs and reached tissue levels 5.6 to 18.9-fold normal overall and 2.7 to 5.9-fold normal in deep brain sections lacking CSF contact. To assess the efficacy and safety in treating lysosomal storage disease, four weekly doses of approximately 1 mg of IT rhIDU were administered to MPS I-affected dogs resulting in a mean 23- and 300-fold normal levels of iduronidase in total brain and meninges, respectively. Quantitative glycosaminoglycan (GAG) analysis showed that the IT treatment reduced mean total brain GAG to normal levels and achieved a 57% reduction in meningeal GAG levels accompanied by histologic improvement in lysosomal storage in all cell types. The dogs did develop a dose-dependent immune response against the recombinant human protein and a meningeal lymphocytic/plasmacytic infiltrate. The IT route of ERT administration may be an effective way to treat the CNS disease in MPS I and could be applicable to other lysosomal storage disorders.

Murine serine proteases MASP-1 and MASP-3, components of the lectin pathway activation complex of complement, are encoded by a single structural gene

Activation of the lectin pathway of complement is initiated by the binding to microbial carbohydrate structures of a multimolecular fluid-phase complex composed of a carbohydrate recognition subcomponent that associates with three specific serine proteases and an enzymatically inert protein of 19 kDa. The first carbohydrate recognition subcomponent of the lectin pathway identified was mannan-binding lectin (MBL), hence the serine proteases were named MBL-associated serine proteases (MASPs) and numbered according to the sequence of their discovery. Here we describe the primary structures of the two distinct serine proteases MASP-1 and MASP-3 in the rat (and of MASP-3 in the mouse), show their association with plasma MBL complexes, and demonstrate that in rat and mouse, as in man, MASP-1 and MASP-3 are encoded by a single structural gene. For both species, we present the genomic region and regulatory elements responsible for the processing of either MASP-1 or MASP-3 mRNA by alternative splicing/alternative polyadenylation. Furthermore, we demonstrate the evolutionary conservation of MASP-3 mRNA in cDNA transcripts from guinea pig, rabbit, pufferfish, and cow.

Observer experience and Cup:Disc ratio assessment

BACKGROUND

The validity of the Cup:Disc (C:D) ratio as a clinical measure depends on the level of agreement among observers. In this study, we investigated the effect of observer experience on interobserver and intraobserver agreement in C:D ratio estimation.

METHODS

Nine 3rd-year (Yr3) and nine 4th-year (Yr4) optometry students and nine optometrists (Opt), determined C:D ratios from 26 optic disc photographs viewed monoscopically and stereoscopically. Observer agreement was investigated using weighted kappa (Kw) analysis.

RESULTS

Interobserver agreement was higher (p < 0.01) among optometrists than among 4th-year students and higher (p < 0.01) among 4th-year than among 3rd-year students (mean Kw: Opt = 0.61; Yr4 = 0.51; Yr3 = 0.39). Stereoscopic estimates of C:D ratios were higher (p < 0.0001) than monoscopic estimates, and interobserver agreement was higher (p < 0.001) when evaluating the vertical rather than the horizontal C:D ratio. Intraobserver agreement (mean Kw: Opt = 0.67; Yr4 = 0.66; Yr3 = 0.62) did not vary significantly (p = 0.78) with experience.

CONCLUSIONS

The extent to which an observer reproducibly assesses the C:D ratio from optic disc photographs (intraobserver agreement) does not increase with experience. However, the agreement between different observers in assessing the C:D ratio (interobserver agreement) increases with experience.

Predictors of good outcome after intravenous tPA for acute ischemic stroke

BACKGROUND

Thrombolytic therapy for acute ischemic stroke with IV alteplase is increasingly well established in North America but not elsewhere. Baseline factors that altered the response to alteplase were not identified by the National Institute of Neurological Disorders and Stroke tPA Stroke Study Group.

METHODS

The authors gathered information from centers in the United States, Canada, and Germany on 1,205 patients with acute ischemic stroke treated with IV alteplase. The purpose was to identify independent factors that were predictive of good outcome using multivariable logistic regression modelling. The modified Rankin Scale score was dichotomized into good outcome (mRS 0 to 1) and poor outcome (mRS >1) as the primary outcome measure.

RESULTS

In relative order of decreasing magnitude, milder baseline stroke severity, no history of diabetes mellitus, normal CT scan, normal pretreatment blood glucose level, and normal pretreatment blood pressure were independent predictors of good outcome among patients treated with IV alteplase for acute ischemic stroke. Confounding was observed among history of diabetes mellitus, CT scan appearance, baseline serum glucose level, and blood pressure, suggesting important relationships among these variables.

CONCLUSIONS

Several factors were independently predictive of good outcome among patients with acute ischemic stroke treated with alteplase. These results require further confirmation before clinical implementation.

A glider swing intervention for people with dementia

The soothing, repetitive movement of rocking and swinging is well known to anyone who has enjoyed a porch swing or rocking chair. Positive effects of rocking have been reported. However, investigations on its effect in people with dementia are limited. The purposes of this quasi-experimental, repeated-measures design study were to measure the effects of a glider swing on emotions, relaxation, and aggressive behaviors in a group of nursing home residents with dementia (n = 30). Data were obtained during a 5-day baseline phase, a 10-day intervention phase, and a 5-day posttreatment phase. Subjects were placed on the glider for 20 minutes each day during the intervention phase. The results of the study indicate that the glider intervention significantly improved emotions and relaxation. The most noted changes were found after 10 minutes of swinging. However, no differences were found in aggressive behaviors.

The introduction of the frontline management initiative in South Western Sydney Area Health Service

This article provides an overview of the development and implementation of a management development strategy for the South Western Sydney Area Health Service (SWSAHS). The program, the Frontline Management Initiative (FMI), was introduced as a developmental tool which enabled managers to identify those competencies that they already possess and those which they need to develop. The FMI will be progressively implemented throughout the five sector health services of SWSAHS comprising approximately 1500 managers. This article outlines the introduction and experience of FMI in one sector health service, the development and assessment of a manager's portfolio, the pathway developed from FMI to university based health management courses, the lessons learnt and the future directions for management development.

Challenges of implementing intervention research in persons with dementia: example of a glider swing intervention

Intervention studies for persons with dementia present many challenges. This article describes challenges encountered in conducting a glider swing intervention study for persons with dementia and the strategies used to manage the problems encountered. The overall purpose of a quasi-experimental study was to explore the effects of a glider swing intervention on emotions, relaxation, and aggressive behaviors in nursing home residents with dementia. Suggestions for investigators conducting intervention studies for persons with dementia are provided.

Abusive behavior is barrier to high-reliability health care systems, culture of patient safety

Addressing abusive behavior in the medical workplace presents an important opportunity to deliver on the national commitment to improve patient safety. Fundamentally, the issue of patient safety and the issue of abusive behavior in the workplace are both about harm. Undiagnosed and untreated, abusive behavior is a barrier to creating high reliability service delivery systems that ensure patient safety. Health care managers and clinicians need to improve their awareness, knowledge, and understanding of the issue of workplace abuse. The available research suggests there is a high prevalence of workplace abuse in medicine. Both administrators at the blunt end and clinicians at the sharp end should consider learning new approaches to defining and treating the problem of workplace abuse. Eliminating abusive behavior has positive implications for preventing and controlling medical injury and improving organizational performance.

Health sector reform and STD/AIDS control in resource poor settings--the case of Tanzania

Integration in health sector reform tends to mean horizontal interaction between vertical programmes. This can result in a larger more complex system than a set of individual vertical programmes. This article looks at the HIV/AIDS programme in Tanzania and the possible impact of system-wide health sector reform involving 'decentralization' and horizontal integration. It implies that the build-up to reform is likely to be costly, at least initially (although eventually the system may become more cost-effective). Integration can thus save resources, but it will also demand additional inputs, and may lead to reduced service output if operations depend on horizontal functions that fail to deliver. The objective of reform must be to create a reasonably sized, well-balanced, system which aims to maximize the output of quality services, both preventive and curative, and to facilitate community efforts to improve health. It is doubtful whether present reform efforts in Tanzania will contribute to more effective services, if not based on a more thorough analysis adapted to the local situation and given considerably more resources, both human and financial. There is also a risk that key preventive programmes, such as those aimed at the control of STD/AIDS, will be further weakened because of both integration with subsequent dependence on poorly functioning horizontal units and reduction in allocated resources.

Synthesis of novel 5-substituted 3-amino-3,4-dihydro-2H-1-benzopyran derivatives and their interactions with the 5-HT1A receptor

A series of new enantiomerically pure 3-amino-3,4-dihydro-2H-1-benzopyrans (3-aminochromans) has been synthesized from (R)- and (S)-5-methoxy-3-amino-3,4-dihydro-2H-1-benzopyran. The absolute configuration of the respective (R)- and (S)-enantiomers was deduced from X-ray crystallography of (R)-3-(N-isopropylamino)-5-methoxy-3,4-dihydro-2H-1-benzopyran, (R)-9a. Various 5-substituents were introduced via palladium-catalyzed carbonylation of N-substituted 3-amino-5-trifluoromethanesulfonyloxy-3,4-dihydro-2H-1-benzopyran. The effect of N- and 5-substitution on affinity for the 5-HT1A receptor was evaluated in competition experiments using rat hippocampal membranes and [3H]8-OH-DPAT as radioligand. Selected compounds were also tested for their affinity to the D1 (rat striatum), D2 (rat striatum), D2A (human cloned), and 5-HT2A (rat cortex) receptors. The intrinsic activity of the compounds was evaluated by measuring their effect on VIP-stimulated cAMP production in GH4ZD10 cells stably transfected with the 5-HT1A receptor. High-affinity compounds with high selectivity for the 5-HT1A receptor were found among structures substituted with carboxylate esters, amides, and ketones in the 5-position. Primary and secondary amines bound with lower affinity than tertiary amines. Larger substituents were well-tolerated by the receptor, but the smaller N-ethyl-N-isopropyl bound with lower affinity. Generally, the (R)-enantiomers displayed higher affinity for the 5-HT1A receptor than the corresponding (S)-enantiomers. In the present series of compounds, both full and partial agonists were found.

A comparison of manual kinetic and automated static perimetry in obtaining ptosis fields

OBJECTIVE

To compare examination time and visual field loss for ptosis fields obtained with manual kinetic (Goldmann) perimetry and automated static (Humphrey) perimetry.

METHODS

Both eyes of 12 patients with bilateral aponeurogenic ptosis were prospectively examined using Goldmann and Humphrey (ptosis protocol) perimetry with the eyelids ptotic and taped into a normal position.

RESULTS

Bilateral examination time for Goldmann fields was 10 +/- 2 minutes and for Humphrey fields was 50 +/- 10 minutes (P<.001, n = 12). Superior fields at the 12:00 meridian were 46 degrees +/- 6 degrees taped, and 28 degrees +/- 12 degrees untaped for Goldmann perimetry (P<.001), and 38 degrees +/- 8 degrees taped, and 24 degrees +/- 12 degrees untaped for Humphrey perimetry P<.001). Goldmann field loss was 18 degrees +/- 9 degrees (taped minus untaped). Humphrey field loss was 14 degrees +/- 13 degrees (P<.04, n = 24). Mean Goldmann radial fields were 56 degrees +/- 6 degrees taped and 39 degrees +/- 13 degrees untaped (P<.001). Goldmann superior hemifield areas were 5,167 +/- 964 degrees2 taped and 2,830 +/- 1,466 degrees2 untaped (P<.001). Humphrey mean vertical superior hemifield was 37 degrees +/- 9 degrees taped and 21 degrees +/- 11 degrees untaped (P<.001). Mean sensitivity of Humphrey fields was 15 +/- 3 dB taped and 9 +/- 5 dB untaped (P<.001). Mean vertical center of gravity was 23 degrees +/- 3 degrees taped and 16 degrees +/- 5 degrees untaped (P <.001).

CONCLUSION

Goldmann manual kinetic and Humphrey automated static visual field testing are both effective in documenting ptosis associated visual field loss. Humphrey automated ptosis fields, as performed in this study, require longer examination times than Goldmann manual fields and may be a less sensitive indicator of field loss.

Economic effects of community versus hospital-based faculty pneumonia care

To compare the length of stay and charges for patients with pneumonia admitted in 1995 to the teaching and nonteaching services of a Northeastern teaching hospital, we reviewed the charts of 237 patients. Patients cared for by hospital-based generalists working with housestaff (teaching service) were discharged more quickly and with lower or equivalent charges than patients cared for by community-based attending physicians working either with housestaff (private teaching service) or alone (nonteaching service). Academic teaching services staffed by general medicine faculty may provide efficient inpatient pneumonia care.

Molecular and cellular characterization of baboon C-Raf as a target for antiproliferative effects of antisense oligonucleotides

C-Raf is a an essential member of the growth factor-ras pathway and a target for intervention strategies aimed at blocking cell proliferative responses. Excessive smooth muscle proliferation is considered one cause of the arterial closure in restenosis. Because of the similarity to the human cardiovascular system, a useful current animal model of the disease is a baboon model. As a foundation for animal studies employing antisense oligonucleotides, efforts were made to characterize the molecular and cellular biology of the baboon system. The nucleotide sequence of baboon c-raf cDNA was determined. Antisense phosphorothioate oligonucleotides specific to the 3'-UTR of c-raf mRNA from human and baboon were compared using primary baboon smooth muscle cells in culture. A particular human antisense oligonucleotide, referred to as ISIS 5132, was different by only 2 of 20 bases from the baboon sequence. The corresponding baboon antisense oligonucleotide ISIS 12959, however, was markedly more effective to inhibit c-raf mRNA, protein production, and DNA synthesis, and the results attest to the species specificity of the approach. After antisense treatment, c-raf mRNA levels dropped rapidly, whereas protein levels decreased with a half-life of roughly 24-48 hours, consistent with the antiproliferative effects. The data are discussed with regard to the profile of protein-protein interactions made by C-Raf and with the view that the baboon system closely parallels the human one at the signal transduction level. As this work progressed, a baboon cDNA homolog of a human c-raf-2 pseudogene was isolated, sequenced, and shown to be transcribed into mRNA.

Outcomes of a nursing intervention for siblings of chronically ill children: a pilot study

PURPOSE

To evaluate the outcomes of a structured, educational, and support group intervention (ISEE, Intervention for Siblings: Experience Enhancement) for siblings of children with chronic illness (cancer, cystic fibrosis, diabetes, and spina bifida), including a session with parents about sibling needs; and to describe sibling and parent perceptions of sibling experiences at home.

DESIGN

One-group, pretest-posttest pilot study.

PARTICIPANTS

A convenience sample of 22 siblings and parents.

SETTING

A Midwestern university medical center.

MAIN OUTCOME MEASURES

Knowledge of Illness Test, parent ratings on a global, single item, 10-point scale.

RESULTS

Sibling test scores increased significantly after intervention, compared to baseline. Parents' average evaluation rating was 9 on a 10-point scale. Parents supported their positive ratings with verbatim descriptions. Sibling and parent perceptions of sibling experiences were congruent, suggesting the sources of potential adjustment problems in siblings, and were consistent with the literature.

CONCLUSIONS

A randomized, clinical trial with a larger sample size is needed to evaluate the intervention further.

Seasonal abundance and distribution of mosquitoes at a rural waste tire site in Illinois

The species composition, abundance, and distribution of mosquito larvae in tires were determined on 3 dates at a relatively large rural tire dump (about 300,000 tires) in southeastern IL (Jasper County). Several observations at this site differed from those in previous reports about mosquitoes in tireyards, including 1) a relatively high percentage of tires positive for Aedes triseriatus larvae in an open-field area, 2) a greater abundance of Culex pipiens than Cx. restuans in late-season collections, 3) a seasonal change in the distribution of Aedes atropalpus larvae in tires from open field and edge of woods areas, and 4) the presence of Ae. albopictus as a major late-season species. Ae. albopictus adults were captured in sod-baited gravid traps along the edge of a wooded riparian area 200 m from the tire pile.

Case management and patient reactions: a study of STD care in a province in Zambia

Sexually transmitted disease (STD) case management was evaluated through observation and interviews at 2 urban and 4 rural health centres and 2 district hospital STD clinics in one urban and 2 rural districts in Central Province, Zambia. The analysis was limited to 59 patients (42 men and 17 women) who paid first visits for their disease and were managed by a clinical officer. The evaluation suffered from the lack of a standard for case management. Results showed that the patients engaged in risky sexual behaviour without being aware of the risks. At the health institutions, few patients were informed about condoms, the risk of HIV, and abstinence from sex during treatment and few were asked to notify their partners. Clinical officers with special STD training performed better than others but sill informed only one-fifth of the patients. Few clinical officers managed patients according to the syndromic approach recommended by the STD control programme.

Effect of varying atrial sensitivity, AV interval, and detection algorithm on automatic mode switching

Automatic mode switching (AMS) is absolutely dependent on atrial tachyarrhythmia detection. The effects of programming several features that could influence tachyarrhythmia detection were assessed in 18 patients (six women; mean age 64 years) with pacemakers having AMS capability. The atrial electrogram amplitude in sinus rhythm at implant (SR-EGM), last measured atrial sensing threshold prior to tachycardia (A-SENS), and atrial sensing threshold for effective AMS during atrial tachyarrhythmia (AMS-SENS) were obtained. Additionally, ten patients had AV intervals increased from 60 to 200 ms, while seven patients had detection algorithms made more stringent from 5 beats at 150 beats/min to 11 beats at 200 beats/min to assess their effects on AMS efficacy.

RESULTS

Sensitivities:Mean SR-EGM = 3.55 mV; mean A-SENS = 2.06 mV; and mean AMS-SENS = 1.46 mV. Fourteen patients developed atrial fibrillation and four atrial flutter. Thirteen of 14 patients who developed atrial fibrillation sensed adequately at > or = 1.0 mV in normal sinus rhythm (NSR), but only six patients had effective AMS at these settings in atrial fibrillation. Three of four patients who developed atrial flutter had effective AMS at > or = 2.0 mV. AV Interval:AMS was effective in eight of ten patients at AV intervals up to 200 ms. One patient lost AMS at an AV interval of 120 ms. Algorithm: In two of seven patients, AMS was not effective if the detection algorithm was more stringent than five beats at 150 beats/min.

CONCLUSIONS

(1) In atrial fibrillation, effective AMS requires more sensitive atrial settings than in NSR; (2) AV intervals as short as 120 ms can interfere with AMS function; and (3) More stringent detection algorithms may be inappropriate for effective AMS function.

STD care in Zambia: an evaluation of the guidelines for case management through a syndromic approach

Clinical diagnosis of STDs is unreliable and therefore constitutes a poor basis for choice of treatment. A syndromic approach has been suggested to increase effectiveness of treatment in resource poor settings. Algorithms for the treatment of STD syndromes were evaluated. A total of 436 patients were followed; cure rates were defined and estimated for genital ulcer disease (GUD), urethral and vaginal discharge. Cure rates for the discharge syndromes were high, 97-98%, for both sexes. The cure rate for GUD was 83% for female and 69% for male patients. A higher prevalence of syphilis in the female study population probably contributed to this. It is likely that a large proportion of the treatment failures were due to decreased susceptibility of Haemophilus ducreyi to trimethoprim-sulpha. The determination of cure rates met with a number of methodological problems. This makes it difficult to evaluate the algorithms as part of routine activities, as suggested earlier by WHO.

Outbreak of Escherichia coli O157 phage type 2 infection associated with eating precooked meats

Fourteen cases of Escherichia coli O157 infection were reported to the consultant in communicable disease control in Sunderland Health Authority in August 1995. E. coli O157 phage type 2, Vero cytotoxin 2 was isolated from the faeces of ten cases. Nine of the isolates were indistinguishable by Vero cytotoxin subtyping and analysis of chromosomal DNA. Two cases with haemolytic uraemic syndrome were confirmed serologically and two cases remained unconfirmed. A case control study showed infection with E. coli O157 to be associated with having eaten precooked meats from a single shop. Environmental investigations at the shop showed that cooked meats were stored close to raw beef, raw meats were left on preparation surfaces, and the same staff served both raw and cooked meats. This outbreak draws attention to standards of food preparation and handling in outbreaks of E. coli O157, the issue of cross contamination, and the need to improve local surveillance of haemolytic uraemic syndrome.

Monoclonal antibodies against Haemophilus ducreyi lipooligosaccharide and their diagnostic usefulness

Monoclonal antibodies against the lipooligosaccharide of Haemophilus ducreyi were produced. Two of them, MAHD6 and MAHD7, were found to be relatively, although not absolutely, specific and reacted with nearly all strains of Haemophilus ducreyi tested: 59 of 60 and 60 of 60, respectively. The diagnostic usefulness of MAHD7 was assessed. Clinical specimens collected in Zambia from patients with genital ulcers were tested using indirect immunofluorescence (IF), enzyme immunoassay (EIA), the polymerase chain reaction (PCR) and bacterial culture. Compared with culture, IF had a sensitivity of 100%; compared with PCR, sensitivity was 89%. The corresponding figures for the EIA were 83% and 74%, respectively. The sensitivity of culture compared with PCR was 63%. The results suggest that IF on genital smears using MAHD7 might be an excellent tool for the diagnosis of chancroid in high-prevalence populations. However, further evaluation of the specificity of this test is needed.

Long term outcome of renal transplantation in the pre cyclosporin era: one centre's experience

The number of renal transplants has been increasing steadily over the last twenty years. This increase has been associated with a significant improvement in the one year graft and patient survival. However, as survival improves, long term complications are becoming more clinically important. We, therefore, retrospectively reviewed our experience of renal transplantation in 165 patients between January 1970 and December 1980, and describe in detail the complications experienced by those whose grafts functioned for 10 years or longer. The 10 year patient survival rate was 47% and graft survival rate was 30%. The graft survival rate for living related grafts was superior to that of cadaveric grafts. The major cause of mortality in the first year following renal transplantation was infection and in subsequent years, cardiovascular disease predominated. Patients whose grafts functioned for 10 years or more developed a variety of complications including infection, skin cancer and hepatic dysfunction. Clinicians involved in the long term care of the patients need to be aware of these problems and skilled in their management.

Cloning and structure-function analysis of the Leishmania donovani kinetoplastid membrane protein-11

This report describes the complete translated gene sequence, predicted secondary structure and lipid bilayer association of a novel kinetoplastid membrane protein (KMP-11) from Leishmania donovani promastigotes. KMP-11 was previously referred to as the lipophosphoglycan-associated protein (LPGAP). The isolation, species distribution and chemical characterization, including a partial protein sequence analysis and post-translational modifications, of this major membrane component have been described [Jardim, Funk, Caprioli and Olafson (1995) Biochem. J. 305, 307-313]. C.d. measurements of KMP-11 indicated a very high helical content estimated to be approximately 86% in trifluoroethanol. This was in agreement with computer-based secondary-structure analyses which predicted KMP-11 to be almost exclusively alpha-helical, with the protein adopting a helix-loop-helix motif. Arrangement of the residues located in the putative helical regions on an Edmundson helical wheel showed that this molecule could have a strongly amphipathic conformation and provided an explanation for how such a highly charged protein might be inserted into the plasma membrane. Evidence in support of KMP-11 association with lipid bilayers was provided by showing that KMP-11 could mediate carboxyfluorescein release from liposomes. These findings suggested that KMP-11 may function in part to increase bilayer pressure, stabilizing molecules such as lipophosphoglycan within the parasite pellicular membrane.

Advance patient directives: are they worth it?

The Patient Self-Determination Act became effective in December 1991. After two complete years of experience, data are emerging to indicate how implementation of the Act has affected the issues of patient autonomy and cost containment. In this third article of a series on advance directives, the authors conclude that the preliminary results of their study are consistent with other studies recently completed that demonstrate the favorable effect of the Act on enhancing patient autonomy and containing the costs of health care. The authors suggest a basic study design for replication and adaptation by others, encourage more uniformity by researchers in future studies to more precisely measure the effect of the Act, and briefly describe the expansion of their continuing study.