An Unusual Case of a Primary Hyperparathyroidism Mimic

A 32-year-old lady with a history of bulimia nervosa was noted to have a raised adjusted calcium of 2.94mmol/L associated with high parathyroid hormone (PTH) 17.2pmol/L. On review, she had an apparent hypercalcaemia for at least three years, and also had a chronic, severe alkalosis with a bicarbonate up to 81.9mEQ/L. Ionised calcium during that time had actually been low, down to 1.03mmol/L. This case highlights the effects of alkalosis on calcium, as more albumin is available for binding to ionised calcium. This results in a low ionised calcium, which triggers PTH release and overall leads to raised adjusted calcium levels. Clinicians may misdiagnose a similar patient with primary hyperparathyroidism and treatment would cause worsening of true hypocalcaemia.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. A randomised controlled trial

OBJECTIVES

To test the hypotheses that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR) and that HBR is less costly.

DESIGN

Two-arm randomised controlled trial.

SETTING

Four trusts in England providing both HBR and DHR.

PARTICIPANTS

Clinical staff reviewed consecutive referrals to identify subjects who were potentially suitable for randomisation according to the defined inclusion criteria.

INTERVENTIONS

Patients were randomised to receive either HBR or DHR.

MAIN OUTCOME MEASURES

The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) scale. Secondary outcome measures included the EuroQol 5 dimensions (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Therapy Outcome Measures (TOMs), hospital admissions and the General Health Questionnaire (GHQ-30) for carers.

RESULTS

Overall, 89 subjects were randomised and 42 received rehabilitation in each arm of the trial. At the primary end point of 6 months there were 32 and 33 patients in the HBR and DHR arms respectively. Estimated mean scores on the NEADL scale at 6 months, after adjustment for baseline, were not significantly in favour of either HBR or DHR [DHR 30.78 (SD 15.01), HBR 32.11 (SD 16.89), p = 0.37; mean difference -2.139 (95% CI -6.870 to 2.592)]. Analysis of the non-inferiority of HBR over DHR using a 'non-inferiority' limit (10%) applied to the confidence interval estimates for the different outcome measures at 6 months' follow-up demonstrated non-inferiority for the NEADL scale, EQ-5D and HADS anxiety scale and some advantage for HBR on the HADS depression scale, of borderline statistical significance. Similar results were seen at 3 and 12 months' follow-up, with a statistically significant difference in the mean EQ-5D(index) score in favour of DHR at 3 months (p = 0.047). At the end of rehabilitation, a greater proportion of the DHR group showed a positive direction of change from their initial assessment with respect to therapist-rated clinical outcomes; however, a lower proportion of HBR patients showed a negative direction of change and, overall, median scores on the TOMs scales did not differ between the two groups. Fewer patients in the HBR group were admitted to hospital on any occasion over the 12-month observation period [18 (43%) versus 22 (52%)]; however, this difference was not statistically significant. The psychological well-being of patients' carers, measured at 3, 6 and 12 months, was unaffected by whether rehabilitation took place at day hospital or at home. As the primary outcome measure and EQ-5D(index) scores at 6 months showed no significant differences between the two arms of the trial, a cost-minimisation analysis was undertaken. Neither the public costs nor the total costs at the 6-month follow-up point (an average of 213 days' total follow-up) or the 12-month follow-up point (an average of 395 days' total follow-up) were significantly different between the groups.

CONCLUSIONS

Compared with DHR, providing rehabilitation in patients' own homes confers no particular disadvantage for patients and carers. The cost of providing HBR does not appear to be significantly different from that of providing DHR. Rehabilitation providers and purchasers need to consider the place of care in the light of local needs, to provide the benefits of both kinds of services. Caution is required when interpreting the results of the RCT because a large proportion of potentially eligible subjects were not recruited to the trial, the required sample size was not achieved and there was a relatively large loss to follow-up.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71801032.

Preliminary results on the effects of CD40/CD40L interactions and SAC-induction on IFN-gamma expression in human schistosomiasis

In this communication the authors analyzed the pattern of expression of IFN-gamma as a surrogate type 1 response in different clinical forms of schistosomiasis in response to stimulation involving T-cell dependent and T-cell independent pathways, to investigate which pathways were functional in human schistosomiasis, and to further characterize the nature of Th1 response impairment in this parasitic disease.

Statewide Tuskegee Alliance for clinical trials. A community coalition to enhance minority participation in medical research

BACKGROUND

Cancer mortality rates for all sites are nearly 2.5 times greater for African-Americans compared with whites. In addition, there are data implying that cancer treatment outcomes for minorities are unfavorable compared with whites. Whether this is due to poor access to health care or a biologic property of malignancies occurring in specific populations remains to be determined. Because of these unknown factors, targeting minorities for clinical trials may contribute toward the reduction of the overall morbidity and mortality associated with specific cancers.

METHODS

The current study describes the establishment of a genuine collaborative partnership between the targeted minority community and clinical investigators at the University of Alabama at Birmingham. This partnership was formed for the purpose of identifying strategies that would enhance the accrual and retention of minority participants into current and future cancer prevention and control trials. Focus groups and key informant interviews were conducted to ascertain the community's perception of participating in clinical trials.

RESULTS

The majority of focus group participants were unclear regarding the nature of clinical trials. Participants indicated that they would participate in research studies if they received adequate information regarding the purpose and benefits of the study, and if the charge came from a pastor or physician. Barriers to participation included time commitments, family obligations, whether blood was involved, and past experiences. The majority of the participants indicated that their knowledge of the Tuskegee Syphilis Study did not influence their decision to participate in research. A major outcome of the conference was the formation of the Statewide Tuskegee Alliance Coalition. The planning coalition decided to continue their efforts to work with communities and promote cancer awareness among minorities. After the conference, the coalition conducted several meetings and in July 1998, 1 year after the conference, the coalition selected a chair, co-chair, and a formal name for the organized group.

CONCLUSIONS

The planning, development, and implementation of this conference provided a valuable experience for researchers and community members. It was discovered that community involvement in the early phase of this project contributed to its success. Furthermore, the partnership that developed between researchers (academic institutions) and communities successfully provided an infrastructure that supported the interest of both groups.

Minority recruitment in clinical trials: a conference at Tuskegee, researchers and the community

PURPOSE

This article describes the planning, implementation, and evaluation of a 2-day conference designed to examine the factors related to the participation of African Americans in cancer clinical trials.

METHODS

Pre-conference formative evaluations (e.g., focus group discussions and key informant interviews with community leaders and health providers) were conducted in several rural and urban counties in the state of Alabama to determine African Americans' perceptions of participation in clinical research. The findings from these evaluations were used to develop a conference format and agenda. The 2-day conference included: (i) a pretest of African Americans' perceptions of cancer research, participation factors, and communication and recruitment issues; (ii) individual presentations high-lighting community leaders, church leaders, and researchers' perspectives regarding minority participation in research; (iii) working group discussions regarding the barriers and solutions to minority participation in research; and (iv) a posttest evaluation to measure changes in African Americans' perceptions of research.

RESULTS

Several recruitment barriers and solutions were identified and reported by the working groups. Comparisons of the pretest and posttest measures showed significant (p > .05) and favorable shifts in the areas of perceptions of cancer research, participation factors, communication issues, and recruitment issues. Participation in the conference reflected a positive change in attitudes on these measures. However, the theme, "barriers that contributed to nonparticipation," did not show any significant changes during the two testing periods. The most critical lesson that resulted from this conference was the need for researchers and community members to have open dialogue about participation in research.

CONCLUSIONS

This conference demonstrated that progress can be made when all parties are at the "table" and can be heard. In this model, community members proved to be valuable resources in providing researchers with information that was vital to the success of recruitment and retention studies and trials.

Cytokines as determinants of disease and disease interactions

The immune response to pathogens results in both host resistance and immunopathology. Cytokines and in particular those lymphokines produced by Th1 and Th2 cells play a key role in determining the balance between these two immunologic outcomes. Recent data suggest that interleukin-10, a product of both Th2 cells and macrophages, protects the host against excessive immunopathology. The cytokine environment generated by different pathogens may also influence the course and outcome of infections with unrelated organisms. This relationship may be particularly important in the case of HIV-1 where prior Th1 or Th2 biases established by helminth or intracellular infections may influence either initial viral susceptibility or drive progression to AIDS through immune activation.

An IL-12-based vaccine approach for preventing immunopathology in schistosomiasis

Schistosomiasis is a major parasitic disease of developing countries. Pathology in schistosome infection is caused by the host granulomatous response to parasite eggs deposited in the tissues and the ensuing fibrosis. Previous work established that Th2 CD4+ cells play a major role in expanding granulomatous lesions and in fibrosis in murine models. We have used IL-12 both therapeutically to downmodulate this response and as an adjuvant with egg antigens to prevent pathology after subsequent parasite challenge. These effects appears to rely on the induction of IFN-gamma by the injected IL-12. Interestingly, while IL-12 treatment or vaccination downregulates most egg-specific Th2 cytokine responses, IL-10 production in vivo is enhanced. Because we have also shown that IL-12 can be used as an adjuvant to augment protective immunity against this helminth, it may be possible to design a combined parasite Ag/IL-12 vaccine which both limits infection and blocks the tissue pathology caused by eggs of worms escaping the resistance mechanisms evoked by immunization. At a more general level, our results demonstrate the potential of IL-12-based vaccine strategies to block Th2-dependent disease processes including allergy.

Effects of O(2) Tension and Temperature during Light Uptake of CO(2) on the Dark Release of CO(2) by Excised C(3) and C(4) Leaves

A study was conducted on a C(4) (Panicum maximum) and a C(3) (Panicum bisulcatum) species to determine the nature of the dark release of (14)CO(2) with respect to its responses to changes in temperature and O(2) tension during light CO(2) uptake of (14)CO(2).The total one minute uptake of (14)CO(2) increased with increased temperatures up to 30 degrees C for both species at all O(2) tensions.The total release of (14)CO(2) during the first four minutes of dark by the C(4) species was 5 to 10 times greater than the C(3) species; however, there was no consistent pattern in the C(4) species as a function of temperature or O(2) tension. In contrast, the dark release by the C(3) species was similar to that of light uptake as a function of temperature or O(2) tension. The percentage of the one-minute (14)CO(2) fixation that was released as (14)CO(2) during the first four minutes of dark increased with O(2) tension for the three highest temperatures (20, 30, and 38 degrees C) and remained, though reduced, after a 10-minute dark chase in (12)CO(2) for the C(3) species.IT WAS CONCLUDED THAT: (a) the source of the dark CO(2) release in C(3) species is different from that of C(4) species; (b) the dark CO(2) release in C(3) species likely is derived from intermediates of photorespiration and is similar to the postillumination burst of CO(2); and (c) the source(s) of the dark CO(2) release in C(4) species is not photorespiration.

Dark Release of CO(2) from Higher Plant Leaves

A study was conducted with 48 species of the amount of (14)CO(2) released during the first minute of dark following fixation of (14)CO(2) in the light. Light fixation periods varied from 5 to 60 seconds. The species examined included both monocots and dicots and represented C(4), C(3), and Crassulacean acid metabolism (CAM) photosynthetic types.Total CO(2) uptake was determined as the sum of soluble (14)C (ethanol and water), insoluble (14)C, and (14)CO(2) released during the first minute of dark. Insoluble (14)C made up a very small percent of the total. The percent of soluble (14)C increased with fixation time in C(4) species, while the percent of (14)CO(2) released in the dark decreased. C(3) species released a very small percent of (14)CO(2) in the dark, and this percent remained relatively constant with time of (14)CO(2) fixation whereas C(4) species released a higher percent initially and this percent declined with time of fixation. CAM species were similar to C(4) species.The species are grouped according to the (14)CO(2) released during the first minute of dark with light labeling times of 5 and 60 seconds. These comparisons are shown to separate C(3) from C(4) and CAM species. Further, the data suggest that the origin of the CO(2) in the dark release of C(4) plants is quite different from that of C(3) plants.