Development and evaluation of a patient self-report case-finding method for rheumatoid arthritis

OBJECTIVE: To describe the development and evaluation of a patient self-report case-finding method for rheumatoid arthritis (RA) not dependent on direct contact with the treating physicians. METHODS: The American College of Rheumatology criteria for RA diagnosis were adapted for patient self-report using a questionnaire, and alternative scoring algorithms were evaluated to balance case-finding sensitivity and specificity. Positive rheumatoid factor tests were used to identify 1053 individuals in 2 large healthcare organizations; 440 agreed to receive study materials. Case-finding results were validated by medical record review (MRR) for a random sample of 90 patients. Three scoring algorithms were compared with MRR for likelihood of RA diagnosis. Cases not classifiable by algorithm were flagged and reviewed by 2 expert physicians for likelihood of RA diagnosis. RESULTS: Pilot testing demonstrated that patients comprehended the questionnaire and were willing to answer the questions. Completed questionnaires were returned by 265 (60%) of the 440 patients contacted. Following expert physician review of 16 flagged cases in the 90-patient MRR subsample, the most accurate scoring algorithm demonstrated 80% sensitivity, 67% specificity, 74% accuracy, and 77% positive predictive value for detecting early RA. CONCLUSION: The case-finding method represents a promising tool for identifying RA patients, with potential application in research and quality-assurance activities. RELEVANCE: This case-finding method should be useful in research and quality-assurance efforts requiring identification of RA patients treated by all types of providers in healthcare organizations in which centralized laboratory data are available.     

Baclofen for alcohol dependence: a preliminary open-label study

BACKGROUND: Recent preclinical and clinical studies have shown that the gamma-aminobutyric acid-B agonist baclofen may be an effective treatment for reducing alcohol consumption. This preliminary open-label investigation examined the tolerability and effect of a 30-mg daily baclofen dose for reducing drinking, subclinical anxiety and depressive symptoms, and craving in alcohol-dependent subjects. METHODS: Nine men and three women participated in a 12-week trial during which they took baclofen on a 10 mg thrice-daily regimen and received four sessions of motivational enhancement therapy. Each participant received a comprehensive physical and psychiatric screening before being enrolled. At each visit, side effects were monitored with a revised version of the Systematic Assessment of Treatment Emergent Events-General Inquiry, and drinking data were collected via the timeline follow-back interview. Participants also completed the Beck Depression Inventory, the Beck Anxiety Inventory, and the Penn Alcohol Craving Scale at each visit. RESULTS: Baclofen was reasonably tolerated. Two participants discontinued because of side effects. No serious adverse events were noted. Six other individuals did not complete the trial. Overall, there were statistically significant reductions in the number of drinks per drinking day and the number of heavy-drinking days, and there was an increase in the number of abstinent days. Significant decreases in anxiety and craving were also shown. CONCLUSIONS: These findings suggest that baclofen is reasonably tolerated in an alcohol-dependent population, although the high dropout rate in the study is of concern. Baclofen may be effective for the reduction of drinking, anxiety, and craving for some alcohol-dependent individuals. A larger-scale placebo-controlled study is needed to further explore these effects and to determine the characteristics of those who respond to this medication.     

Induction of redox imbalance and apoptosis in multiple myeloma cells by the novel triterpenoid 2-cyano-3,12-dioxoolean-1,9-dien-28-oic acid

The synthetic oleanane triterpenoid 2-cyano-3,12-dioxoolean-1,9-dien-28-oic acid (CDDO) and its chemical derivatives induce differentiation and apoptosis of human leukemia cells. The precise mechanisms responsible for the effects of CDDO, however, remain unclear. In the present study, we examined the effects of CDDO and its C-28 imidazolide ester (CDDO-Im) on apoptosis of multiple myeloma (MM) cells. The results show that both CDDO and CDDO-Im are potent inducers of MM cell apoptosis and that CDDO-Im is more active than CDDO. CDDO-Im treatment was associated with (a) depletion of glutathione, (b) increases in reactive oxygen species, (c) a reduction of the Fas-associated death domain (FADD)-like interleukin-1-converting enzyme (FLICE) inhibitory protein, (d) activation of caspase-8, and (e) a decrease of the mitochondrial transmembrane potential. The reducing agents, N-acetyl-L-cysteine, DTT, and catalase inhibited each of these CDDO-Im-induced proapoptotic signals. Inhibition of caspase-8 with z-IETD-fmk also abrogated CDDO-Im-induced decreases of the mitochondrial transmembrane potential and inhibited apoptosis. These results demonstrate that CDDO-Im disrupts intracellular redox balance and thereby activates the extrinsic caspase-8-dependent apoptotic pathway. We further show that CDDO-Im induces apoptosis of primary MM cells at submicromolar concentrations and that MM cells are more sensitive to this agent than normal bone marrow mononuclear cells. These results suggest that CDDO compounds have potential as new agents for the treatment of MM.     

Selective embolization of the splenic vein in patients with hepatic encephalopathy and splenorenal shunt

Obliteration of portal-systemic shunts is effective for portosystemic encephalopathy but is often associated with complications such as retention of ascites and worsening of esophageal varices. Selective embolization of the splenic vein was performed on six patients with hepatic encephalopathy and splenorenal shunts. Hepatic encephalopathy was not observed in four patients after the procedure. Neither retention of ascites nor rupture of esophageal varices was observed because postoperative elevation of portal venous pressure was not as great as that seen when shunt obliteration is performed. This procedure can be an effective and safe treatment option for hepatic encephalopathy with a splenorenal shunt.     

A surgical case of subdural hematoma with hemophilia A

A 54-year-old man presented with unconsciousness. Computed tomography revealed acute subdural hematoma. Emergency evacuation of hematoma was performed showing any excessive tendency to bleed or difficulty to stop bleeding during the operation. However transfusion of fresh frozen plasma was needed to stop continuous bleeding from the surgical wound after the operation. The patient underwent craniotomy again 18 days after the operation because he suffered hemorrhagic infarction and recurrence of acute subdural hematoma. After the second operation, a coagulability examination revealed that his activated partial thromboplastin test was prolonged (74.5 seconds) and his plasma factor VIII level was 20% of normal, so he was diagnosed as having mild hemophilia A. Cranioplasty was accomplished with replacement therapy, and he was discharged with mild recent memory disturbance and homonymous hemianopsia.     

Specialized nutrition support for the patients with advanced or recurrent carcinoma of the gastrointestinal tract

Various nutritional disorders can occur in patients with advanced or recurrent carcinoma of the gastrointestinal tract due to the disease itself or the absence of the organs after surgery. Routine parenteral nutrition for cancer patients who undergo chemotherapy results in no benefit and troublesome complications such as catheter sepsis. Consequently, it is important to provide sufficient and proper specialized nutritional support to patients who need it, taking into account the pathologic status resulting from malignant disease. Patients with advanced or recurrent carcinoma of the gastrointestinal tract are likely to be deficient in folate and/or vitamin B12 for various reasons. Neurological disorders in vitamin B12 deficiency should worsen when folate is administered without supplementation of vitamin B12. This phenomenon should be avoided when 5-fluorouracil is used with reduced folate in cancer chemotherapy. The indications for specialized nutritional support for patients with advanced or recurrent carcinoma of the gastrointestinal tract are the same as for malnourished patients without cancer. The initial dose and formula of nutrition for cancer patients with malnutrition and various metabolic disorders should be calculated to avoid overloading. The oral intake of normal food is desirable for such patients. The placement of a central venous catheter to prevent the toxicity of chemotherapy or for venous access is contraindicated. Jejunal feeding or percutaneous endoscopic gastrostomy is performed in patients who cannot eat even a liquid diet. Total parenteral nutrition should be introduced when these accesses cannot be used. If any bowel obstruction occurs in the small intestine and/or colon, it is necessary to discuss the efficacy of surgery to resolve the obstruction.     

Usefulness of Radio-guided Surgery Using Technetium-99m Methoxyisobutylisonitrile for Primary and Secondary Hyperparathyroidism

The efficacy of technetium-99m methoxyisobutylisonitrile (^99mTc-MIBI)-guided surgery for detecting abnormal parathyroid glands in patients with secondary hyperparathyroidism (2-HPT) was evaluated and compared with the results from the same examination in patients with primary hyperparathyroidism (1-HPT). The results were also compared with those found by ultrasonography (US) and preoperative ^99mTc-MIBI scintigraphy was also made. At operation ^99mTc-MIBI accumulated in 64 nodules of 15 cases of 2-HPT, and all of 60 parathyroid swellings were detected (true-positives 60, sensitivity 100%, accuracy 94%). In the cases of 1-HPT, ^99mTc-MIBI revealed 11 hot nodules in 10 cases, and the evaluation was true-positive 10, sensitivity 100%, and accuracy 91%. US and preoperative ^99mTc-MIBI scintigraphy in patients with 2-HPT had a sensitivity of 75% and 67% and an accuracy of 70% and 66%, respectively. The usefulness of ^99mTc-MIBI-guided surgery for detecting abnormal parathyroid tissue in 2-HPT patients was similar to that in 1-HPT patients but was superior to US and preoperative ^99mTc-MIBI scintigraphy. Intraoperative ^9mTc-MIBI for patients with 2-HPT is effective and makes the surgery easier, especially when the parathyroid glands are ectopic or when a few glands are markedly enlarged but the other glands are atrophied.     

Correlation between angiogenesis and reduction ratio measured using<Superscript>201</Superscript>Tl chloride single photon emission computed tomography in patients with oral cavity squamous cell carcinoma

OBJECTIVE: The aim of this study is to examine the correlation between tumor angiogenesis and response to preoperative radiotherapy evaluated using 201Tl single photon emission computed tomography (Tl SPECT) in oral cavity squamous cell carcinoma (SCC). METHODS: Tl SPECTs before and after preoperative radiotherapy were obtained from 11 patients diagnosed with SCC in oral cavity. Regions of interest were set around the tumor and scalp respectively, and the ratio of mean counts in the tumor to those in the scalp was calculated (T/N). Immunohistochemical staining for investigating microvessel density of pre-treatment biopsy specimen was performed using CD31 monoclonal antibody. We compared microvessel density with semi-quantitative parameters obtained using Tl SPECT (T/N at pre- an post-treatment, reduction ratio) and prognosis. RESULTS: The subgroup with higher microvessel density showed a significantly higher reduction ratio than the one with lower microvessel density. Regarding prognosis, the subgroup with locoregional recurrent disease exhibited a significantly higher microvessel density than the one without recurrence. CONCLUSIONS: In SCC of the oral cavity, there was a significant correlation between microvessel density and response to preoperative radiotherapy. Namely, it was revealed that change of 201Tl uptake after preoperative radiotherapy correlated with tumor angiogenesis of oral cavity SCC.