Remitting seronegative symmetrical synovitis with pitting edema. RS3PE syndrome

Eight elderly men and two elderly women presented with symmetrical polysynovitis of acute onset involving most of their appendicular joints and flexor digitorum tendons associated with pitting edema of the dorsum of both hands and both feet. Onset of seven of the ten cases could be pinpointed almost to the hour. Rheumatoid factors were absent from serum samples in all, and no radiologically evident erosions developed. Clinical and laboratory signs of inflammation and the edema disappeared gradually in each case. Treatment consisted of aspirin or other nonsteroidal anti-inflammatory drugs. Hydroxychloroquine, 200 to 400 mg/day, was given in six and gold therapy in two cases. Painless limitation of motion of the wrists and/or fingers persisted in all, although the patients were both unaware of and unhampered by this abnormality. Six of eight cases where typing was possible were positive for HLA-B7, CW7, and DQW2 (relative risk for B7, 9.5). Three cases of this syndrome were found in a consecutive series of 52 men diagnosed as having definite "rheumatoid arthritis," and thus represent a distinctive condition with an excellent prognosis.     

Phacoemulsification devices: a consumer's update

This report extends a previous paper on the various characteristics of the most popular phacoemulsification devices. An evaluation of 11 devices by ten different manufacturers was attempted. Only five manufacturers of six devices agreed to critical evaluation or reevaluation. As in the previous report, the devices were compared for level of patient safety, dependability, efficiency, ease of usage, and operating cost for the first 1,000 cases. At the completion of this study, we ranked the nine devices evaluated over the past 17 months as follows: (1) United Surgical (Optikon) Systems Plus, (2) Optical Micro Systems (OMS), (3) United Surgical (Optikon) Phacotron, (4) CooperVision 10,000, (5) Site XTR, (6) CooperVision KCP, (7) CooperVision 9001, (8) Phakosystems CES 4000 and (9) United Sonics. To enhance the usefulness of this consumer's guide, we asked 40 experienced cataract surgeons what they wanted in the "ideal" phacoemulsification device. The opinions of 27 who responded are included.     

How to stay motivated: A focus group study of Norwegian caregivers' experiences with community healthcare services to their parents with dementia

Motivation to provide care is a significant predictor of informal caregiving among family caregivers of persons with dementia. Adequate support is an important source of help and relief to caregivers, but fragmentation of dementia care services is common and better ways of supporting these caregivers are needed. Knowledge of adult-child caregivers' motivation and how this motivation is influenced by community healthcare services is lacking. The aim of this study is therefore to describe and explore adult children's experiences with community healthcare services for their home-dwelling parent with dementia and how these influence their caregiver motivation. The study applied a qualitative design based on three focus group interviews with 15 of these caregivers (40–69 years) in Norway in 2017. The study results indicate three categories supporting adult children's sustained motivation as caregivers: (a) caregivers prioritize their parent's need for healthcare services over their own need for support; (b) caregivers need acknowledgement through respect and involvement; and (c) caregivers need timely information and competence as the dementia progresses. To stimulate collaboration among adult-child caregivers, their parents with dementia, and community healthcare services, we claim that a relationship-centred care framework could be emphasised as a way of supporting sustained motivation among caregivers to parents with dementia as part of community healthcare services.     

Patterns of E-Cigarette Use Among Primary Care Patients at an Urban Community Center

Tobacco use remains the leading cause of preventable disease and death in the US. The number of tobacco products has grown over the past decade. E-cigarette use has increased rapidly in recent years, but patterns and correlates of use have not been thoroughly assessed. We examined relationships among demographic factors, e-cigarette and conventional cigarette use in a large sample (N?=?12,409) of adult patients at a community health center in the Northeastern US. Overall, 13% (N?=?1675) of the sample reported ever using e-cigarettes. In logistic regression models, ever having used e-cigarettes was associated with younger age (ages 18–25; OR?=?3.5, p?<?0.001). Being transgender (OR?=?1.8, p?<?0.001), bisexual (OR?=?1.5, p?<?0.001), un-partnered (OR?=?1.5, p?<?0.001), having a lower income (OR?=?1.6, p?<?0.001) or a high BMI (OR?=?1.4, p?=?0.009) were associated with increased odds of use, whereas being a woman (OR?=?0.7, p?<?0.001) or Black/African American (OR?=?0.7, p?=?0.007) were associated with lower odds of use. Of the participants who reported e-cigarette use, a majority also endorsed current or former use of conventional cigarettes. Individuals who formerly used conventional cigarettes were nearly three times more likely to report daily e-cigarette use than current users. Among primary care patients at a community health center, e-cigarette use was reported by a sizeable portion of the sample. Overall, odds of use were higher in certain patient populations, and individuals who formally used cigarettes were more likely to report e-cigarette use than individuals who currently smoke, suggesting that e-cigarettes may be functioning as a cessation aid or a strategy to reduce conventional cigarette use.

     

Methadone Maintenance and State Medicaid Managed Care Programs

Coverage for methadone services in state Medicaid plans may facilitate access to the most effective therapy for heroin dependence. State Medicaid plans were reviewed to assess coverage for methadone services, methadone benefits in managed care, and limitations on methadone treatment. Medicaid does not cover methadone maintenance medication in 25 states (59 percent). Only 12 states (24percent) include methadone services in Medicaid managed care plans. Moreover, two of the 12 states limit coverage for counseling or medication and others permit health plans to set limits. State authorities for Medicaid and substance abuse can collaborate to ensure that appropriate medication and treatment services are available for Medicaid recipients who are dependent on opioids andto construct payment mechanisms that minimize incentives that discourage enrollment among heroin-dependent individuals.     

The need for cataract surgery: projections based on lens opacity, visual acuity, and personal concern

AIM: To assess the projected needs for cataract surgery by lens opacity, visual acuity, and patient concern. METHODS: Data were collected as part of the Melbourne Visual Impairment Project, a population based study of age related eye disease in a representative sample of Melbourne residents aged 40 and over. Participants were recruited by a household census and invited to attend a local screening centre. At the study sites, the following data were collected: presenting and best corrected visual acuity, visual fields, intraocular pressure, satisfaction with current vision, personal health history and habits, and a standardised eye examination and photography of the lens and fundus. Lens photographs were graded twice and adjudicated to document lens opacities. Cataract was defined as nuclear greater than or equal to standard 2, 4/16 or greater cortical opacity, or any posterior subcapsular opacities. RESULTS: 3271 (83% response) people living in their own homes were examined. The participants ranged in age from 40 to 98 years and 1511 (46.2%) were men. Previous cataract surgery had been performed in 107 (3.4%) of the participants. The overall prevalence of any type of cataract that had not been surgically corrected was 18%. If the presence of cataract as defined was considered the sole criterion for cataract surgery with no reference to visual acuity, there would be 309 cataract operations per 1000 people aged 40 and over (96 eyes of people who were not satisfied with their vision, 210 eyes of people who were satisfied with their vision, and three previous cataract operations). At a visual acuity criterion of less than 6/12 (the vision required to legally drive a car), 48 cataract operations per 1000 would occur and people would be twice as likely to report dissatisfaction with their vision. CONCLUSIONS: Estimates of the need for cataract surgery vary dramatically by level of lens opacity, visual acuity, and patient concern. These data should be useful for the planning of health services.     

Bilateral cystoid macular edema following successful treatment of AIDS-associated CMV retinitis

Background: Cystoid macular edema (CME) in AIDS patients with inactive cytomegalovirus (CMV) retinitis is an uncommon but potentially sight-threatening complication. The pathogenesis of CME in these patients is unclear. This study tries to identify possible risk factors by analyzing the charts of five patients. Methods: Ten eyes of 5 patients that finally developed CME were followed for an average of 18 months. The initial retinal lesions, their response to antiviral treatment, the development of CME, and the patients' immune status were prospectively monitored. Results: CMV retinitis was diagnosed at a median CD4+ count of 3 cells/mm³ (range 0–11). All eyes responded to the initial systemic anti-viral treatment. At the onset of CME, CMV retinitis was controlled by antiviral maintenance therapy in all patients [ganciclovir (n = 2), cidofovir (n = 2), foscarnet (n = 1)]. The median time between diagnosis of CMV retinitis and onset of CME was 11.5 months (range 5–24). Development of CME was associated with significant visual loss: acuity ranged from 0.05 to 0.7 when CME was first noticed, compared to 0.8–1.25 at diagnosis of CMV retinitis. Duration of inflammation, size or zone of retinal necrosis did not favor the development of CME, neither did the antiviral therapy. A weak correlation of CME development and immune status (expressed as increase of CD4+ cells) was found. Due to systemic corticosteroids CME resolved. Conclusions: CME is a new visual threat to AIDS-patients with CMV retinitis whose immune status improved under the latest combined antiretroviral therapy. Therapy with oral corticosteroids may positively influence this condition.      

The conduct of in vitro and in vivo drug-drug interaction studies: a Pharmaceutical Research and Manufacturers of America (PhRMA) perspective.

Current regulatory guidances do not address specific study designs for in vitro and in vivo drug-drug interaction studies. There is a common desire by regulatory authorities and by industry sponsors to harmonize approaches, to allow for a better assessment of the significance of findings across different studies and drugs. There is also a growing consensus for the standardization of cytochrome P450 (P450) probe substrates, inhibitors and inducers and for the development of classification systems to improve the communication of risk to health care providers and to patients. While existing guidances cover mainly P450-mediated drug interactions, the importance of other mechanisms, such as transporters, has been recognized more recently, and should also be addressed. This article was prepared by the Pharmaceutical Research and Manufacturers of America (PhRMA) Drug Metabolism and Clinical Pharmacology Technical Working Groups and represents the current industry position. The intent is to define a minimal best practice for in vitro and in vivo pharmacokinetic drug-drug interaction studies targeted to development (not discovery support) and to define a data package that can be expected by regulatory agencies in compound registration dossiers.     

Methylated DNA collected by tampons--a new tool to detect endometrial cancer.

This proof of principle study aimed to define a new and simple strategy for detection of endometrial cancer using epigenetic markers. We investigated DNA isolated from vaginal secretion collected from tampon for aberrant methylation of five genes (CDH13, HSPA2, MLH1, RASSF1A, and SOCS2) using MethyLight in 15 patients with endometrial cancer and 109 patients without endometrial cancer. All endometrial cancer patients revealed three or more methylated genes, whereas 91% (99 of 109) of the patients without endometrial cancer had no or fewer than three genes methylated in their vaginal secretion. The methods developed in this study provide the basis for a prospective clinical trial to screen asymptomatic women who are at high risk for endometrial cancer.