Improved outcome for children with acute lymphoblastic leukemia: results of Total Therapy Study XIIIB at St Jude Children's Research Hospital

St Jude Total Therapy Study XIIIB for childhood acute lymphoblastic leukemia (ALL) incorporated more stringent risk classification, early intensification of intrathecal chemotherapy, reinduction treatment, and the addition of dexamethasone to postremission therapy to increase the proportion of event-free survivors without jeopardizing their quality of life. Cranial irradiation was reserved for the 12% of patients who had T-cell ALL and a presenting leukocyte count of 100 x 10(9)/L or more, or CNS-3 (5 or more leukocytes/microL with identifiable blast cells in an atraumatic sample or the presence of cranial nerve palsy) status. Among the 247 consecutive patients enrolled in the study, 117 were classified as having lower-risk leukemia and received mainly antimetabolite-based continuation therapy; the 130 cases with higher-risk leukemia received more intensive continuation chemotherapy with multiple drug pairs administered in weekly rotation. The 5-year event-free survival estimate was 80.8% +/- 2.6% (SE); the 8-year rate was 78.6% +/- 5.8%. The 5-year cumulative risk of an isolated central nervous system (CNS) relapse was 1.7% +/- 0.8%, and that of isolated plus combined CNS relapse was 3.0% +/- 1.1%. The 5-year cumulative risks of etoposide-related myeloid malignancies were 1.8% +/- 1.3% in the lower-risk patients who received a cumulative dose of 1.2 g/m(2) and 5.0% +/- 2.0% in the higher-risk patients who received a cumulative dose of up to 14.4 g/m(2) (P = .18). Independent adverse prognostic features included the presence of MLL-AF4 or BCR-ABL fusion gene and minimal residual leukemia of 0.01% or more at the end of the 6-week remission induction phase. Our results suggest the efficacy of early intensification of intrathecal chemotherapy and provide the basis for studies omitting cranial irradiation altogether.     

Percepção Inadequada do Risco Cardiovascular e Baixo Conhecimento sobre Hipercolesterolemia Familiar em Indivíduos com Hipercolesterolemia Grave

BackgroundIndividuals with severe hypercholesterolemia are at a high risk of developing atherosclerotic cardiovascular disease (ASCVD). Many of them have familial hypercholesterolemia (FH).ObjectivesTo assess from a patient perspective the degree of awareness about severe hypercholesterolemia, especially FH, ASCVD risk perception, cascade screening performance, and treatment of individuals participating in a routine health evaluation program.MethodsFrom a database of 70,000 Brazilian individuals evaluated between 2006 and 2016, 1,987 (2.8%) met the inclusion criteria (age ≥ 18 years and LDL-C ≥ 190 mg/dL or ≥ 160 mg/dL, respectively, if not in use of statins or on statin therapy). Two-hundred individuals were randomly invited to complete an extensive questionnaire. FH was diagnosed if suspected by the attending physician.ResultsAlthough 97% of the sample (age 48±9 years; 16% women; 95% college/university education; 88% primary prevention; LDL-C 209±47 mg/dL) had severe hypercholesterolemia, only 18% and 29.5% believed to be at high ASCVD risk and reported knowledge of their recommended LDL-C goal, respectively. Fifty-eight percent reported being informed that high cholesterol could be a family disease, 24.5% (n = 49) had ever heard about FH, and merely 14% (n = 29) had been previously identified as suspected of having FH (age at FH diagnosis 35±12 years; 79% and 31% diagnosed, respectively, > 30 and > 40 years old). Only 2.5% underwent genetic tests, 17% underwent cascade screening, and 17% were not in use of pharmacological treatment.ConclusionsAn important gap in risk perception, cholesterol management, and aspects related to FH was encountered in individuals with severe hypercholesterolemia. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)     

A practical approach to reporting treatment abandonment in pediatric chronic conditions

Treatment abandonment, the failure to complete therapy that is required for definitive disease control, frequently causes treatment failure for pediatric patients in low‐ and middle‐income countries with chronic conditions, particularly cancer. Other forms of incomplete treatment affecting children in all settings, such as nonadherence and loss to follow‐up, are often confused with treatment abandonment. Unclear definitions of incomplete treatment dramatically affect reported outcomes. To facilitate disease‐specific and cross‐sector analyses, we outline a practical approach to categorize forms of incomplete treatment, present distinct semantic categories with case examples and provide an algorithm that could be tailored to disease‐ and context‐specific needs. Pediatr Blood Cancer 2015;62:565–570. © 2015 Wiley Periodicals, Inc.     

Adenosine triphosphate/adenosine guided pulmonary vein isolation does not improve the outcomes of ablation: a meta-analysis of randomized controlled trials

Background: Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs).

Objectives: To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis.

Methods and results: Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 s after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p = 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p = 0.98].

Conclusions: ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.     

Hispanic Men in the United States: Acculturation and Recent Sexual Behaviors With Female Partners, 2006–2010

Objectives. We examined Hispanic men’s recent risky and protective sexual behaviors with female partners by acculturation.Methods. Using the 2006–2010 National Survey of Family Growth, we performed bivariate analyses to compare acculturation groups (Hispanic Spanish-speaking immigrants, Hispanic English-speaking immigrants, Hispanic US natives, and non-Hispanic White men) by demographics and recent sexual behaviors with women. Multivariable logistic regression models for sexual behaviors by acculturation group were adjusted for demographics.Results. Compared with Hispanic Spanish-speaking immigrants, non-Hispanic White men were less likely to report exchange of money or drugs for sex (adjusted odds ratio [AOR] = 0.3; 95% confidence interval [CI] = 0.1, 0.9), but were also less likely to report condom use at last vaginal (AOR = 0.6; 95% CI = 0.4, 0.8) and anal sex (AOR = 0.4; 95% CI = 0.3, 0.7). Hispanic US natives were less likely to report condom use at last vaginal sex than were Spanish-speaking immigrants (AOR = 0.6; 95% CI = 0.4, 0.8). English- and Spanish-speaking immigrants did not differ in risky or protective sexual behaviors.Conclusions. Our findings suggest that targeted interventions focusing on unique sexual risks and sociodemographic differences by acculturation level, particularly nativity, may be helpful for preventing sexually transmitted infections.In the United States, Hispanics are one of the subpopulations disproportionately affected by sexually transmitted infections (STIs).1 In 2010, reported cases of chlamydia were 2.7 times higher for Hispanics than for non-Hispanic Whites.1 Similarly, primary and secondary syphilis cases were 2.2 times higher for Hispanics than for non-Hispanic Whites, an increase of 9.5% since 2009.1 Reported gonorrhea rates were also 2.2 times higher for Hispanics than for non-Hispanic Whites. Regarding gender, the racial/ethnic disparity in gonorrhea rates was higher for men (48.7 per 100 000 for Hispanics vs 19.5 per 100 000 for non-Hispanic Whites) than for women (51.1 per 100 000 for Hispanics vs 26.6 per 100 000 for non-Hispanic Whites).1 Among young adult men (18–26 years), STI disparities were even greater; among Hispanic men, the prevalence of chlamydia and gonorrhea was 5.3 and 4.1 times higher than for non-Hispanic White men, respectively.2Research has shown that Hispanics face many unique challenges that increase their risks for STIs, including immigration-related challenges, living apart from their spouse or regular partner, language barriers, racism, social isolation, and limited access to health care.1,3–5 Compared with non-Hispanic Whites, Hispanics often also have higher poverty, unemployment, and high school dropout rates, and are younger.1,4,6 From 2000 to 2010, the Hispanic population in the United States increased by more than 15.2 million (an increase of 43%), contributing to half of the total population growth in the country.7 Because of the growing Hispanic population, the disproportionate burden of STIs, and the numerous barriers and challenges increasing their risk for STIs, an assessment of the sexual behaviors of Hispanics, including risk and protective behaviors, are of public health importance.An epidemiological concept known as the Hispanic paradox posits that health outcomes for Hispanics tend to be more similar to those of non-Hispanic Whites than those of non-Hispanic Blacks because of less acculturation, or “Americanization,” among Hispanics, which has been shown to be associated with lower sexual risk behaviors and better health outcomes.8–10 Some research suggests that the Hispanic paradox is variable and fluid or may not exist at all.11,12 Although many studies have examined the relationship between acculturation and sexual risk behaviors that are related to STI transmission, most of this research has focused on Hispanic women, adolescents, or men who have sex with men.13–22 Fewer studies have examined differences among Hispanic men in their sexual behaviors with female partners in terms of acculturation group. One study found that low-income, recent-immigrant Hispanic men (living in the United States less than 5 years) were more likely to commercially exchange sexual services and less likely to have a main sex partner than established immigrants (living in the United States for more than 5 years).23 Conversely, established Hispanic immigrant men were more likely to report unprotected sexual intercourse and multiple sex partners than recent immigrants.23 For protective behaviors, condom use at last sex did not significantly differ by acculturation among Hispanic men, although condom use is positively associated with acculturation for women.18,24,25 All of these studies were restricted to specific local areas.Acculturation of Hispanics has been measured in many ways—the use of a single variable, a combination of variables, or scales developed to capture the various aspects of acculturation. Complex measures of acculturation include attitudinal and behavioral factors focused on cultural values.10 More intricate scales of acculturation include heritage and mainstream scales with measures of attitude, behavior, and social relations.10,26 However, it is difficult to include comprehensive measures of acculturation in national surveys that have limited space and competing interests. Measures such as language, country of origin, nativity, and length of time in the country are considered proxy measures of acculturation.11,13,19,27–29 The most frequently used variable to measure acculturation is language of interview (English or Spanish) or the language spoken at home.3,13,14,17,19,21,22,24,27–33 Although acculturation is a multifaceted concept, research suggests that language preference may be a reliable proxy for more complex acculturation measures of Hispanics living in the United States.17For an examination of differences in Hispanic men’s sexual behaviors with female partners by level of acculturation, a national-level examination is useful given the diversity of the Hispanic population in the United States, where origin (Mexican, Puerto Rican, Cuban, Central American, etc.) differs by geography.34 Using data from a national survey, we analyzed the recent sexual behaviors of acculturation groups of Hispanic men (categorized by language of interview and nativity) and compared them with those of non-Hispanic White men. Specifically, we sought to examine differences in recent risky and protective sexual behaviors with female partners among acculturation groups using the 2006–2010 National Survey of Family Growth (NSFG).     

Anesthesia for subcutaneous implantable cardioverter‐defibrillator implantation: Perspectives from the clinical experience of a U.S. panel of physicians

1 Background and objective

Worldwide adoption of the subcutaneous implantable cardioverter‐defibrillator (S‐ICD) for preventing sudden cardiac death continues to increase, as longer‐term evidence demonstrating the safety and efficacy of the S‐ICD expands. As a relatively new technology, comprehensive anesthesia guidance for the management of patients undergoing S‐ICD placement is lacking. This article presents advantages and disadvantages of different periprocedural sedation and anesthesia options for S‐ICD implants including general anesthesia, monitored anesthesia care, regional anesthesia, and nonanesthesia personnel administered sedation and analgesia.

2 Methods

Guidance, for approaches to anesthesia care during S‐ICD implantation, is presented based upon literature review and consensus of a panel of high‐volume S‐ICD implanters, a regional anesthesiologist, and a cardiothoracic anesthesiologist with significant S‐ICD experience. The panel developed suggested actions for perioperative sedation, anesthesia, surgical practices, and a decision algorithm for S‐ICD implantation.

3 Conclusions

While S‐ICD implantation currently requires higher sedation than transvenous ICD systems, the panel consensus is that general anesthesia is not required or is obligatory for the majority of patients for the experienced S‐ICD implanter. The focus of the implanting physician and the anesthesia services should be to maximize patient comfort and take into consideration patient‐specific comorbidities, with a low threshold to consult the anesthesiology team.     

Lethal and sublethal effects of azadirachtin on the bumblebee Bombus terrestris (Hymenoptera: Apidae)

Ecotoxicology - Azadirachtin is a biorational insecticide commonly reported as selective to a range of beneficial insects. Nonetheless, only few studies have been carried out with pollinators,...     

Comparable long-term outcomes between DAS28-ESR remission criteria and ACR/EULAR definitions in patients with established rheumatoid arthritis

Clinical Rheumatology - To compare long-term clinical, immunological, and radiographic outcomes between five sets of remission criteria (four clinical and one ultrasound (US)-based) in a cohort of...     

Varicella zoster virus in health care workers in northern Israel: seroprevalence and predictive value of history of varicella infection

Health care workers (HCWs) are susceptible to hospital acquired varicella zoster virus (VZV). We evaluated seroprevalence and predictive value of a history of varicella disease (VD) with VZV serology in HCWs in northern Israel. A total of 200 HCWs were enrolled. A high rate of seropositivity for VZV-IgG was found: 98.5% seropositive and only 1.5% seronegative. A positive history of VD was an excellent predictor for the presence of VZV-IgG; however, a negative history of VD does not rule out the presence of VZV-IgG.