A Provider-Based Approach to Address Racial Disparities in Lupus Clinical Trial Participation.

OBJECTIVE: Substantial disparities exist in clinical trial participation, which is problematic in diseases such as lupus that disproportionately affect racial/ethnic minority populations. Our objective was to examine the effectiveness of an online educational course aiming to train medical providers to refer Black and Latino patients to lupus clinical trials (LCTs). METHODS: The American College of Rheumatology's Materials to Increase Minority Involvement in Clinical Trials (MIMICT) study used an online, randomized, 2-group, pretest/posttest design with medical and nursing providers of multiple specialties. We exposed intervention group participants to an education course, while the control group participants received no intervention. Controlling for the effects of participant characteristics, including specialty, and professional experience with lupus, we modeled relationships among exposure to the education course and changes in knowledge, attitudes, self-efficacy, and intentions to refer Black and Latino patients to LCTs. We also examined education course satisfaction. RESULTS: Compared to the control group, the intervention group had significantly higher posttest scores for knowledge, self-efficacy, and intentions to refer Black and Latino patients to LCTs. Both medical and nursing trained intervention group participants had significantly higher mean posttest scores for knowledge and intentions to refer compared to the medical and nursing trained control group participants. Attitude was insignificant in analysis. The online education course, which received a favorable summary score, indicated that satisfaction and intentions to refer were strongly and positively correlated. CONCLUSION: The MIMICT education course is an effective method to educate medical providers about LCTs and to improve their intentions to refer Black and Latino patients.

Applicability and safety of discontinuous ADVanced Organ Support (ADVOS) in the treatment of patients with acute-on-chronic liver failure (ACLF) outside of intensive care.

BACKGROUND: ADVanced Organ Support (ADVOS) is a novel type of extracorporeal albumin dialysis and holds promise to sustain liver function and recovery of patients with acute-on-chronic liver failure (ACLF). Previously, ADVOS was tested as continuous treatment for intensive care patients with liver failure. Data related to the applicability and safety as discontinuous treatment outside of ICU is not available. AIM: Evaluation of ADVOS as discontinuous treatment for patients with ACLF outside intensive care unit and comparison with a matched historic cohort. METHODS AND RESULTS: In this retrospective study, 26 patients with ACLF and the indication for renal replacement therapy related to HRS-AKI were included. Majority of patients were male (65%) with alcoholic cirrhosis in 88% and infections as a trigger of ACLF in 96%. Liver function was severely compromised reflected by high median MELD and CLIF-C ACLF scores of 37 (IQR 32;40) and 56.5 (IQR 51;60), respectively. Patients were treated discontinuously with ADVOS over a median time of 12 days (IQR 8.25;17) and received 8 (IQR 4.25;9.75) treatment cycles on average. No treatment related adverse events were recorded, and safety laboratory parameters remained constant during the observation time. After 16 h cumulative dialysis therapy, ADVOS significantly reduced protein-bound bilirubin (14%), creatinine (11.8%) and blood urea nitrogen (BUN, 33%). Using a matched cohort with ACLF treated with hemodialysis, ADVOS achieved a stronger decrease in bilirubin (p = 0.01), while detoxification of water-soluble catabolites' including creatinine and BUN was comparable. The 28-days mortality in the ADVOS group was 56% (14/26) and was not inferior to predicted survival (predicted median 28-days mortality was 44%, IQR 30; 59). CONCLUSION: Discontinuous ADVOS treatment was safe and effective in patients with ACLF outside intensive care and outperformed hemodialysis in reducing protein-bound metabolites.

[A case report on mobbing in a school child]. / Mobbing in der Grundstufe - ein Fallbericht.

Forty percent of the work of a paediatrician in private practice consists of counselling parents and children. There is a danger that behavioural symptoms are not taken seriously and brushed away with simple advices. This case vignette demonstrates that difficult and complex symptoms can be solved by using a concept-oriented approach.

Challenges in measuring obstetric fistula.

Obstetric fistula is gaining visibility within national and international public health agencies. With increased attention to this dire condition comes the demand for better epidemiologic data. This article assesses the current state of knowledge regarding population-based estimates of the incidence and prevalence of obstetric fistulas; proposes a method for better estimating these rates; and discusses the feasibility of this method. We show that there are no solid population-based estimates of the numbers of obstetric fistulas anywhere (the estimate from the most rigorous study being based on only 2 reported fistula cases); and for advocacy purposes, we recommend using the estimates from the 1990 Global Burden of Disease report. To estimate the incidence and prevalence of obstetric fistula, we propose an adaptation of the sibling-based method for direct estimation of maternal mortality. A series of questions are proposed for this use and sample size calculations are provided. The questions may require refinement, however, and we invite research groups to consider testing them.

Social and economic consequences of obstetric fistula: life changed forever?

OBJECTIVES: To summarize the social, economic, emotional, and psychological consequences incurred by women with obstetric fistula; present the results of a meta-analysis for 2 major consequences, divorce/separation and perinatal loss; and report on improvements in health and self-esteem and on the possibility of social reintegration following successful fistula repair. METHODS: We conducted a review of the literature published between 1985 and 2005 on fistula in developing countries. We then performed a meta-analysis for 2 of the major consequences of having a fistula, divorce/separation and perinatal child loss. RESULTS: Studies suggest that surgical treatment usually closes the fistula and improves the physical and mental health of affected women. CONCLUSION: With additional social support and counseling, women may be able to successfully reintegrate socially following fistula repair.

Dietary exposures to food contaminants across the United States.

Food consumption is an important route of human exposure to pesticides and industrial pollutants. Average dietary exposures to 37 pollutants were calculated for the whole United States population and for children under age 12 years by combining contaminant data with food consumption data and summing across food types. Pollutant exposures were compared to benchmark concentrations, which are based on standard toxicological references, for cancer and noncancer health effects. Average food ingestion exposures for the whole population exceeded benchmark concentrations for arsenic, chlordane, DDT, dieldrin, dioxins, and polychlorinated biphenyls, when nondetects were assumed to be equal to zero. For each of these pollutants, exposure through fish consumption accounts for a large percentage of food exposures. Exposure data for childhood age groups indicated that benchmark concentrations for the six identified pollutants are exceeded by the time age 12 years is reached. The methods used in this analysis could underestimate risks from childhood exposure, as children have a longer time to develop tumors and they may be more susceptible to carcinogens; therefore, there may be several additional contaminants of concern. In addition, several additional pollutants exceeded benchmark levels when nondetects were assumed to be equal to one half the detection limit. Uncertainties in exposure levels may be large, primarily because of numerous samples with contaminant levels below detection limits.

Characterization of murine dendritic cells derived from adherent blood mononuclear cells in vitro.

The therapeutic potential of dendritic cells loaded with tumour antigens for the induction of effective immune responses against cancer is currently being tested in numerous clinical trials. In most cases, the dendritic cells are generated in vitro from peripheral blood monocytes. Many aspects of dendritic cell-based vaccination have not yet been examined in detail, and homologous mouse model systems may prove very valuable for optimizing clinical procedures. In the murine system, however, dendritic cells are usually isolated from either lymphoid tissues or bone marrow cultures. To date, murine monocyte-derived dendritic cells have been described only sporadically. Here, we describe a culture system for the generation of murine dendritic cells from adherent peripheral blood mononuclear cells by culturing in the presence of granulocyte-macrophage colony stimulating factor and interleukin-4. After 7 days of culture the nonadherent cells were harvested from the cultures. Most of these cells exhibited well-accepted characteristics of mature dendritic cells (e.g. veiled appearance, high expression of major histocompatibility complex class II and CD86) and stimulated vigorous proliferation of allogeneic T cells in a primary mixed leucocyte reaction following stimulation with bacterial lipopolysaccharide. Interestingly, staining the cells for expression of the putative antigen-uptake receptor DEC-205 revealed a distinct bimodal distribution.

Strain-specific variations in the development of dendritic cells in murine bone-marrow cultures.

The dendritic cell (DC) is a professional antigen-presenting cell of central importance in immunity. In this paper, we examined DCs generated by 11-day culture of bone-marrow cells from the four mouse strains C57BL/6J, BALB/cA, C3H/HeN and B10.PL-H2u (73NS)/Sn with respect to cell yield as well as surface-marker phenotype and morphology. We also investigated the phenotypic changes and the T-cell stimulatory activity of the DCs induced by bacterial lipopolysaccharide (LPS). Morphologically, we observed low levels (5-10%) of granulocyte contamination of the cultures after a culture period of 11 days. Considerable strain-specific differences were found in the expression levels of the surface markers in addition to the differences in the ratio of the immature to mature DCs in the cultures that were not stimulated with LPS. Furthermore, we found that LPS strongly induces maturation of DCs in all strains investigated with the exception of the B10.PL strain.

Postoperative capsular bag distension.

Seven cases of capsular bag distension following capsulorhexis and phacoemulsification with posterior chamber intraocular lens insertion are presented. The proposed physiological mechanism, associated consequences, and complications and treatment are presented.

Gammopathy with proximal motor axonopathy simulating motor neuron disease.

We report a 38-year-old man with a pure motor syndrome and IgM gammopathy leading to flaccid quadriplegia. Improvement followed treatment with dexamethasone, cyclophosphamide, and plasmapheresis, but he died of pulmonary embolism. At autopsy, he had a proximal motor axonopathy with lymphocytic infiltration of ventral roots. Proximal motor neuropathy may masquerade as motor neuron disease. The association with gammopathy and response to treatment suggest that patients with motor neuron disease should be routinely screened for serum protein abnormalities.

Descemet membrane detachment.

Four eyes of three patients had extensive postoperative Descemet membrane (DM) detachment. Blood was present just anterior to the DM in three of the four eyes and later converted to and persisted as pigment. Haziness of the cornea at the level of the DM could be seen with reattachment. Detachments of the DM are classified as planar when there is 1 mm or less separation of the DM from its overlying stroma in all areas. Nonplanar DM detachments exceed 1 mm of separation. Planar detachments have a much better prognosis than nonplanar detachments do, with or without descemetopexy. Repair of DM detachments, when necessary, should include air injection, with the lease possible instrumentation of the DM.

The retrotracheal space.

The retrotracheal space may be abnormal when a frontal chest radiograph is normal. Common abnormalities, seen usually on the lateral view, are widening of the anterior soft tissue stripe separating the tracheal air column from the clear space behind it, and a mass density overlying the space. A barium esophagram generally facilitates the diagnosis.