Pain improvement in rheumatoid arthritis with hyperbaric oxygen: report of three cases.

Rheumatoid arthritis (RA) is a chronic, erosive, symmetrical inflammatory disease that can progress to synovial destruction, severe disability and premature mortality. Immunotherapies, while beneficial, can cause significant adverse events. Three patients with RA treated in our facility with hyperbaric oxygen (HBO2) for unrelated diagnoses all reported significant but unanticipated improvement in RA-related pain, increased activity and improved sleeping patterns. Two improved while continuing traditional RA medications; the other patient had all RA meds held due to cancer and postoperative wound healing problems. The significant symptomatic improvement in these three patients led us to hypothesize that HBO2 for patients with RA may result in decreased joint pain, increased activity level, improvement in sleeping patterns and possibly a decreased need for standard rheumatologic medications, effectively reducing or avoiding the effects of immunosuppression. A clinical trial is planned to objectively assess these findings.

Toward real-time reporting of cancer incidence: methodology, pilot study, and SEER Program implementation.

BACKGROUND: A lag time between cancer case diagnosis and incidence reporting impedes the ability to monitor the impact of recent events on cancer incidence. Currently, the data submission standard is 22 months after a diagnosis year ends, and the reporting standard is 27.5 months after a diagnosis year ends. This paper presents the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program's efforts to minimize the lag and achieve "real-time" reporting, operationalized as submission within 2 months from the end of a diagnosis year. METHODS: Technology for rapidly creating a consolidated tumor case (CTC) from electronic pathology (e-path) reports is described. Statistical methods are extended to adjust for biases in incidence rates due to reporting delays for the most recent diagnosis years. RESULTS: A registry pilot study demonstrated that real-time submissions can approximate rates obtained from 22-month submissions after adjusting for reporting delays. A plan to be implemented across the SEER Program rapidly ascertains unstructured e-path reports and uses machine learning algorithms to translate the reports into the core data items that comprise a CTC for incidence reporting. Across the program, cases were submitted 2 months after the end of the calendar year. Registries with the most promising baseline values and a willingness to modify registry operations have joined a program to become certified as real-time reporting. CONCLUSION: Advances in electronic reporting, natural language processing, registry operations, and statistical methodology, energized by the SEER Program's mobilization and coordination of these efforts, will make real-time reporting an achievable goal.

Early changes in the biophysical properties of the aorta in pre-adolescent children born small for gestational age.

OBJECTIVE: To assess the biophysical properties of the aorta in children born small for gestational age (SGA) with an echo-Doppler method and to determine associations with known perinatal risk factors. STUDY DESIGN: In this cross-sectional study, 39 SGA and 41 control subjects aged 8 to 13 years were recruited. Perinatal risk factors were recorded. The aortic diameters and pulse wave transit time around the aortic arch were measured with echo-Doppler and the blood pressure recorded. Pulse wave velocity, aortic input impedance (Zi), characteristic impedance (Zc), arterial pressure-strain elastic modulus (Ep), and arterial wall stiffness index (beta-index) were calculated. RESULTS: Pulse wave velocity (374 +/- 46 vs 348 +/- 47 cm/sec, P < .02); Zi (177 +/- 39 vs 142 +/- 27 dynes x sec/cm(5), P < .0001); Zc (185 +/- 29 vs 152 +/- 37 dynes x sec/cm(5), P < .0001); Ep (286 +/- 101 vs 216 +/- 41 mm Hg, P < .0001); and beta-index (2.43 +/- 0.32 vs 2.17 +/- 0.15, P < .0001) were all higher in SGA. We found negative associations between the following: birth weight and Zi, Zc, Ep, and beta-index; as well as body mass index and Zi, Zc. CONCLUSION: This simple echo-Doppler method demonstrated abnormal biophysical properties of the aorta in a cohort of pre-adolescent patients born SGA who remain small in stature and continue to have normal blood pressure.

Lessons learned from a pilot randomized controlled trial of dyadic interpersonal psychotherapy for perinatal depression in a low-income population.

BACKGROUND: Perinatal depression is a public health burden impacting mothers and their offspring. This study extended brief-Interpersonal Psychotherapy delivered during pregnancy by incorporating a postpartum attachment based dyadic-component to maintain mother's treatment gains and enhance the mother-infant relationship (called IPT-Dyad). The current report presents data from a pilot randomized controlled trial comparing IPT-Dyad to Enhanced Treatment as Usual (ETAU). METHODS: Women, ages 18 and older, between 12-30 weeks gestation meeting criteria for a depressive disorder were eligible. Participants were randomized to either IPT-Dyad (n = 21) or ETAU (n = 21). Maternal and infant outcomes were assessed through one-year postpartum. RESULTS: Participants were primarily African American (77%), single (80%), with low-incomes. Attrition was high in both groups (IPT-Dyad 30%; ETAU 40%). Depression scores improved from baseline in both groups and remained improved over the 12 month follow-up. There were no between group differences on measures of parenting stress, mother-infant interactions, and infant socioemotional functioning. LIMITATIONS: The small sample size of this study was further reduced by attrition, despite efforts to maintain engagement. Reliance on self-report outcome measures is also a limitation. CONCLUSIONS: IPT-Dyad may be a promising intervention for perinatal depression with potential benefit for mothers and babies. Treatment engagement and management of psychosocial needs were persistent challenges throughout the postpartum period. Further refinement of intervention content and schedule to better meet the needs and values of under-resourced mothers is needed. Earlier screening; better integration of care within OB settings; and delivering care in conjunction with social service resources may also improve outcomes.

Abnormal flow in the posterior descending artery: an echo Doppler clue to the anomalous origin of left anterior descending coronary artery from the pulmonary trunk.

Anomalous origin of the left anterior descending coronary (LAD) from the pulmonary trunk is a rare lesion. We describe a neonate with anomalous origin of the LAD from the pulmonary artery and the circumflex artery arising normally from the left-facing sinus. The finding of a tortuous and dilated posterior descending coronary artery suggested increased intercoronary collateral flow and provided a clue to the identification of the anomaly in an otherwise asymptomatic neonate. Interrogation of the posterior descending coronary artery should be included in the routine echocardiographic examination of children, as unusual flow patterns may help identify aberrant coronary artery connections.

Brief Interpersonal Psychotherapy for depression during pregnancy in a low-income population: A randomized controlled trial.

BACKGROUND: Depression is common in low-income pregnant women, and treatments need to be fitted to meet their needs. We conducted a randomized controlled trial comparing brief Interpersonal Psychotherapy (brief-IPT) to enhanced treatment as usual (ETAU) for perinatal depression in low-income women. The brief-IPT model is designed to better engage low-income women by utilizing an engagement session, providing flexible delivery of sessions, and pragmatic case management. METHODS: Pregnant women, aged ≥18, between 12 and 30 weeks gestation were recruited from an urban prenatal clinic. Women scoring ≥10 on the Edinburgh Depression Scale and meeting depressive disorder criteria were randomized to either brief-IPT (n=21) or ETAU (n=21). We assessed treatment outcomes, acceptability, and feasibility of the intervention (measured by session attendance). RESULTS: Depression scores significantly decreased in both brief-IPT and ETAU. Brief-IPT participants reported significant improvements in social support satisfaction as compared to ETAU participants, even after controlling for concurrent depressive symptoms. Brief-IPT participants reported high satisfaction with the program. However, many participants did not participate in the full 9-session course of treatment (average sessions attended =6, range 0-17). LIMITATIONS: Small sample size, use of self-report measures, and lack of an active psychotherapy control group limits interpretation of study results. CONCLUSIONS: Brief-IPT for perinatal depression is acceptable to low-income women and is helpful for improving depressive symptoms and social support. However, feasibility of the treatment was limited by relatively low session attendance in spite of efforts to maximize treatment engagement. Additional modifications to meet the needs of low-income women are discussed.

SEER*Educate-Learn by Doing.

Historically, newly hired staff members were trained using a labor intensive one-on-one strategy and experienced staff participated in monthly education meetings. With the ever-expanding data collection requirements and guideline changes, helping every staff member remain current became impossible to achieve using this methodology. To better address the training needs of each staff member and to do so in a cost effective way, a comprehensive e-training platform was designed.

SEER*Educate: Use of Abstracting Quality Index Scores to Monitor Improvement of All Employees.

Integral parts of the Seattle-Puget Sound's Cancer Surveillance System registry's continuous improvement model include the incorporation of SEER*Educate into its training program for all staff and analyzing assessment results using the Abstracting Quality Index (AQI). The AQI offers a comprehensive measure of overall performance in SEER*Educate, which is a Web-based application used to personalize learning and diagnostically pinpoint each staff member's place on the AQI continuum. The assessment results are tallied from 6 abstracting standards within 2 domains: incidence reporting and coding accuracy. More than 100 data items are aligned to 1 or more of the 6 standards to build an aggregated score that is placed on a continuum for continuous improvement. The AQI score accurately identifies those individuals who have a good understanding of how to apply the 6 abstracting standards to reliably generate high quality abstracts.

Echocardiographic Doppler assessment of the biophysical properties of the aorta in pediatric patients with the Marfan syndrome.

In the Marfan syndrome (MS), aortic root involvement is usually clinically monitored according to the aortic sinus of Valsalva dilation. Using an echocardiographic Doppler method in this cross-sectional study, abnormal biophysical properties of the ascending aorta were found in pediatric patients with MS compared with healthy controls but not consistently in association with the aortic sinus of Valsalva dilation.

A randomized, double blind pilot study to assess the effects of losartan vs. atenolol on the biophysical properties of the aorta in patients with Marfan and Loeys-Dietz syndromes.

BACKGROUND: Patients with Marfan (MFS) and Loeys-Dietz (LDS) syndromes have been shown to have abnormal aortic biophysical properties. The purpose of this study was to compare the effects of 12-months of therapy with atenolol or losartan on vascular function in young patients with MFS and LDS. METHODS: Seventeen patients with MFS or LDS were recruited and randomized to treatment with atenolol, 25-50mg, or losartan, 25mg daily. Prior to treatment and following therapy, echocardiography for left ventricular size, function and aortic root size was performed. Pulse wave velocity (PWV), input (Zi, ZiF) and characteristic (Zc, ZcF) impedances, arterial stiffness (Ep and ß-index), total arterial compliance (TAC), mean (Wm) and total (Wt) hydraulic power, efficiency, power cost per unit of forward flow (Wt/CI) and brachial artery flow-mediated dilation (FMD) were measured. RESULTS: The atenolol group consisted of 9 females (17.6years) and the losartan group 7 males and 1 female (17.0years). Their height, weight, BSA, BMI, systolic and diastolic blood pressures were similar. Baseline to 12-month changes for atenolol and losartan were PWV (20% vs -14%), Zi (-2% vs -27%), Zc (-20% vs -27%), Ep (1%, vs -13%), ß-index (10% vs 14%), FMD (11% vs 20%), TAC (3% vs 42%), Wm (-24% vs 15%), Wt (-24% vs 17%), and Wt/CI (3% vs 21%). There was a trend for losartan to decrease PWV and stiffness indexes while atenolol decreased power and power/unit flow. CONCLUSION: This pilot study suggests that atenolol and losartan may have different mechanisms of action on vascular function. A larger clinical trial is needed to confirm these effects.Clinical trials registration NCT00593710 (ClinicalTrials.gov).

A novel Doppler echocardiographic method of measuring the biophysical properties of the aorta in pediatric patients.

BACKGROUND: This study was performed to: (1) assess the feasibility of measuring pulse wave velocity (PWV) from aortic (AO) Doppler flow and deriving AO input and characteristic impedances and the arterial pressure strain elastic modulus; and (2) compare these indices in pediatric patients with arterial disease to control (C) patients. METHODS: There were 14 healthy children in the C group, 9 with inflammatory connective tissue diseases (ICTD), and 6 with Marfan syndrome (M). Using standard echocardiographic equipment, the AO annulus, AO root diameter in systole (AO(S)) and diastole (AO(D)), and AO length (L) were measured. The time taken for the Doppler signal to travel from the ascending to descending aorta was measured. AO peak flow was calculated from AO annulus cross-sectional area x peak aortic velocity (AoV); PWV = L/time taken for the Doppler signal to travel from the ascending to descending aorta; input impedance = (systolic - diastolic blood pressure)/(AO cross-sectional area x AoV); characteristic impedance = (PWV x rho)/Ao cross-sectional area (where rho = 1.06); and pressure strain elastic modulus = (systolic - diastolic blood pressure)/[(AO(S) - AO(D))/AO(D)]; beta index = ln (systolic/diastolic blood pressure)/[(AO(S) - AO(D))/AO(D)]. RESULTS: Results for PWV were ICTD = M > C (533, 496, 362 cm/s; P <.02); for input impedance were ICTD > M = C (245, 120, 116; P <.03); for characteristic impedance were ICTD < M = C (249, 107, 142; P <.05); for pressure strain elastic modulus were M > ICTD = C (262, 447, 187; P <.003); and for beta index were M > ICTD > C (2.91, 2.51, 2.13; P <.0006). CONCLUSIONS: This novel, relatively simple method of assessing the biophysical properties of the aorta shows abnormal function in patients with M and ICTD. This technique may be helpful in the long-term follow up of patients with arterial disease.

Utilization of cancer registry data for monitoring quality of care.

BACKGROUND: Cancer Program Practice Profile Reports (CP(3)R), established by the Commission on Cancer, are based on 6 guidelines for breast and colorectal cancer care using cancer registry data. The long-term goal is the use of cancer registry data for real-time interventions to optimize the process of individual patient multidisciplinary care. METHODS: CP(3)R results using 593 analytic breast cancer cases in 2008 were compared in 3 databases: an institutional breast cancer research database, an institutional cancer registry, and a regional Cancer Surveillance System. RESULTS: Compliance with the CP(3)R guidelines calculated using the 3 databases was 80% to 98% for radiation therapy following breast-conserving surgery, 78% to 88% for combination chemotherapy of hormone receptor-negative stage T1c, II, or III disease, and 53% to 85% for hormone therapy of hormone receptor-positive stage T1c, II, or III disease. There was a high rate of discrepancy of tumor characteristics, treatment, and CP(3)R resulting from inaccurate and incomplete data. CONCLUSIONS: Using national cancer databases prospectively to monitor and ensure optimal multidisciplinary cancer care will require dramatic changes in cancer registry processes.

Echocardiographic tools for pacemaker optimization of ventricular function in an infant following surgical repair for double outlet right ventricle.

A case of an infant, following surgical repair for double outlet right ventricle, who developed low cardiac output syndrome and complete heart block that required insertion of a pacemaker is presented. The infant underwent optimization of his ventricular function to determine whether pacing the right ventricle or left ventricle or both would improve cardiac function. Using standard two-dimensional echocardiography and Doppler imaging, tissue synchronization imaging, and two-dimensional speckle-tracking strain analysis, improvement in cardiac output and function was demonstrated. The present case highlights the usefulness of newer echocardiographic techniques in pacemaker optimization in the acute postoperative setting.

Feasibility study for collection of HER2 data by National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program central cancer registries.

The clinical importance of human epidermal growth factor receptor-2 (HER2) in breast cancer is now clearly established, given that expression of this tumor marker is used to guide therapy and as a prognostic indicator. Despite its now routine evaluation in breast cancer patients, population-based data are lacking because information on HER2 status is not routinely collected in the majority of population-based cancer registries. We assessed the feasibility of collecting HER2 data and its completeness in three registries in the Surveillance Epidemiology and End Results (SEER) Program. Among a sample of invasive first primary breast cancer patients diagnosed between June and December 2007, HER2 tests had been done on 96.5% (n = 522), and test results were available for 95.2% (n = 515) of patients. The majority of HER2 tests were performed by immunohistochemistry alone (50.9%), 35.3% by both immunohistochemistry and fluorescence in situ hybridization (FISH), and 11.8% of tests by FISH alone. As a result of these findings, SEER registries will collect HER2 data on all invasive breast cancer patients as an optional data element for those diagnosed in 2009 and HER2 will likely be a required data element for these patients in 2010.

A stress echocardiography study of cardiac function during progressive exercise in pediatric oncology patients treated with anthracyclines.

BACKGROUND: Anthracycline-treated patients (AP) are at risk for cardiac dysfunction years after treatment. Cardiac function has not been evaluated during exercise in AP. The purpose of this study was to assess exercise tolerance, left ventricular (LV) function, and hemodynamics during progressive exercise. PROCEDURE: We studied 47 AP (cumulative dose: 36-504 mg/m(2)) who were in complete remission and 12 healthy controls (CON). AP were further grouped by cumulative dose (LOW or= 260 mg/m(2)) and resting echocardiographic function. All subjects performed 3-min incremental stages on a semi-recumbent cycle ergometer until volitional fatigue. Using echocardiography and Doppler, LV dimensions, posterior wall thickness (LVPWs), peak aortic velocity (PAoV), shortening fraction (SF), rate-corrected mean velocity of fiber shortening (MVCFc), wall stress at peak systole (sigmaPS), stroke volume index (SVI), and cardiac index (CI) were determined. Measurements were performed at rest, during each stage of exercise, and in recovery. RESULTS: AP did less work than CON (P < 0.050). CON and LOW had similar resting function, while HIGH had a lower SF and MVCFc (P < 0.050) and a higher sigmaPS (P < 0.001). Resting SVI and CI were also lower in HIGH. At peak exercise, MVCFc and sigmaPS remained different in HIGH, and both AP groups had a lower SF, SVI, and CI (P < 0.001). AP had an abnormal SVI response to exercise. AP showed a smaller initial increase in SVI that was not maintained throughout exercise. CONCLUSIONS: AP have reduced exercise tolerance. There also appears to be a dose-related effect on myocardial contractility and SVI. These findings may help to guide treatment.