Contemporary evaluation of estrogen receptor and progesterone receptor expression in breast cancer-associated stroma.

PURPOSE: To investigate nuclear estrogen receptor α (ERα) and progesterone receptor (PR) immunohistochemistry (IHC) patterns in the stroma surrounding invasive carcinoma and assess associations with clinicopathologic features. METHODS: A retrospective database search (1/2017-12/2020) identified breast core biopsies with invasive carcinoma. ERα/PR IHC expression in invasive carcinoma and stromal cells was categorized visually as positive (> 10%), low positive (1-10%) or negative (< 1%). Tumors were divided into 4 subtypes by IHC: Luminal, Luminal HER2, HER2 enriched, and triple negative. Clinicopathologic features associated (univariate p-value < 0.15) with ERα/PR stromal expression were investigated further using stepwise multivariable logistic regression. RESULTS: Of 1512 biopsies, 1278 had accessible IHC. 55.6% (711/1278) and 10.4% (133/1274) of cases showed cancer-associated stromal fibroblast expression of ERα and PR, respectively. Stromal ER positivity was significantly associated with use of the Ventana (with SP1 clone) versus Leica (with 6F11 clone) platform and in cases with Luminal cancer subtype. PR stromal expression was significantly associated with Luminal subtype, obesity, and younger age. CONCLUSIONS: Expression of ERα and PR in breast cancer-associated stroma showed associations that suggest both biologic and analytic influence. Reproducible expression patterns may inform expansion of ERα/PR guidelines for the assessment of internal controls.

Contrasting demographic histories revealed in two invasive populations of the dry rot fungus Serpula lacrymans.

Globalization and international trade have impacted organisms around the world leading to a considerable number of species establishing in new geographic areas. Many organisms have taken advantage of human-made environments, including buildings. One such species is the dry rot fungus Serpula lacrymans, which is the most aggressive wood-decay fungus in indoor environments in temperate regions. Using population genomic analyses of 36 full genome sequenced isolates, we demonstrated that European and Japanese isolates are highly divergent and the populations split 3000-19,000 generations ago, probably predating human influence. Approximately 250 generations ago, the European population went through a tight bottleneck, probably corresponding to the fungus colonization of the built environment in Europe. The demographic history of these populations, probably lead to low adaptive potential. Only two loci under selection were identified using a Fst outlier approach, and selective sweep analyses identified three loci with extended haplotype homozygosity. The selective sweep analyses found signals in genes possibly related to decay of various substrates in Japan and in genes involved DNA replication and protein modification in Europe. Our results suggest that the dry rot fungus independently established in indoor environments in Europe and Japan and that invasive species can potentially establish large populations in new habitats based on a few colonizing individuals.

Primary Liver Cancer: An NCDB Analysis of Overall Survival and Margins After Hepatectomy.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC) constitute the majority of primary liver cancers. This retrospective review aimed to determine whether site of care is a significant predictor of patient outcome after hepatectomy as measured by overall survival, hazard ratios (HRs), and resection margin status. METHODS: Data regarding patients with a new diagnosis of ICC and HCC who underwent hepatectomy were analyzed from the national cancer database. The patients were divided into two cohorts: those receiving treatment at academic cancer centers (ACCs) and those receiving treatment at community cancer centers (CCCs). The study adjusted for confounding variables and selection bias using propensity score matching. Median overall survival (months), hazard ratios, and resection margin status (R0, R1/R2, unknown) were examined. RESULTS: The inclusion criteria were met by 10,463 patients. After propensity matching, 5600 patients remained, with half receiving treatment at ACCs and half at CCCs. Median overall survival from the date of diagnosis for patients undergoing hepatectomy was longer at ACCs than at CCCs (28.3 vs 24.8 months; p < 0.001). Additionally, multivariable Cox proportional hazards models showed that treatment at CCCs was associated with poorer survival than treatment at ACCs (HR, 1.226; 95% confidence interval [CI], 1.142-1.316; p < 0.0001). Treatment facility designation also was a predictive indicator of resection margin status, with patients at CCCs exhibiting higher odds of R1/R2 resections (odds ratio [OR], 1.41; 95% CI, 1.19-1.67; p < 0.0001). CONCLUSION: Hepatectomy for ICC and HCC performed at ACCs was associated with improved outcomes compared with CCCs. Centralization of care to ACCs may lead to improved patient outcomes.

Is Radiotherapy Warranted Following Intrahepatic Cholangiocarcinoma Resection? The Impact of Surgical Margins and Lymph Node Status on Survival.

BACKGROUND: The role of radiotherapy (RT) for surgically resected intrahepatic cholangiocarcinoma (ICC) remains poorly defined. Radiotherapy is often considered when positive resection margins exist. The present study sought to examine the impact of radiotherapy following ICC resection. METHODS: Patients with early-stage disease, who underwent surgical resection, were identified from the National Cancer Database (1998-2013). Patients were stratified by the receipt of RT. Survival outcomes were examined following propensity score matching (PS), and a Cox regression for survival analysis was used to examine predictors of survival. RESULTS: A total of 2897 patients were identified. R0 status was achieved in 1951 patients (67.3 %). RT was delivered to 525 patients (R0 = 255, R1/R2 = 230, unknown = 43). Following PS matching, the overall survival for R0 versus R1/R2 resection was 31.2 versus 19.5 months (p < .001), respectively. RT was associated with a trend toward improved survival for R1/R2 lymph node negative patients (39.5 vs. 21.1 months; p = .052). In a multivariate model accounting for different patient and disease characteristics, RT was not associated with survival. In contrast, age, comorbidities, tumor grade, resection margins, lymph nodes status, and tumor's T stage were identified as negative predictors of survival. CONCLUSIONS: Patients with negative resection margins demonstrated improved survival outcome among ICC patients. In patients with positive resection margins and node negative disease, radiotherapy did not provide a survival benefit. Further studies are warranted to confirm and further define these results.

Chemotherapy for Surgically Resected Intrahepatic Cholangiocarcinoma.

BACKGROUND: The benefit of chemotherapy for surgically resected intrahepatic cholangiocarcinoma (ICC) remains poorly defined. The present study sought to determine the survival impact of chemotherapy for surgically resected ICC. METHODS: Patients with non-metastatic ICC who underwent surgery were identified from the National Cancer Database (1998-2011) and stratified by receipt of chemotherapy. Survival outcomes were analyzed following propensity score modeling using the greedy matching algorithm. RESULTS: A total of 2751 patients were identified (median age 64 years); 985 (35.8 %) received chemotherapy. Younger age, advanced tumor stage, R1/R2 surgical margins, and lymph node metastasis were all independently associated with receipt of chemotherapy (p < 0.05). Following propensity score matching, advanced tumor stage, lymph node metastasis, poorly differentiated tumors, and R1/R2 surgical margins were associated with poorer overall survival (OS) (p < 0.05). Median OS comparing patients who received chemotherapy compared with surgery alone was 23 versus 20 months (p = 0.09). However, when stratified by lymph node status, chemotherapy demonstrated a significant improvement in median OS among N1 patients (19.8 vs. 10.7 months; p < 0.001). In contrast, patients with N0 disease derived no benefit from chemotherapy (29.4 vs. 29 months; p = 0.33). Additional tumor characteristics associated with improved survival with chemotherapy included T3/T4 tumors (21.3 vs. 15.6 months; p < 0.001) and R1/R2 surgical margins (19.5 vs. 11.6 months; p = 0.006). CONCLUSION: The use of chemotherapy was associated with a survival benefit only for ICC patients with nodal metastasis, advanced tumor stage, or an inadequate surgical resection. Chemotherapy for resected ICC should be strongly considered for tumors harboring high-risk features.

Surgical resection versus ablation for hepatocellular carcinoma ≤ 3 cm: a population-based analysis.

BACKGROUND: Ablation for ≤ 3-cm hepatocellular carcinoma (HCC) has been demonstrated to be an effective treatment strategy. The present study sought to examine the outcomes of patients with ≤3 cm HCC after ablation versus resection. METHODS: Patients treated by ablation or surgical resection for ≤ 3 cm T1 HCC were identified from the National Cancer Database (2002-2011). Survival outcomes were analysed according to propensity score modelling. RESULTS: A total of 2804 patients underwent ablation (n = 1984) or a resection (n = 820) for solitary HCC ≤ 3 cm. Patients treated with ablation as compared with a resection had a higher frequency in alpha-fetoprotein level (AFP) elevation (46.5% versus 39.1%, P < 0.01) and the presence of cirrhosis (22.2% versus 14.5%, P < 0.01). Unadjusted overall survival (OS) at 3 and 5 years was greater after a resection (67%, 55%) versus ablation (52%, 36%, P < 0.01). After propensity score matching, the improved overall survival (OS) was sustained among the resection cohort (5 year OS: 54% versus 37%, P < 0.001). In multivariable models, a resection was independently associated with an improved OS [hazard ratio (HR): 0.62, 95% confidence interval (CI): 0.48-0.81; P < 0.01]. CONCLUSION: Resection of HCC ≤ 3 cm results in better long-term survival as compared with ablation. Treatment strategies for small solitary HCC should emphasize a resection first approach, with ablation being reserved for patients precluded from surgery.

Molecular profiling in gastric cancer: examining potential targets for chemotherapy.

BACKGROUND AND OBJECTIVES: Current NCCN guidelines recommend epirubicin (E), cisplatin (C), and 5-fluorouracil (F) as a first-line therapeutic approach for operable gastric adenocarcinoma (GC). Molecular profiling (MP) was used to evaluate the expression of chemotherapy targeted biomarkers associated with ECF therapy and other first-line cytotoxic regimens for GC. METHODS: GC specimens were analyzed by immunohistochemistry (IHC) for TOP2A, TS, ERCC1, PGP, and TOPO1 expression (Caris Life Sciences, Phoenix, AZ) from 2009 to 2012. RESULTS: A total of 230 GC specimens were analyzed. The median age of patients was 61 (IQR: 50-72) years with the majority being male (n = 139, 60%). IHC actionable targets included: 60% (n = 138) high TOP2A, 55% (n = 127) negative ERCC1, and 63% (n = 145) negative TS, indicating potential benefit from E, C, and F, respectively. Simultaneous expression analysis demonstrated only 24% (n = 55) of patients had gene expression levels that suggested uniform sensitivity to ECF. Biomarker results of 6.5% (n = 15) of patients revealed a potential complete lack of sensitivity to first-line ECF. CONCLUSIONS: MP of GC has the potential to define patients who would derive the greatest benefit from current therapies. Prospective controlled studies are required to validate the role of biomarkers in the management of GC patients.

Evaluation of a peer-led hypertension intervention for veterans: impact on peer leaders.

Volunteer peer leaders (PLs) benefit from their involvement in health interventions but we know little about how they compare with other non-PL volunteers or with the intervention recipients themselves. We randomized 58 veterans' service organizations' posts (e.g. VFW) to peer- versus professionally led self-management support interventions. Our primary research questions were whether hypertensive PLs changed over the course of the project, whether they changed more than hypertensive volunteers who were not randomized to such a role [i.e. post representatives (PRs)] and whether they changed more than the intervention recipients with respect to health knowledge, health beliefs and health outcomes from baseline to 12 months. After the intervention, PLs provided open-ended feedback and participated in focus groups designed to explore intervention impact. Hypertensive PLs improved their systolic blood pressure and hypertension knowledge and increased their fruit/vegetable intake and pedometer use. We found no differences between PLs and PRs. PLs improved knowledge and increased fruit/vegetable intake more than intervention recipients did; they provided specific examples of personal health behavior change and knowledge acquisition. Individuals who volunteer to be peer health leaders are likely to receive important benefits even if they do not actually take on such a role.

Amelioration of oral mucositis pain by NASA near-infrared light-emitting diodes in bone marrow transplant patients.

PURPOSE: This study seeks to investigate the use of extra-orally applied near-infrared phototherapy for the reduction of oral pain secondary to chemotherapy- and radiation therapy-induced mucositis in adult and pediatric hematopoietic stem cell transplant (HSCT) patients. METHODS: Eighty HSCT patients were divided into regular (R) and low (L) risk groups, then to experimental (E) and placebo (P) groups, resulting in four groups (ER, EL, PR, PL). Experimental subjects received 670 (± 10) nm gallium-aluminum-arsinide light-emitting diode device for 80 s at ~50 mW/cm(2) energy density and power exposure of 4 J/cm(2). Placebo patients received the same procedures, but with a placebo phototherapy (identical device but <5 mW/cm(2) energy density). Patients received their respective light therapy once per day starting on the day of the HSCT (day 0) and continued through day +14. Blinded evaluators examined the patients three times per week and scored their oral tissues and patient-reported pain assessments at each evaluation utilizing the WHO, NCI-CTCAE, and OMAS scales. RESULTS: Analysis of the mean scores at each observation demonstrate that the extra-oral application of phototherapy resulted in a significant reduction in patient-reported pain between the ER and PR patients (p < 0.05) at day +14 when graded via the WHO criteria. The ER and EL patients were improved in almost all other categories and assessment scales, but the differences were not statistically significant. CONCLUSION: Phototherapy demonstrated a significant reduction in patient-reported pain as measured by the WHO criteria in this patient population included in this study. Improvement trends were noted in most other assessment measurements.

Volatile organic compounds of Metarhizium brunneum influence the efficacy of entomopathogenic nematodes in insect control.

The entomopathogenic fungus (EPF) Metarhizium brunneum occupies the same ecological niche as entomopathogenic nematodes (EPN), with both competing for insects as a food source in the rhizosphere. Interactions between these biocontrol agents can be antagonistic or synergistic. To better understand these interactions, this study focussed on investigating the effect of M. brunneum volatile organic compounds (VOCs), 1-octen-3-ol and 3-octanone, on EPN survival and behaviour. These VOCs proved to be highly toxic to the infective juveniles (IJs) of the EPN Steinernema carpocapsae, Steinernema feltiae and Heterorhabditis bacteriophora with mortality being dose dependent. Chemotaxis studies of H. bacteriophora IJs in Pluronic F127 gel revealed significant preference for the VOCs compared with controls for all tested concentrations. The VOCs also impacted on the test insects in a dose-dependent manner with 3-octanone being more toxic to Galleria mellonella, Cydia splendana and Curculio elephas larvae than 1-octen-3-ol. Mortality of C. splendana and G. mellonella larvae was significantly higher when exposed to relatively high doses (>25%) of 3-octanone. Lower doses of 3-octanone and 1-octen-3-ol immobilised test insects, which recovered after exposure to fresh air for 2 hrs. In depth studies on H. bacteriophora showed that exposure of IJs to > 10% concentration of 3-octanone or 1-octen-3-ol negatively affected infectivity whereas exposure to lower doses (0.1%, 0.01%) had no effect. The VOCs affected IJs, reducing penetration efficacy and the number of generations inside G. mellonella but they failed to inhibit the bacterial symbiont, Photorhabdus kayaii. The ecological significance of VOCs and how they could influence EPF-EPN insect interactions is discussed.

Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections.

INTRODUCTION: Steroid injection around the intercostal nerves is one of the treatment options for intercostal neuralgia. The technique may be performed blindly, under fluoroscopic guidance (FSG) or with the use of ultrasound guidance (USG). This study is a retrospective comparison of image guidance for intercostal steroid injections. METHODS: After Institutional Review Board approval, a retrospective review of all patient charts who received intercostal steroid injections from 2005 to 2009 was performed. A total of 39 blocks were performed in that period. Of that 12 were USG blocks and 27 FSG blocks. The preprocedure visual analog scale (VAS) and postprocedure VAS and the duration of pain relief were compared between the 2 techniques. A Mann-Whitney test and Kruskal-Wallis test were performed looking for differences between the techniques. RESULTS: The median change in the VAS for FSG and USG were -5.000 and -4.000, respectively, and duration of pain relief with a median difference of 2 weeks (95% confidence interval of -4, 7). There were 2 occasions of intravascular spread noticed with the FSG although this should not affect the study result as the needle was repositioned and steroid injected only after contrast dye confirmation. CONCLUSION: With similar change in VAS scores and duration of pain relief between the 2 guidance methods based on this retrospective study, both image guidance techniques may offer similar pain relief.

The mitochondrial genome contribution to the phylogeny and identification of Metarhizium species and strains.

The genus Metarhizium is composed of entomopathogenic fungal biological control agents (BCAs) used for invertebrate pest control. The phylogenetic relationships of species within this genus are still under scrutiny as several cryptic species can be found. In this work, the mitochondrial (mt) genome of Metarhizium brunneum ARSEF 4556 was fully sequenced and a comparative genome analysis was conducted with 7 other available mt genomes, belonging to 5 Metarhizium species: M. anisopliae, M. brunneum, M. robertsii, M. guizhouense and M. majus. Results showed that Metarhizium demonstrates greater conserved stability than other fungal mt genomes. Furthermore, this analysis located 7 diverse regions in both intergenic domains and gene fragments which were ideal for species/strain discrimination. The sequencing of these regions revealed several SNPs among 38 strains tested, 11 of which were uncharacterized. Single gene phylogenies presented variable results which may be used further for intra-species discrimination. Phylogenetic trees based on the concatenation of mt domains and the nuclear ITS1-5.8S-ITS2 region showed discrimination of the species studied and allowed the identification of uncharacterized strains. These were mostly placed within species M. anisopliae and M. brunneum. Five strains clustered together in a clade related to M. brunneum, suggesting that they comprise a cryptic species.

FISHing in fungi: Visualisation of mushroom virus X in the mycelium of Agaricus bisporus by fluorescence in situ hybridisation.

Agaricus bisporus is a commercial mushroom crop susceptible to a disease caused by a complex of viruses known collectively as mushroom virus X (MVX). Symptoms of MVX include bare patches and mushroom cap discolouration (browning) in the fruiting bodies, phenotypes associated with the viruses AbV6 and AbV16, respectively. Limited understanding exists of the localisation and mobilisation of these viruses within the mycelium of A. bisporus. To this end, a non-destructive fluorescence in situ hybridisation (FISH) method was developed for in situ targeting of AbV6 and AbV16 in A. bisporus mycelium. An MVX strain associated with the bare patch disease phenotype revealed predominantly high signal towards the growing edges of cultures when probed for AbV6, with a 'halo-effect' of high signal intensity around putative vacuoles. An MVX strain associated with the browning disease phenotype showed high signal intensities within reticulating networks of hyphae in a highly compartmentalised manner when probed for AbV16. Localisation of the two viruses in MVX-infected cultures appears independent, as both viruses were found in completely discrete areas of the mycelium in differential patterns. FISH detected low level presence of the two viruses, AbV6 and AbV16 in a number of cultures which had tested negative for the viruses by RT-PCR. This suggests that FISH may be more sensitive at detecting viruses at low levels than molecular methods. This study demonstrates that FISH is a powerful tool in the field of mycovirology.

Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit.

OBJECT: The aim of this study was to evaluate the impact of a newly appointed neurointensivist on outcomes in head-injured patients in the neurological/neurosurgical intensive care unit (NICU). METHODS: The mortality rate, length of stay (LOS), and discharge disposition of all patients with head trauma who had been admitted to a 10-bed tertiary care university hospital NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University HealthSystem Consortium (UHC) database. Samples of medical records were reviewed for Glasgow Coma Scale (GCS) score documentation. The authors analyzed data pertaining to 328 patients before and 264 after the neurointensivist's appointment. The unadjusted mean in-hospital mortality rate increased 1.1% in the after period, but this increase was significantly lower compared with the UHC-based expected increase of 8.1% in the mortality rate during the same period (p < 0.0001). The unadjusted mean mortality rate in the NICU decreased from 13.4 to 12.9% (relative mortality rate reduction 4%) and the mean NICU LOS increased from 3.1 to 3.6 days (relative NICU LOS increase 16%), both nonsignificantly. A 51% reduction in the NICU-associated mortality rate (p = 0.01), a 12% shorter hospital LOS (p = 0.026), and 57% greater odds of being discharged to home or to rehabilitation (p = 0.009) were found in the after period in multivariate models after controlling for baseline differences between the two time periods. Better documentation of the GCS score by the NICU team was also found in the after period (from 60.4 to 82%, p = 0.02). CONCLUSIONS: The institution of a neurointensivist-led team model had an independent, positive impact on patient outcomes, including a lower NICU-associated mortality rate and hospital LOS, improved disposition, and better chart documentation.

Educational attainment does not modify the effect of educational interventions on blood pressure control: a secondary analysis of data from a randomised trial.

OBJECTIVES: To assess whether the effects of community-based educational interventions to improve blood pressure, weight and health behaviours benefit participants with lower educational levels more than those with higher educational levels. DESIGN: Secondary data analysis. SETTING: Two 12-month community-based educational interventions, one led by trained peers and one delivered by health professionals. PARTICIPANTS: A total of 403 hypertensive individuals, grouped by education (high school or less; 1-3 years college; 4 + years college). MAIN OUTCOME MEASURES: Blood pressure, weight, physical activity and fruit and vegetable intake. RESULTS: We found that changes in blood pressure, weight and physical activity were similar across education levels; college graduates consumed more daily servings of fruits and vegetables at baseline (3.7 versus 3.6 for those with 12-15 years and 3.1 for those with < 12 years, p = 0.0112), and increased intake more after the intervention (+0.4 versus -0.1 and -0.1, p = 0.0142). The two methods of delivery - peer-led versus professional - had similar effects on all measures. CONCLUSIONS: We conclude that educational interventions, whether delivered by peers or professionals, may improve chronic disease self-management among participants but do not confer greater benefits on participants with lower educational levels.

Does breast tumor location influence success of sentinel lymph node biopsy?

BACKGROUND: Controversy exists regarding the influence of sentinel lymph node (SLN) mapping technique or patient variables on the success rate of SLN mapping. We undertook a prospective study in a single institution series to evaluate multiple variables that could adversely affect SLN identification rates. STUDY DESIGN: Data were collected on 174 patients who underwent 177 SLN mapping procedures followed by axillary dissection from October 1996 through January 2000. Patient demographics, body mass index (BMI), biopsy method, tumor size, palpability, and location were recorded. SLNs were identified by blue dye only (n = 31), Tc-99m sulfur colloid only (n = 34), or combined techniques (n = 112). Data were analyzed by logistic regression analysis and expressed as the probability of failure to map the SLN. RESULTS: SLNs were identified successfully in 150 of 177 procedures (85%) with a false negative rate of 3.7%. Mapping success reached 93% using combination blue dye and isotope. Variables found to adversely affect SLN mapping success and the odds ratio of failure (OR) included lower inner quadrant (LIQ) location (OR 35.6), blue dye only (OR 42.4), BMI >30 and upper outer quadrant (UOQ) location (OR 14.6), and nonpalpable UIQ location (OR 25). LIQ location adversely affects mapping success independent of technique, tumor size, or obesity. Obesity and nonpalpability were adverse factors when tumors were located in the UOQ and UIQ, respectively. Age, biopsy technique, and tumor diameter did not affect SLN mapping success. CONCLUSIONS: SLN mapping success is influenced by technique and tumor location, with best results achieved using combined techniques and for lesions located in quadrants other than the LIQ. Obesity and tumor palpability influence success in the context of tumor location.

Subconjunctival antibiotics for acute postcataract extraction endophthalmitis--is it necessary?

PURPOSE: To evaluate the efficacy of adjunctive subconjunctival antibiotic injection in the treatment of acute postcataract extraction endophthalmitis. DESIGN: Retrospective cohort study. METHODS: Patients who presented with hand motions or better vision and received subconjunctival antibiotics (SC+ group) were compared with those who did not (SC- group) in the treatment of acute postoperative endophthalmitis. RESULTS: The rate of obtaining a final vision of 20/40 or better was 60% in the SC+ group (n = 25) compared with 72% in the SC- group (n = 18) (P =.69), and the mean change in logMAR was -1.36 (improvement) versus -1.34 (P =.93). Based on a linear regression model controlling for presenting vision, there was no statistical difference in the mean logMAR change between the two groups (P =.73). CONCLUSION: Subconjunctival antibiotic injection as an adjunct to intravitreal antibiotics was unassociated with treatment benefit in patients with acute postoperative endophthalmitis presenting with vision of hand motions or better.

Subtenon's depot corticosteroid injections in patients with a history of corticosteroid-induced intraocular pressure elevation.

PURPOSE: To determine whether a history of intraocular pressure elevation from local corticosteroid administration could predict subsequent intraocular pressure elevation after posterior subtenon's corticosteroid injection. METHODS: A retrospective review was performed of 64 consecutive patients (64 eyes) receiving posterior subtenon's corticosteroid injection. Patients were categorized as either historical corticosteroid responders or nonresponders based on intraocular pressure response to topical corticosteroid drops in the same eye or to previous posterior subtenon's corticosteroid injection of the fellow eye. Historical responders were defined as having a relative intraocular pressure increase of 5 mm Hg and absolute intraocular pressure greater than 24 mm Hg with an anatomically open angle. Relative risk of intraocular pressure elevation was evaluated based on historical response and presenting diagnosis. RESULTS: Nine eyes were historical responders, and 55 eyes were historical nonresponders. A higher rate of recurrent intraocular pressure elevation developed in historical responder eyes (4 of 9, 44%) compared with nonresponders (7 of 55, 13%) after posterior subtenon's injection (P = .04, Fisher's test; P = .07, Kaplan-Meier analysis). Historical responders with uveitis were at significantly higher risk of intraocular pressure elevation than nonresponders without uveitis (hazard ratio = 10.8, P = .04, Cox proportional hazards). All but one eye that developed intraocular pressure elevation from posterior subtenon's injection was adequately controlled with topical antiglaucoma therapy. CONCLUSION: In nonglaucomatous eyes, a previous history of corticosteroid-induced intraocular pressure elevation is a relative, not absolute, contraindication to posterior subtenon's corticosteroid injection, because the risk of intraocular pressure elevation is not absolute, and because it can usually be well controlled with topical antiglaucoma therapy.

A randomized trial of peer-delivered self-management support for hypertension.

BACKGROUND: Peer-led interventions to improve chronic disease self-management can improve health outcomes but are not widely used. Therefore, we tested a peer-led hypertension self-management intervention delivered at regular meetings of community veterans' organizations. METHODS: We randomized 58 organizational units ("posts") of veterans' organizations in southeast Wisconsin to peer-led vs. professionally delivered self-management education. Volunteer peer leaders at peer-led posts delivered monthly presentations regarding hypertension self-management during regular post meetings. Volunteer post representatives at seminar posts encouraged post members to attend 3 didactic seminars delivered by health professionals at a time separate from the post meeting. Volunteers in both groups encouraged members to self-monitor using blood pressure cuffs, weight scales, and pedometers. Our primary outcome was change in systolic blood pressure (SBP) at 12 months. RESULTS: We measured SBP in 404 participants at baseline and in 379 participants at 12 months. SBP decreased significantly (4.4mm Hg; P < 0.0001) overall; the decrease was similar in peer-led and seminar posts (3.5mm Hg vs. 5.4mm Hg; P = 0.24). Among participants with uncontrolled BP at baseline, SBP decreased by 10.1mm Hg from baseline to 12 months but was again similar in the 2 groups. This pattern was also seen at 6 months and with diastolic blood pressure. CONCLUSIONS: Our peer-led educational intervention was not more effective than didactic seminars for SBP control. Although peer-led educational programs have had important impacts in a number of studies, we did not find our intervention superior to a similar intervention delivered by healthcare professionals. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00571038.

Factors that influence parathyroid hormone half-life: determining if new intraoperative criteria are needed.

IMPORTANCE: Minimally invasive parathyroidectomy using intraoperative parathyroid hormone monitoring remains the standard approach to the majority of patients with primary hyperparathyroidism. This study demonstrates that individual patient characteristics do not affect existing criteria for intraoperative parathyroid hormone monitoring. OBJECTIVE: To identify patient characteristics, such as age, sex, race, body mass index (BMI), and renal function, that may affect existing criteria for intraoperative parathyroid hormone (IOPTH) levels during minimally invasive parathyroidectomy. DESIGN: Retrospective review of a prospectively collected parathyroid database populated from August 2005 to April 2011. SETTING: Academic medical center. PARTICIPANTS: Three hundred six patients with sporadic primary hyperparathyroidism who underwent initial parathyroidectomy between August 2005 and April 2011. INTERVENTIONS: All patients underwent minimally invasive parathyroidectomy with complete IOPTH information. MAIN OUTCOME AND MEASURES: Individual IOPTH kinetic profiles were fitted with an exponential decay curve and individual IOPTH half-lives were determined. Univariate and multivariate analyses were performed to determine the association between patient demographics or laboratory data and IOPTH half-life. RESULTS: Mean age of the cohort was 60 years, 78.4% were female, 90.2% were white, and median BMI was 28.3. Overall, median IOPTH half-life was 3 minutes, 9 seconds. On univariate analysis, there was no association between IOPTH half-life and patient age, renal function, or preoperative serum calcium or parathyroid hormone levels. Age, BMI, and an age × BMI interaction were included in the final multivariate median regression analysis; race, sex, and glomerular filtration rate were not predictors of IOPTH half-life. The IOPTH half-life increased with increasing BMI, an effect that diminished with increasing age and was negligible after age 55 years (P = .001). CONCLUSIONS AND RELEVANCE: Body mass index, especially in younger patients, may have a role in the IOPTH half-life of patients undergoing parathyroidectomy. However, the differences in half-life are relatively small and the clinical implications are likely not significant. Current IOPTH criteria can continue to be applied to all patients undergoing parathyroidectomy for sporadic primary hyperparathyroidism.