Type 2 diabetes is associated with vertebral fractures in a sample of clinic- and hospital-based Latinos.

Latinos are the fastest growing ethnic population in the United States and type 2 diabetes is a major health burden in this population, but little effort has been made to study the prevalence of diabetic vertebral fragility in Latinos. We performed a cross-sectional study to determine vertebral fracture prevalence in a hospital-based population of South Texas residents (N = 296). We defined fractures in X-rays as a >20% reduction in vertebral body height. Numerous variables were recorded, including age, body mass index, indicators of diabetes management and others. 71% of the sample (N = 296) was Latino. The prevalence of vertebral fracture was increased in diabetic subjects relative to non-diabetic subjects (diabetic 27.9%, non-diabetic 13.8%) and, regardless of sex and diabetics status, decreased in Latinos relative to non-Latinos (Latino 16.7%, non-Latino 26.4%). These data suggest that vertebral fractures may be a growing concern for diabetic Latinos as well as diabetics of any racial/ethnic background.

Concordance of psychiatric symptom ratings between a subject and informant, relevancy to post-mortem research.

Investigators are interested in determining whether lifetime behavioral traits and specific mood states experienced close to death affect brain gene and protein expression as assessed in post-mortem human brains. Major obstacles to conducting this type of research are the uncertain reliability of the post-mortem psychiatric diagnoses and clinical information because of the retrospective nature of the information. In this study, we addressed the concordance of clinical information obtained through an informant compared with information obtained through a clinician interview of the subject. To test this, we measured both lifetime and within the week psychiatric symptoms of subjects (n=20) and an informant, their next-of-kin (n=20) who were asked identical questions. We found Diagnostic and Statistical Manual (DSM)-IV axis 1 diagnoses by Mini-International Neuropsychiatric Interview proportion of positive agreement for major depression was 0.97, bipolar disorder was 0.81, whereas proportion of negative agreement was 0.97 for schizophrenia. Symptom scale intra-class correlation coefficients and 95% confidence interval were: Bipolar Inventory of Signs and Symptoms=0.59 (0.23, 0.81), Brief Psychiatric Rating Scale=0.58 (0.19, 0.81), Hamilton Depression Rating Scale=0.44 (0.03, 0.72), Montgomery Asberg Depression Rating Scale=0.44 (0.03, 0.72), Young Mania Rating Scale=0.61 (0.30, 0.82), Barratt Impulsiveness Score=0.36 (-0.11, 0.70) and Childhood Trauma Questionnaire=0.48 (-0.15, 0.83). We show that DSM-IV diagnoses; lifetime impulsivity severity, childhood trauma score and symptom scores were significantly consistent between the subjects and their informants. These data suggest, with some limitations, that both retrospective and informant obtained information can provide useful clinical information in post-mortem research.

Protein kinase C iota as a therapeutic target in alveolar rhabdomyosarcoma.

Alveolar rhabdomyosarcoma is an aggressive pediatric cancer exhibiting skeletal-muscle differentiation. New therapeutic targets are required to improve the dismal prognosis for invasive or metastatic alveolar rhabdomyosarcoma. Protein kinase C iota (PKCι) has been shown to have an important role in tumorigenesis of many cancers, but little is known about its role in rhabdomyosarcoma. Our gene-expression studies in human tumor samples revealed overexpression of PRKCI. We confirmed overexpression of PKCι at the mRNA and protein levels using our conditional mouse model that authentically recapitulates the progression of rhabdomyosarcoma in humans. Inhibition of Prkci by RNA interference resulted in a dramatic decrease in anchorage-independent colony formation. Interestingly, treatment of primary cell cultures using aurothiomalate (ATM), which is a gold-containing classical anti-rheumatic agent and a PKCι-specific inhibitor, resulted in decreased interaction between PKCι and Par6, decreased Rac1 activity and reduced cell viability at clinically relevant concentrations. Moreover, co-treatment with ATM and vincristine (VCR), a microtubule inhibitor currently used in rhabdomyosarcoma treatment regimens, resulted in a combination index of 0.470-0.793 through cooperative accumulation of non-proliferative multinuclear cells in the G2/M phase, indicating that these two drugs synergize. For in vivo tumor growth inhibition studies, ATM demonstrated a trend toward enhanced VCR sensitivity. Overall, these results suggest that PKCι is functionally important in alveolar rhabdomyosarcoma anchorage-independent growth and tumor-cell proliferation and that combination therapy with ATM and microtubule inhibitors holds promise for the treatment of alveolar rhabdomyosarcoma.

Increased platelet:RBC ratios are associated with improved survival after massive transfusion.

BACKGROUND: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT). METHODS: A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units. RESULTS: Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007). CONCLUSION: Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

Antifungal prophylaxis with voriconazole or itraconazole in lung transplant recipients: hepatotoxicity and effectiveness.

Invasive fungal infections (IFI) are common after lung transplantation and there are limited data for the use of antifungal prophylaxis in these patients. Our aim was to compare the safety and describe the effectiveness of universal prophylaxis with two azole regimens in lung transplant recipients. This is a retrospective study in lung transplant recipients from July 2003 to July 2006 who received antifungal prophylaxis with itraconazole or voriconazole plus inhaled amphotericin B to compare the incidence of hepatotoxicity. Secondary outcomes include describing the incidence of IFI, clinical outcomes after IFI and mortality. Sixty-seven consecutive lung transplants received antifungal prophylaxis, 32 itraconazole and 35 voriconazole and inhaled amphotericin B. There were no significant differences between groups in the acute physiology and chronic health evaluation (APACHE) score at the time of transplantation, demographic characteristics, comorbidities and concomitant use of hepatotoxic medications. Hepatotoxicity occurred in 12 patients receiving voriconazole and inhaled amphotericin B and in no patients receiving itraconazole (p < 0.001). There was no significant difference between groups with regard to the percentage of transplants with IFI, but one case of zygomycosis occurred in a transplant treated with voriconazole. Voriconazole prophylaxis after lung transplantation was associated with a higher incidence of hepatotoxicity and similar clinical effectiveness when compared to itraconazole.

PDGFR-A is a therapeutic target in alveolar rhabdomyosarcoma.

Alveolar rhabdomyosarcoma is an aggressive skeletal muscle cancer of childhood. Our initial studies of rhabdomyosarcoma gene expression for patients enrolled in a national clinical trial suggested that platelet-derived growth factor receptor A (PDGFR-A) may be a mediator of disease progression and metastasis. Using our conditional mouse tumor models that authentically recapitulate the primary mutations and metastatic progression of alveolar rhabdomyosarcomas in humans, we found by immunoblotting and immunokinase assays that PDGFR-A and its downstream effectors, mitogen-activated protein kinase and Akt, were highly activated in both primary and metastatic tumors. Inhibition of PDGFR-A by RNA interference, small molecule inhibitor or neutralizing antibody had a dramatic effect on tumor cell growth both in vitro and in vivo, although resistance evolved in one-third of tumors. These results establish proof-of-principal for PDGFR-A as a therapeutic target in alveolar rhabdomyosarcoma.

Serum dioxin and peripheral neuropathy in veterans of Operation Ranch Hand.

We studied whether exposure to Agent Orange and its contaminant, 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin), during the Vietnam War is related to peripheral neuropathy. The index subjects were veterans of Operation Ranch Hand, the unit responsible for aerial herbicide spraying in Vietnam from 1962 to 1971. We report peripheral nerve function assessed in 1982, 1985, 1987, 1992 and 1997, nerve conduction velocities measured in 1982, and vibrotactile thresholds of the great toes measured in 1992 and 1997. We assigned each Ranch Hand veteran to one of three exposure categories named "background", "low" and "high", based on his serum dioxin level. Other than the bilateral vibrotactile abnormalities, we consistently found a statistically significant increased risk of all indices of peripheral neuropathy among Ranch Hand veterans in the high exposure category in 1997, and a statistically significant increased risk of diagnosed peripheral neuropathy, incorporating bilateral vibrotactile abnormalities of the great toes, in the high category in 1992. Restricting to the enlisted veterans did not alter these results. Cautious interpretation of these results is appropriate until the relationship between pre-clinical diabetes mellitus and peripheral neuropathy is further evaluated in future examinations.

Serum dioxin and cognitive functioning among veterans of Operation Ranch Hand.

We used the Halstead-Reitan neuropsychological test battery, the Wechsler adult intelligence scale-revised, the Wechsler memory scale, and the wide range achievement test to assess cognitive functioning among Air Force veterans exposed to Agent Orange and its contaminant, 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin), during the Vietnam war The index subjects were veterans of Operation Ranch Hand (N = 937), the unit responsible for aerial herbicide spraying in Vietnam from 1962 to 1971. A comparison group of other Air Force veterans (N= 1,052), who served in Southeast Asia during the same period but were not involved with spraying herbicides served as referents. Cognitive functioning was assessed in 1982, and dioxin levels were measured in 1987 and 1992. We assigned each Ranch Hand veteran to the background, low, or high dioxin exposure category on the basis of a measurement of dioxin body burden. Although we found no global effect of dioxin exposure on cognitive functioning, we did find that several measures of memory functioning were decreased among veterans with the highest dioxin exposure. These results became more distinct when we restricted the analysis to enlisted personnel, the subgroup with the highest dioxin levels. An analysis based on dioxin quintiles in the combined cohort produced consistent results, with veterans in the fifth quintile exhibiting reduced verbal memory function. Although statistically significant, these differences were relatively small and of uncertain clinical significance.

Serum dioxin and hepatic abnormalities in veterans of Operation Ranch Hand.

PURPOSE: We studied hepatic abnormalities and indices of hepatic function in relation to exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin) in veterans of Operation Ranch Hand, the Air Force unit responsible for the aerial spraying of herbicides in Vietnam from 1962 to 1971. METHODS: The prevalence of ever having liver disease through March 1993, and level of alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltransferase (GGT), lactic dehydrogenase (LDH), alkaline phosphatase, and total bilirubin were examined according to serum dioxin levels. RESULTS: We found an increased risk of "other liver disorders" among veterans with the highest dioxin levels [adjusted odds ratio (OR) = 1.6, 95% confidence interval (CI) 1.2 to 2.1], due primarily to increased transaminases or LDH (adjusted OR = 2.7, 95% CI 1.4 to 5.1) and to other nonspecific liver abnormalities (adjusted OR = 1.4, 95% CI 1.0 to 2.0). CONCLUSIONS: Whether the associations observed were causal is unclear from these data.

Relation of serum tetrachlorodibenzo-p-dioxin concentration to diet among veterans in the Air Force Health Study with background-level exposure.

To examine the contribution of various foods to exposure to 2,3,7,8-tetrachloro-p-dibenzodioxin (TCDD) in a background-exposed U.S. population, serum TCDD levels were examined in relation to diet as assessed by a standard diet assessment instrument among men with no known unusual exposure to TCDD. Our subjects were male veterans aged 42-76 yr who were in the unexposed comparison group in the Air Force Health Study, a study of the health effects of exposure to Agent Orange and herbicides in Vietnam. Food consumption was assessed by a 126-item food frequency questionnaire. Two hundred and ninety veterans who had both TCDD levels and diet assessed in 1992 were included. In general, associations between serum TCDD and consumption of foods in specific groups or nutrients, that is, meats and fats, were not evident. Among younger men, fish and chicken intake were associated with higher serum TCDD levels. The results suggest that no single food group accounts for a large proportion of variation in TCDD exposure in older U.S. men.

Temporal changes in TCDD levels in 1419 Air Force Vietnam-era veterans not occupationally exposed to herbicides.

We summarize temporal changes in the distribution of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) measurements made in serum drawn in 1987, 1992, and 1997 from 1419 Air Force Vietnam-era veterans who served as comparisons in a 20-year prospective study of health and exposure to herbicides and their TCDD contaminant in Air Force veterans of Operation Ranch Hand, the unit responsible for aerial spraying of Agent Orange and other herbicides in Vietnam. Among comparison veterans, TCDD levels decreased significantly with time at a rate of -- 0.25 parts per trillion per year. We also describe paired serum TCDD measurements in a subgroup of 33 veterans who had detectable levels in both 1987 and 1992. The paired measurements suggested that serum TCDD levels decreased with time, including those near the limit of detection.

Relation of serum 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) level to hematological examination results in veterans of Operation Ranch Hand.

The authors studied indices of hematologic function and exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in Vietnam War veterans of Operation Ranch Hand--the Air Force unit responsible for the aerial spraying of Agent Orange and other herbicides in Vietnam. The herbicides were contaminated with TCDD. The authors measured TCDD serum levels in 1987 or later and extrapolated the result to the time of service in Vietnam. The authors studied serum TCDD level in relation to red blood cell count, hemoglobin, hematocrit, mean corpuscular volume, white blood cell count, platelet count, and erythrocyte sedimentation rate at each of 4 physical examinations. Compared with veterans not involved in Operation Ranch Hand, those with the highest TCDD levels in Operation Ranch Hand had mean corpuscular volumes that were about 1% higher and platelet counts that were about 4% higher. These small increases were unlikely to be of clinical significance and may not have been caused by TCDD.

Maximum likelihood estimation for longitudinal data with truncated observations.

We obtain maximum likelihood estimates of the parameters when the observations on the response variable in a repeated measures design are truncated above a cutpoint. The maximum likelihood equations are solved iteratively using an EM-like procedure. It is observed that these estimates have smaller mean squared error than recently proposed iterative weighted least-squares estimates. The results are applied to data arising from a study of dioxin elimination in Air Force veterans. Published in 2000 by John Wiley & Sons, Ltd.

Serum dioxin level in relation to diabetes mellitus among Air Force veterans with background levels of exposure.

Data from several epidemiologic studies suggest that exposure to unusually high amounts of dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin) increases the risk of diabetes mellitus, and experimental data suggest that the mechanism for this is decreased cellular glucose uptake. To investigate the dose-response relation more closely, we examined the association of serum dioxin level with prevalence of diabetes mellitus and with levels of serum insulin and glucose among 1,197 veterans in the Air Force Health Study who never had contact with dioxin-contaminated herbicides and whose serum dioxin level was within the range of background exposure typically seen in the United States (< or =10 ng/kg lipid). Compared with those whose serum dioxin level was in the first quartile (<2.8 ng/kg lipid), the multivariate-adjusted odds of diabetes among those in the highest quartile (> or =5.2 ng/kg lipid) was 1.71 (95% confidence interval = 1.00-2.91). The association was slightly attenuated after adjustment for serum triglycerides. Whether adjustment for serum triglycerides was appropriate, however, cannot be determined with available data. The association of background-level dioxin exposure with the prevalence of diabetes in these data may well be due to reasons other than causality, although a causal contribution cannot be wholly dismissed.

Pharmacokinetics of TCDD in veterans of Operation Ranch Hand: 15-year follow-up.

Using multiple measurements from serum collected over 15 yr (in 1982, 1987, 1992, and 1997), the half-life of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in 97 veterans of Operation Ranch Hand, the Air Force unit responsible for the aerial spraying of Agent Orange in Vietnam, was estimated. The potential influences of age, percent body fat, and changes in percent body fat on the half-life estimate were also examined. The elimination rate of TCDD for these veterans was 0.0915 per year with 95% confidence interval 0.0844 to 0.0986 per year; the corresponding half-life estimate was 7.6 yr with 95% confidence interval 7.0 to 8.2 yr. The elimination rate decreased significantly with increasing body fat, but not with age or relative changes in percent body fat.

Treatment of primary Sjögren's syndrome with low-dose natural human interferon-alpha administered by the oral mucosal route: a phase II clinical trial. IFN Protocol Study Group.

The purpose of this investigation was to examine the safety and efficacy of four dosages of natural human interferon-alpha (nHuIFN-alpha) delivered over a 12-week period orally in lozenges (150 IU and 450 IU, once [QD] or three times [TID] daily) compared to placebo in subjects with primary Sjögren's syndrome. This randomized, double-blinded clinical trial demonstrated that nHuIFN-alpha at a dose of 150 IU administered TID by oral lozenge significantly improved stimulated whole saliva output compared to placebo after 12 weeks of treatment. The 150 IU TID dose also was suggestive of benefit for 5 of 7 subjective measures of oral and ocular comfort. IFN lozenges demonstrated a good safety profile, with no serious adverse events found in any treatment group. There were no significant differences between the placebo and the four doses of IFN for adverse events by total number, organ system, severity, dropouts, and number judged to be related to treatment. In conclusion, these results demonstrated that the use of 150 IU IFN lozenges TID for 12 weeks in subjects with primary Sjögren's syndrome improved salivary output and decreased complaints of xerostomia without causing significant adverse medical events.

Reduction of morning stiffness and improvement in physical function in fibromyalgia syndrome patients treated sublingually with low doses of human interferon-alpha.

One hundred and twelve fibromyalgia syndrome (FMS) patients were randomized into one of four demographically similar groups (n = 28/group). Sequential primary FMS patient volunteers were to receive daily sublingual placebo or interferon-alpha (IFN-alpha) at 15, 50, or 150 IU. After a screening evaluation, analgesic or sedative hypnotic medications were withdrawn. Two weeks later, daily IFN-alpha or placebo was initiated with follow-up evaluations at 2-week intervals ending with week 6. One primary, three secondary, and seven tertiary variables were assessed. Study outcome was based on improvement in the tender point index (TPI). The TPI did not improve with any IFN-alpha dose. However, significant improvement was seen in morning stiffness and in physical function with the 50 IU IFN-alpha (p < 0.01). None of the other outcome means changed significantly and no adverse events were attributable to IFN-alpha therapy.

Lymphocyte markers and natural killer cell activity in fibromyalgia syndrome: effects of low-dose, sublingual use of human interferon-alpha.

A clinical study was designed to utilize flow cytometric immunophenotyping and chromium release from cultured tumor target cells to characterize peripheral blood mononuclear leukocyte (PBML) subpopulations and natural killer activity in healthy normal controls (n = 18) and in patients with fibromyalgia syndrome (FMS) at baseline (n = 124) and again after 6 weeks of treatment with low-doses of orally administered human interferon-alpha (IFN-alpha). Volunteer subjects discontinued all analgesic and sedative hypnotic medications for 2 weeks prior to the baseline phlebotomy. Laboratory measures included a complete blood count; a phenotypic analysis of PBML by flow cytometry; and in vitro natural killer (NK) cell activity. After baseline blood sample collection, the FMS patients were randomized to one of four parallel treatment groups (n = 28/group) to receive sublingual IFN-alpha (15 IU, 50 IU, 150 IU), or placebo every morning for 6 weeks. The tests were repeated at week 6 to evaluate treatment effects. At baseline, FMS patients exhibited fewer lymphocytes and more CD25+ T lymphocytes than did normal controls. By week 6, the main significant and consistent change was a decrease in the HLA-DR+ CD4+ subpopulation in the 15 IU and 150 IU treatment groups. These data do not support an immunologically dysfunctional PBML phenotype among patients with FMS as has been observed in the chronic fatigue syndrome.

Serum dioxin and immunologic response in veterans of Operation Ranch Hand.

The authors studied immune response and exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin) among veterans of Operation Ranch Hand, the US Air Force unit responsible for the aerial spraying of herbicides in Vietnam from 1962 to 1971. A comparison group of Air Force veterans who served in Southeast Asia but were not involved in spraying herbicides was included. The authors studied delayed-type hypersensitivity skin test responses to Candida albicans, mumps, Trichophyton, and a bacterial antigen made from lysed Staphylococcus aureus. Lymphocyte measurements included total lymphocyte counts; T-cell (CD3, CD4, CD5, and CD8), B-cell (CD20), and NK-cell (CD16 and CD56) subsets; and expression of the activation antigen CD25 on CD3 T cells. The authors quantitated the serum concentrations of immunoglobulin (Ig)A, IgG, and IgM; examined sera for the presence of monoclonal immunoglobulins (M proteins); and looked for a broad range of autoantibodies (rheumatoid factor, antinuclear antibody, smooth muscle autoantibody, mitochondrial autoantibody, parietal cell autoantibody, and thyroid microsomal autoantibodies). They measured the level of dioxin in 1987 or 1992, extrapolated the result to the time of service in Vietnam, and assigned each veteran to one of four exposure categories: Comparison and three Ranch Hand groups (Background, Low, or High). Overall, the authors found no evidence of a consistent relation between dioxin exposure category and immune system alteration.