Effect of late prophylaxis in hemophilia on joint status: a randomized trial.

Essentials High-quality data are lacking on use of prophylaxis in adults with hemophilia and arthropathy. SPINART was a 3-year randomized clinical trial of late/tertiary prophylaxis vs on-demand therapy. Prophylaxis improved function, quality of life, activity and pain but not joint structure by MRI. Prophylaxis improves function but must start before joint bleeding onset to prevent arthropathy. SUMMARY: Background Limited data exist on the impact of prophylaxis on adults with severe hemophilia A and pre-existing joint disease. Objectives To describe 3-year bleeding, joint health and structure, health-related quality-of-life (HRQoL) and other outcomes from the open-label, randomized, multinational SPINART study. Patients/Methods Males aged 12-50 years with severe hemophilia A, ≥ 150 factor VIII exposure days, no inhibitors and no prophylaxis for > 12 consecutive months in the past 5 years were randomized to sucrose-formulated recombinant FVIII prophylaxis or on-demand therapy (OD). Data collected included total and joint bleeding events (BEs), joint structure (magnetic resonance imaging [MRI]), joint health (Colorado Adult Joint Assessment Scale [CAJAS]), HRQoL, pain, healthcare resource utilization (HRU), activity, and treatment satisfaction. Results Following 3 years of prophylaxis, adults maintained excellent adherence, with a 94% reduction in BEs despite severe pre-existing arthropathy; 35.7% and 76.2% of prophylaxis participants were bleed-free or had fewer than two BEs per year, respectively. As compared with OD, prophylaxis was associated with improved CAJAS scores (least squares [LS] mean, - 0.31 [n = 42] versus + 0.63 [n = 42]) and HAEMO-QoL-A scores (LS mean, + 3.98 [n = 41] versus - 6.00 [n = 42]), less chronic pain (50% decrease), and approximately two-fold less HRU; activity, Euro QoL-5D-3L (EQ-5D-3L) scores and satisfaction scores also favored prophylaxis. However, MRI score changes were not different for prophylaxis versus OD (LS mean, + 0.79 [n = 41] versus + 0.96 [n = 38]). Conclusions Over a period of 3 years, prophylaxis versus OD in adults with severe hemophilia A and arthropathy led to decreased bleeding, pain, and HRU, better joint health, activity, satisfaction, and HRQoL, but no reduction in structural arthropathy progression, suggesting that pre-existing joint arthropathy may be irreversible.

Medical comorbidity in narcolepsy: findings from the Burden of Narcolepsy Disease (BOND) study.

OBJECTIVE/BACKGROUND: The objective of this study was to evaluate medical comorbidity patterns in patients with a narcolepsy diagnosis in the United States. PATIENTS/METHODS: This was a retrospective medical claims data analysis. Truven Health Analytics MarketScan® Research Databases were accessed to identify individuals ≥18 years of age with ≥1 diagnosis code for narcolepsy (International Classification of Diseases (ICD)-9, 347.0, 347.00, 347.01, 347.1, 347.10, or 347.11) continuously insured between 2006 and 2010, and controls without narcolepsy matched 5:1 on age, gender, region, and payer. Narcolepsy and control subjects were compared for frequency of comorbid conditions, identified by the appearance of >1 diagnosis code(s) mapped to a Clinical Classification System (CCS) level 1 category any time during the study period, and on specific subcategories, including recognized narcolepsy comorbidities of obstructive sleep apnea (OSA) and depression. RESULTS: The final study group included 9312 subjects with narcolepsy and 46,559 controls (each group: average age, 46.1 years; 59% female). As compared with controls, patients with narcolepsy showed a statistically significant excess prevalence in all the CCS multilevel categories, the only exceptions being conditions originating in the perinatal period and pregnancy/childbirth complications. The greatest excess prevalence in the narcolepsy cohort was seen for mental illness (31.1% excess prevalence; odds ratio (OR) 3.8, 95% confidence interval (CI) 3.6, 4.0), followed by diseases of the digestive system (21.4% excess prevalence; OR 2.7, 95% CI 2.5, 2.8) and nervous system/sense organs (excluding narcolepsy; 20.7% excess prevalence; OR 3.7, 95% CI 3.4, 3.9). CONCLUSIONS: In this claims analysis, a narcolepsy diagnosis was associated with a wide range of comorbid medical illness claims, at significantly higher rates than matched controls.

Seven challenges in modeling vaccine preventable diseases.

Vaccination has been one of the most successful public health measures since the introduction of basic sanitation. Substantial mortality and morbidity reductions have been achieved via vaccination against many infections, and the list of diseases that are potentially controllable by vaccines is growing steadily. We introduce key challenges for modeling in shaping our understanding and guiding policy decisions related to vaccine preventable diseases.

High-level endoscope disinfection processes in emerging economies: financial impact of manual process versus automated endoscope reprocessing.

BACKGROUND: The use of flexible endoscopes is growing rapidly around the world. Dominant approaches to high-level disinfection among resource-constrained countries include fully manual cleaning and disinfection and the use of automated endoscope reprocessors (AERs). Suboptimal reprocessing at any step can potentially lead to contamination, with consequences to patients and healthcare systems. AIM: To compare the potential results of guideline-recommended AERs to manual disinfection along three dimensions - productivity, need for endoscope repair, and infection transmission risk in India, China, and Russia. METHODS: Financial modelling using data from peer-reviewed published literature and country-specific market research. FINDINGS: In countries where revenue can be gained through productivity improvements, conversion to automated reprocessing has a positive direct impact on financial performance, paying back the capital investment within 14 months in China and seven months in Russia. In India, AER-generated savings and revenue offset nearly all of the additional operating costs needed to support automated reprocessing. CONCLUSION: Among endoscopy facilities in India and China, current survey-reported practices in endoscope reprocessing using manual soaking may place patients at risk of exposure to pathogens leading to infections. Conversion from manual soak to use of AERs, as recommended by the World Gastroenterology Organization, may generate cost and revenue offsets that could produce direct financial gains for some endoscopy units in Russia and China.

Development and characterization of 11 microsatellite loci for the Mona Island iguana (Cyclura cornuta stejnegeri).

We isolated and characterized 11 microsatellite loci in the Mona Island iguana (Cyclura cornuta stejnegeri). Eleven loci exhibit moderate to high allelic diversity (two to 12 alleles, mean = 4.5) and polymorphism (mean observed heterozygosity, 0.56; range, 0.26 to 0.78) in 41 adults. This marker set has low probability of identity and high parentage exclusion power and will be suitable for studies of paternity, social organization and relatedness in this species.

Adsorption of CO2 on oxidized, defected, hydrogen and oxygen covered rutile (1 x 1)-TiO2(110).

Presented are initial, S(0) and coverage, Theta, dependent S(Theta), adsorption probability measurements of CO(2) as a function of impact energy, E(i) = 0.12-1.3 eV, adsorption temperature, T(s) = 85-300 K, hydrogen and oxygen pre-exposure, as well as density of defects, Gamma, as varied by annealing (T = 600-900 K) and Ar(+) ion sputtering (dose chi(Ar) at 600 eV at 85 K) of a rutile (1 x 1) TiO(2)(110) surface. The defect densities were qualitatively characterized by thermal desorption spectroscopy (TDS) of CO(2). The CO(2) TDS curves consisted of two structures that can be assigned to adsorption on pristine and oxygen vacancy sites, in agreement with earlier studies. S(0) decreased linearly with E(i) and was independent of T(s). The adsorption dynamics were dominated by the effect of precursor states leading to Kisliuk-like shapes over the E(i) and T(s) range studied. Oxygen vacancy sites reduced S(0) of CO(2). Preadsorbed oxygen blocked preferentially defect sites, which led to an increase in S(0). Hydrogen preadsorption results in physical site blocking with decreased S(0) as H-preexposure increased, while the shape of S(Theta) curves was conserved. In contrast to oxygen, hydrogen does not adsorb preferentially on defect sites. The adsorption probability data were parameterized by analytic functions (Kisliuk model) and by Monte Carlo simulations (MCSs).

Recent developments in clinimetric instruments.

Assessment of impairment and function is essential in order to monitor joint status and evaluate therapeutic interventions in patients with haemophilia. The improvements in the treatment of haemophilia have required the development of more sensitive tools to detect the more minor dysfunctions that may now be apparent. This paper outlines some of the recent developments in this field. The Haemophilia Joint Health Score (HJHS) provides a systematic and robust measure of joint impairment. The MRI Scoring System has been designed to provide a comprehensive scoring system combining both progressive and additive scales. The Functional Independence Score for Haemophilia (FISH) has been developed to assess performance of functional activities and can be used in conjunction with the Haemophilia Activities List (HAL) which provides a self report measure of function. It is recommended that both measures are evaluated as these tools measure different constructs. Further refinement and testing of the psychometric properties of all of these tools is in progress. More widespread use of these tools will enable the sharing of data across the world so promoting best practice and ultimately enhancing patient care.

The city-fox phenomenon: genetic consequences of a recent colonization of urban habitat.

The red fox (Vulpes vulpes) is one of the best-documented examples of a species that has successfully occupied cities and their suburbs during the last century. The city of Zurich (Switzerland) was colonized by red foxes 15 years ago and the number of recorded individuals has increased steadily since then. Here, we assessed the hypothesis that the fox population within the city of Zurich is isolated from adjacent rural fox populations against the alternative hypothesis that urban habitat acts as a constant sink for rural dispersers. We examined 11 microsatellite loci in 128 foxes from two urban areas, separated by the main river crossing the city, and three adjacent rural areas from the region of Zurich. Mean observed heterozygosity across individuals and the number of detected alleles were lower for foxes collected within the city as compared with their rural conspecifics. Genetic differentiation was significantly lower between rural than between rural and urban populations, and highest value of pairwise FST was recorded between the two urban areas. Our results indicate that the two urban areas were independently founded by a small number of individuals from adjacent rural areas resulting in genetic drift and genetic differentiation between rural and urban fox populations. Population admixture and immigration analysis revealed that urban-rural gene flow was higher than expected from FST statistics. In the five to seven generations since colonization, fox density has dramatically increased. Currently observed levels of migration between urban and rural populations will probably erode genetic differentiation over time.

Results of secondary prophylaxis in children with severe hemophilia.

In this study, 13 children with severe hemophilia were given routine replacement infusions of factor VIII or IX to treat arthropathy. The children who had a mean age of 6.9 years (range 2.0-12.5) at initiation of prophylaxis had experienced an average of 43 acute hemorrhages (range 8-127) in the year prior to prophylaxis, of which a mean of 24 (range 5-46) were into joints. Therapy was begun in five children, using factor VIII concentrate at 20 U/kg three times a week, and one boy received factor IX concentrate 40 U/kg twice a week. This dose schedule was inadequate for three factor VIII-deficient boys and for the one factor IX-deficient boy. Two of three factor VIII-deficient boys responded to an increase to 30 U/kg prior to the 3-day interval. The dose frequency was increased to three times a week for the factor IX-deficient boy, but he continued to bleed and was taken to synovectomy. One of the original five factor VIII-deficient boys plus seven other factor VIII-deficient boys were begun on factor VIII 20 U/kg every other day; 3 boys ceased bleeding. Trough factor VIII levels were measured 24 hr after an infusion in the five boys who continued to bleed. Factor VIII dosage was adjusted to achieve a trough level of > 1%; 4 responded to an increase in the dose of factor VIII; 1 had an adequate trough but, due to compliance issues, was taken to synovectomy. Serial clinical and radiographic assessments determined stabilization of joint disease in more than one-half of the boys. No child showed reversal of abnormal radiographic findings. Institution of aggressive factor VIII and IX concentrate in children with established hemophilic arthropathy does not reverse joint disease but may alter the clinical course of hemophilia. Future studies to compare this intervention with primary prophylaxis instituted prior to the onset of recurrent joint hemorrhage are warranted.

How to write a research grant proposal.

Good writing will not of itself produce a good research grant proposal. Nevertheless, a well-organized, well-written proposal can help you get funded, so it's worth some effort. This article provides guidelines for writing all the standard parts of a proposal.