Boosting enrollment in neurology trials with Local Identification and Outreach Networks (LIONs).

OBJECTIVE: Our purpose was to develop a geographically localized, multi-institution strategy for improving enrolment in a trial of secondary stroke prevention. METHODS: We invited 11 Connecticut hospitals to participate in a project named the Local Identification and Outreach Network (LION). Each hospital provided the names of patients with stroke or TIA, identified from electronic admission or discharge logs, to researchers at a central coordinating center. After obtaining permission from personal physicians, researchers contacted each patient to describe the study, screen for eligibility, and set up a home visit for consent. Researchers traveled throughout the state to enroll and follow participants. Outside the LION, investigators identified trial participants using conventional recruitment strategies. We compared recruitment success for the LION and other sites using data from January 1, 2005, through June 30, 2007. RESULTS: The average monthly randomization rate from the LION was 4.0 participants, compared with 0.46 at 104 other Insulin Resistance Intervention after Stroke (IRIS) sites. The LION randomized on average 1.52/1,000 beds/month, compared with 0.76/1,000 beds/month at other IRIS sites (p = 0.03). The average cost to randomize and follow one participant was $8,697 for the LION, compared with $7,198 for other sites. CONCLUSION: A geographically based network of institutions, served by a central coordinating center, randomized substantially more patients per month compared with sites outside of the network. The high enrollment rate was a result of surveillance at multiple institutions and greater productivity at each institution. Although the cost per patient was higher for the network, compared with nonnetwork sites, cost savings could result from more rapid completion of research.

Capsule endoscopy - comparison of two strategies of bowel preparation.

BACKGROUND: Capsule endoscopy can identify lesions of the small bowel that cannot be detected by other techniques. In addition to patient safety, quality of care and cost-efficiency, good preparation is an important factor for good visualization. AIM: To evaluate the efficacy of oral sodium phosphate preparation. METHODS: Forty-six consecutive patients scheduled for capsule endoscopy in two medical centres. The patients treated in Dallas were prepared by 12 h fasting (group A), and those treated in Israel were also asked to drink 45 mL of sodium phosphate with water (group B). An experienced endoscopist, blinded to the method used, graded the quality of preparation according to visual capability, and to relative durations of each grade. RESULTS: The quality of the preparation was poor in 35% of group A compared with 4% of group B (P = 0.023). The mean duration of good preparation with excellent visualization was 122 +/- 110 min in group A and 180 +/- 96 min in group B (P = 0.006). Preparation with sodium phosphate and lower patient weight were significant predictive factors for good visualization. CONCLUSIONS: Bowel preparation offers better visualization than overnight fasting alone and is associated with fewer disturbances by intraluminal turbid fluid.

Uncoupling of bone turnover following hip replacement.

Studies using total hip replacement surgery as a model for acute hip injury have shown that bone mineral density of the proximal femur decreases 6-18% in the 6 months following surgery. To examine the acute biochemical mechanism associated with bone loss, we measured two indicators of bone formation [serum osteocalcin (OC), serum bone-specific alkaline phosphatase (BSAP)], as well as two markers for bone resorption [urine and serum N-telopeptide cross-linked collagen type 1 (NTx)], in 20 patients (10 men, 10 women, mean age 59.4 years) prior to hip replacement and 1-2 days postsurgery. The average OC value (ng/ml) decreased by 57.3% following surgery (7.5 +/- 4.3 to 3.2 +/- 1.1, P <0.001), and the average BSAP level (U/L) decreased by 27.6% (19.9 +/- 5.6 to 14.4 +/- 3.7, P <0.001). In contrast, levels of urine NTx (nmol BCE/mmol Cr) did not change significantly after the surgery (73.9 +/- 47.2 to 70.1 +/- 29.7). In addition, there was no change in serum NTx (nmol BCE) after surgery (11.8 +/- 2.3 to 11.8 +/- 3.0). Six months after surgery, bone mass had not changed significantly from baseline. These findings suggest that there is an uncoupling of bone turnover following hip replacement surgery which is characterized by significant reductions in bone formation without compensatory decreases in bone resorption, potentially leading to bone loss. Longer periods of follow-up are needed to assess long-term bone mass changes.

Rapid detection of Escherichia coli O157:H7 in ground beef using a fiber-optic biosensor.

A portable fiber-optic biosensor was used to detect Escherichia coli O157:H7 in seeded ground beef samples. The principle of the system is a sandwich immunoassay using cyanine 5 dye-labeled polyclonal anti-E. coli O157:H7 antibodies for generation of a specific fluorescent signal. Signal acquisition is effected by launching light from a 635-nm diode laser into a dual tapered 600-microm silica fiber. Fluorescent molecules within approximately 100 nm of the fiber surface are excited by the evanescent field, and a portion of the emission recouples into the fiber. A photodiode allows for quantitation of the collected emission light at wavelengths of 670 to 710 nm. Biotin-avidin interactions are used to attach polyclonal antibodies specific for E. coli O157:H7 to the final 7.5 cm of the fiber probe. The biosensor was able to detect E. coli O157:H7 to 3 to 30 CFU/ml in seeded ground beef samples. The reaction was highly specific. Signals with Listeria monocytogenes, Salmonella Typhimurium, or E. coli nonO157:H7 were 2 to 3% of those observed with a similar concentration of E. coli O157:H7. Assays were conducted at or near real-time with results obtained within 20 min of sampling.

gamma-Linolenic acid treatment of rheumatoid arthritis. A randomized, placebo-controlled trial.

OBJECTIVE: To assess the clinical efficacy and adverse effects of gamma-linolenic acid (GLA), a plant seed oil-derived unsaturated fatty acid that suppresses inflammation and joint tissue injury in animal models, in the treatment of active rheumatoid arthritis (RA). METHODS: Fifty-six patients with active RA were randomized to treatment groups in a 6-month, double-blind trial of GLA versus placebo. This was followed by a 6-month, single-blind trial during which all patients received GLA. Patients were treated with 2.8 gm/day of GLA as the free fatty acid or with sunflower seed oil (placebo) administered in identical capsules. RESULTS: Treatment with GLA for 6 months resulted in statistically significant and clinically relevant reductions in the signs and symptoms of disease activity in patients with RA. Overall meaningful responses (at least 25% improvement in 4 measures) were also better in the GLA treatment group (14 of 22 patients versus 4 of 19 in the placebo group; P = 0.015). During the second 6 months, both groups exhibited improvement in disease activity. Thus, patients taking GLA during the entire study showed progressive improvement during the second 6 months. In this group, 16 of 21 patients showed meaningful improvement at 12 months compared with study entry. CONCLUSION: GLA at doses used in this study is a well-tolerated and effective treatment for active RA. GLA is available as a component of several plant seed oils and is usually taken in far lower doses than were used in this trial. It is not approved in the United States for the treatment of any condition, and should not be viewed as therapy for any disease. Further controlled studies of its in RA are warranted.

Effects of fatty acids on proliferation and activation of human synovial compartment lymphocytes.

The object of this study was to determine the effects of eicosanoid precursor fatty acids on activation and proliferation of T lymphocytes from synovial fluid and synovial tissue of rheumatoid arthritis patients. Proliferation was determined by direct cell counts; phenotypic characterization of surfaces molecules was by cytofluorometric analysis. Dihomogammalinolenic acid, arachidonic acid, and eicosapentaenoic acid suppressed proliferation of interleukin-2-dependent lymphocytes by as much as 80%; cell viability was not altered by fatty acids. Administration of particular fatty acids may prove to be a useful therapeutic intervention in rheumatoid arthritis patients because of their ability to suppress activation and proliferation of synovial compartment T lymphocytes.

Restricted heterogeneity of T cell receptor transcripts in rheumatoid synovium.

RA is characterized by massive proliferation of synovial tissue, accompanying infiltration of the tissue with CD4+ T lymphocytes, and a genetic linkage to the MHC antigen HLA-DR4. Since T cells are restricted by class II MHC molecules such as DR4, this suggests a direct role for these CD4+ cells in pathogenesis. To investigate T cell receptor (TCR) usage in RA, we used oligonucleotide primers specific for each of the major alpha and beta TCR subfamilies to amplify cDNA derived from whole synovium or synovial tissue T cell lines in a family-specific manner. Detection of amplified DNA was facilitated by utilizing oligonucleotide probes derived from the constant regions of the TCRs. The TCR repertoire present in the synovial T cell lines was quite heterogeneous, with an average of 15 alpha chains and 15.8 beta chains detected. When synovial tissue was analyzed, the predominant TCR subfamilies detected tended to be more restricted, with an average of 4.6 alpha chains and 8.6 beta chains detected. This compared with an average of six alpha chains and 12 beta chains in nonrheumatoid synovial samples. The average percentage of synovia positive per TCR beta family was significantly lower for RA versus non-RA specimens (46.1 vs 65.6%, P = 0.034). These findings indicate that while a polyclonal population of T cells is present in RA synovium, the predominant patterns of TCR transcript expression may be somewhat more restricted, suggesting that TCR-based therapy of RA is possible.

Interleukin-1 induced gene expression of neutrophil activating protein (interleukin-8) and monocyte chemotactic peptide in human synovial cells.

We report here that human synovial cells stimulated by interleukin-1 alpha and interleukin-1 beta express mRNA for both IL-8 (neutrophil chemotactic peptide) and monocyte chemotactic protein. IL-1 stimulated synovial cells from both osteoarthritis and rheumatoid arthritis patients exhibited similar mRNA expression of interleukin-8 and monocyte chemotactic protein. A capacity to produce factors selectively chemotactic for neutrophils, lymphocytes and monocytes provides a mechanism whereby synovial cells can facilitate inflammatory arthritis.

Alteration of the cellular fatty acid profile and the production of eicosanoids in human monocytes by gamma-linolenic acid.

We administered borage seed oil (9 capsules/day) for 12 weeks to 7 normal controls and to 7 patients with active rheumatoid arthritis. The therapy provided 1.1 gm/day of gamma-linolenic acid (GLA). GLA administration resulted in increased proportions of its first metabolite, dihomo-gamma-linolenic acid (DGLA), in circulating mononuclear cells. The ratios of DGLA to arachidonic acid and DGLA to stearic acid increased significantly in these cells. Significant reductions in prostaglandin E2, leukotriene B4, and leukotriene C4 produced by stimulated monocytes were seen after 12 weeks of GLA supplementation. The antiinflammatory effects of GLA administration observed in animal models, and the apparent clinical improvement experienced by 6 or 7 rheumatoid arthritis patients given borage seed oil in this open, uncontrolled study may be due in part to reduced generation of arachidonic acid oxygenation products.

Antinuclear antibody in pericardial fluid from a patient with primary cardiac lymphoma.

Pericarditis may be the initial manifestation of systemic lupus erythematosus. Although it is known that antinuclear antibody can be detected in the serum of patients with a wide variety of diseases, it has been proposed that the detection of antinuclear antibody in serosal fluid is a sensitive and specific test for determining that effusions are due to systemic lupus erythematosus. A case is presented in which antinuclear antibody in high titer was identified in the pericardial fluid of a patient who was found at autopsy to have a primary cardiac lymphoma. The case indicates that antinuclear antibody detected in serosal effusions should not be considered pathognomonic for systemic lupus erythematosus.

Staphylococcus aureus bacteremia: significance of hyperbilirubinemia.

We studied 233 consecutive episodes of Staphylococcus aureus bacteremia in 230 patients between 1980 and 1984 at a community teaching hospital. Bacteremia was community-acquired in 78 episodes, acquired from nursing homes in 22 episodes and hospital-acquired in 133 episodes. The over-all mortality was 48.9%. Patients greater than or equal to 60 years had higher mortality (62.0%) than patients less than 60 years old (25.3%). Hospital-acquired bacteremia was associated with a higher mortality (59.4%) than community-acquired bacteremia (29.5%). The respiratory tract as the portal of entry of bacteremia was associated with a higher mortality (80.4%), as compared to 53.5% when the portal of entry was undetermined, and 28.1% when the portal of entry was other sources. Increasing serum creatinine levels were associated with increasing mortality: less than 88.4 mumol/l (26.5%), 97.2-168.0 mumol/l (51.1%), and greater than 176.8 mumol/l (67.9%). Increasing serum bilirubin levels were also associated with increasing mortality: less than 17.1 mumol/l (40.6%), 18.8-49.6 mumol/l (57.1%), and greater than 51.3 mumol/l (84.2%). Very high leukocyte counts were associated with higher mortality: greater than 20 X 10(9)/l (73.9%), 10-20 X 10(9)/l (37.4%), and less than 10 X 10(9)/l (45.8%).

Percutaneous endoscopic gastrostomy--to push or pull. A prospective randomized trial.

A prospective randomized study was undertaken to evaluate the Ponsky-Gauderer and Sachs-Vine types of gastrostomy kits. The techniques, complications, morbidity, and mortality with each type of device are compared. Both devices are found to compare favorably to the traditional surgically placed gastrostomy.