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Inpatient medication order verification is an important skill for pharmacy students to learn for patient safety. This article describes a systematic approach to order verification that enables students to apply didactic knowledge and determine the presence of drug therapy problems during verification decisions.At two different colleges of pharmacy, an order verification module for second-year pharmacy students introduced a checklist for reviewing medication orders in a patient chart and identifying the presence of drug therapy problems. Students had to make a "verify or not" decision for each non-verified order and document their decision in both the chart and on a game-based learning platform.Over four academic years, 756 students participated in the module. With the checklist approach to order verification, students were able to identify the drug therapy problems of "dose too high" and "no drug therapy problem present" but were challenged by "wrong drug," "dose too low/renal dosing," and "duplication of therapy."The order verification checklist was a beneficial tool for teaching a systematic approach to inpatient medication order verification.

After potentially curative treatment, colorectal cancer (CRC) patients remain at high risk for recurrence, second primary CRC, and high-risk adenomas. In combination with existing data, our previous findings provide a rationale for reducing tissue polyamines as tertiary prevention in non-metastatic CRC patients. The goal of this study was to demonstrate rectal tissue polyamine reduction in optimally treated stage I-III CRC patients after intervention with daily oral aspirin + dietary arginine restriction. A single-institution phase IIa clinical trial was conducted. Patients were treated with aspirin 325 mg/day and an individualized dietary regimen designed to reduce arginine intake by ≥30% over a 12-week study period. Dietary intake, endoscopy with rectal biopsies, and phlebotomy were performed pre- and post-intervention. The primary endpoint was to demonstrate ≥50% decrease in rectal tissue putrescine levels from baseline as a measure of polyamine reduction in the target tissue. Twenty eligible patients completed the study. After study intervention, mean dietary arginine intake decreased from 3.7 g/day ± 1.3 SD to 2.6 g/day ± 1.2 SD (29.7% decrease, p < 0.02 by Sign test). Mean plasma arginine levels decreased from 46.0 ng/mL ± 31.5 SD at baseline to 35 ng/mL ± 21.7 SD (p < 0.001). Rectal tissue putrescine levels were 0.90 nMol/mg-protein pre-intervention and 0.99 nMol/mg-protein post-intervention (p < 0.64, NS). No significant differences were observed for the other tissue polyamines investigated: spermidine (p < 0.13), spermine (p < 0.21), spermidine:spermine ratio (p < 0.71). Among CRC survivors, treatment with daily oral aspirin and an individualized dietary arginine restriction intervention resulted in lower calculated dietary arginine intake and plasma arginine levels but did not affect rectal tissue polyamine levels.

345 Background: Most mGEA patients (pt) progress on therapy including ICI, with about 5% progression-free at 6mo (PFS-6) with single agent ICI in later lines of therapy. Alternative therapeutic approaches are needed. Cabo is a multi-tyrosine kinase inhibitor which might modulate immunosuppression in the tumor microenvironment. This study reports on safety and efficacy of the combination of Cabo+Pembro in mGEA refractory to ICI. Methods: Investigator-initiated, single‐arm, two-stage, single institution, phase 2 study in pts with mGEA after ≥1L of fluoropyrimidine and platinum-containing regimens. Additionally, pts with a PD-L1 CPS score ≥10% had also progressed on ICI. Cabo dose was 40mg p.o. daily on days 1 through 21 of a 21‐day cycle, with Pembro 200 mg i.v. on day 1. The primary endpoint was PFS-6, with H0=5%, Ha≥20%. Stage one results (n=19) exceeded the futility threshold. The complete design requires 27 evaluable pts and n≥4 pts with PFS-6 to reject H0 in favor of Ha. Results: 25 pts are currently enrolled. Because stage one did not signal futility, enrollment continues. Median age 58 years (24-75), female (n=13), ECOG 0/1= 13/12, GC/GEJ= 14/11, Caucasian/Hispanic/Asian/other = 7/7/8/3. After a median follow-up of 5.1mo (1.2-24.6), the median PFS and OS are 2.9mo (95% CI 2.1-4.6) and 9.5mo (95% CI 3.1-14.6), respectively. 11/25 had disease progression on or before the first imaging timepoint at 8 weeks, i.e. the clinical benefit rate is 56% (14/25). 13/20 pts had measurable disease by RECISTv1.1: PR 1(7.7%), SD 7(41.2%), PD 5(38.5%). The most common any grade (G) treatment related adverse events (TRAE) were diarrhea (28%), fatigue (20%), and hypertension (16%). G3-4 TRAE were seen in n=3 pts (Hypertension, Thromboembolic event, esophageal perforation; each n=1). No G5 were reported. Conclusions: In this interim analysis of this ongoing study, the combination of Cabo+Pembro shows promising clinical benefit with an estimated OS of 9.5mo in mGEA pts resistant to prior ICI. Follow-up of the primary endpoint is ongoing. The regimen appears tolerable with no new safety signals. More mature data including the primary endpoint and correlative studies will be presented at the meeting. Clinical trial information: NCT04164979 .

98 Background: Salvage treatments for refractory mCRC are an unmet need. This study determined the safety and Recommended Phase 2 Dose (RP2D) of the multi-kinase inhibitor Cabo in combination with FDT/TPI in mCRC. Methods: Single institution investigator-initiated phase 1 study using 3+3 design. Patients (pts) with mCRC previously treated with a fluoropyrimidine, oxaliplatin, irinotecan and appropriate biologics were eligible. Cabo was given orally (p.o.) at 20 mg (dose level [DL] 0) or 40 mg (DL 1) daily on days 1-28, and FTD/TPI p.o. at 35 mg/m2 on days 1-5 and 8-12 every 28 days. Prophylactic growth factors were allowed. The primary endpoint was Dose Limiting Toxicity (DLT) at 28 days. Secondary endpoints included overall survival (OS), progression-free survival (PFS), objective response rate and CEA response. Results: 12 pts were enrolled. Median age 57 years (31-80), male (9/12), ECOG 0/1 = 7/5, Caucasian/Hispanic/Asian = 7/4/1. 3 pts were treated at DL 0 with no observed DLT. Another 9 pts (n = 6 pts to determine RPD2 and additional n = 3 pts in expansion) were treated at DL 1, none exhibiting a DLT. The most common any grade (G) treatment related adverse events (TRAE) were diarrhea (50%), nausea (42%), neutropenia (42%), fatigue (33%) and rash (25%). G3-4 TRAE in > 5% of patients were neutropenia (25%) and thrombocytopenia, hypokalemia, weight loss (each 8%). No serious TRAE or G5 were reported. The RP2D was determined to be DL 1. Median PFS and OS were 4.1 (95% CI 1.9-6.8) and 6.7 (95% CI 2.2-not evaluable) months, respectively. The disease control rate was 75%. 5/12 (42%) pts had a CEA decline > 30%. Conclusions: The combination of Cabo and FTD/TPI is feasible and tolerable and showed encouraging clinical activity in refractory mCRC. Additional pts are being enrolled at DL 1 and will be presented at the meeting. Clinical trial information: NCT04868773 .

Propionibacterium species are associated with normal skin flora and cultures may be dismissed as contaminants. They are increasingly recognized as a cause of septic arthritis following shoulder arthroplasty and arthrotomy. We identified three cases of Propionibacterium septic arthritis in native joints mimicking atypical osteoarthritis and review the literature, clinical course, and treatment of 18 cases. Two cases of Propionibacterium acne in native knee joints and one in a sternoclavicular joint are described. A literature search for Propionibacterium septic arthritis was performed. Clinical course, treatment, and outcome are reviewed for all cases. Our three cases were combined with 15 cases from the literature. Fourteen cases showed few signs of acute infection, slow culture growth, and delayed diagnosis. In 3 cases an early culture was dismissed as a contaminant. Six cases were reported as caused by recent arthrocentesis. Fifteen cases were cured with antibiotics, although 5 of these 15 also required surgical intervention. Two patients were diagnosed while undergoing surgery for osteoarthritis. Four patients required arthroplasty and two of our patients will require arthroplasty for good functional results. Propionibacterium as a cause of septic arthritis in native joints demonstrates few signs of acute infection, presents with prolonged course, and is often misdiagnosed or unsuspected. Anaerobic growth may be delayed or missed altogether, and outcomes are consequently poor. Consider Propionibacterium septic arthritis in atypical osteoarthritis prior to arthroplasty.

The China GAVI Project (CGP) was initiated in 2002 to provide hepatitis B (HB) vaccine to infants born in the less developed areas of China including the Western provinces and poverty counties of Middle provinces, to prevent the consequences of hepatitis B virus infection. By 2009, the project areas had raised coverage of 3 doses of HB vaccine and timely birth doses to almost 90% among infants, comparable to those in wealthier Eastern provinces, and reduced HBV prevalence to

Introduction Pneumococcal vaccines are highly effective at preventing invasive pneumococcal disease (IPD), a leading cause of global morbidity. Because pneumococcal vaccines can be expensive, it is useful to estimate what impact might be expected from their introduction. Our objective was to develop a statistical model that could predict rates of IPD following introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in the U.S. Methods We used active surveillance data to design and validate a Poisson model forecasting the reductions in IPD observed after U.S. introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in 2000. We used this model to forecast rates of IPD from 2010 to 2020 in the presence of PCV13. Because increases in non-PCV7-type IPD were evident following PCV7 introduction, we evaluated varying levels of increase in non-PCV13-type IPD (“serotype replacement”) by sensitivity analyses. Results A total of 43,507 cases of IPD were identified during 1998–2009; cases from this period were used to develop the model, which accurately predicted indirect effects of PCV7 in adults, as well as serotype replacement. Assuming that PCV13 provides similar protection against PCV13 serotypes as PCV7 did against PCV7 serotypes, the base-case model predicted approximately 168,000 cases of IPD prevented from 2011 to 2020. When serotype replacement was varied in sensitivity analyses from 0 to levels comparable to that seen with serotype 19A (the most common replacement serotype since PCV7 was introduced), the model predicted 167,000–170,000 cases prevented. The base-case model predicted rates of IPD in children under five years of age decreasing from 21.9 to 9.3 cases per 100,000 population. Conclusions This model provides a “benchmark” for assessing progress in the prevention of IPD in the years after PCV13 introduction. The amount of serotype replacement is unlikely to greatly affect the overall number of cases prevented by PCV13.

Background Because pneumococcal pneumonia was prevalent during previous influenza pandemics, we evaluated invasive pneumococcal pneumonia (IPP) rates during the 2009 influenza A(H1N1) pandemic. Methods We identified laboratory-confirmed, influenza-associated hospitalizations and IPP cases (pneumococcus isolated from normally sterile sites with discharge diagnoses of pneumonia) using active, population-based surveillance in the United States. We compared IPP rates during peak pandemic months (April 2009-March 2010) to mean IPP rates in nonpandemic years (April 2004-March 2009) and, using Poisson models, to 2006-2008 influenza seasons. Results Higher IPP rates occurred during the peak pandemic month compared to nonpandemic periods in 5-24 (IPP rate per 10 million: 48 vs 9 (95% confidence interval [CI], 5-13), 25-49 (74 vs 53 [CI, 41-65]), 50-64 (188 vs 114 [CI, 85-143]), and ≥65-year-olds (229 vs 187 [CI, 159-216]). In the models with seasonal influenza rates included, observed IPP rates during the pandemic peak were within the predicted 95% CIs, suggesting this increase was not greater than observed with seasonal influenza. Conclusions The recent influenza pandemic likely resulted in an out-of-season IPP peak among persons ≥5 years. The IPP peak's magnitude was similar to that seen during seasonal influenza epidemics.

Background. Streptococcus pneumoniae infections have become increasingly complicated and costly to treat with the spread of antibiotic resistance. We evaluated the relationship between antibiotic prescribing and nonsusceptibility among invasive pneumococcal disease (IPD) isolates. Methods. Outpatient antibiotic prescription data for penicillins, cephalosporins, macrolides, and trimethoprim-sulfamethoxazole were abstracted from the IMS Health Xponent database to calculate the annual number of prescriptions per capita. We analyzed IPD data from 7 of the Centers for Disease Control and Prevention’s Active Bacterial Core surveillance sites (population, 18.6 million) for which data were available for the entire time period under study (1996–2003). Logistic regression models were used to assess whether sites with high antibiotic prescribing rates had a high proportion of nonsusceptible and serotype 19A IPD. Results. Yearly prescribing rates during the period 1996–2003 for children ,5 years of age decreased by 37%, from 4.23 to 2.68 prescriptions per capita per year (P , .001), and those for persons $5 years of age decreased by 42%, from 0.98 to 0.57 prescriptions per capita per year (P , .001); increases in azithromycin prescribing were noted for both groups. Sites with high rates of antibiotic prescribing had a higher proportion of IPD nonsusceptibility than did low-prescribing sites (P 5 .003 for penicillin, P , .001 for every other antibiotic class). Cephalosporin and macrolide prescribing were associated with penicillin and multidrug nonsusceptibility and serotype 19A IPD (P , .001). Conclusions. In sites where antibiotic prescribing is high, the proportion of nonsusceptible IPD is also high, suggesting that local prescribing practices contribute to local resistance patterns. Cephalosporins and macrolides seem to be selecting for penicillin- and multidrug-resistant pneumococci, as well as serotype 19A IPD. Antibiotic use is a major factor contributing to the spread of antibiotic resistance; strategies to reduce antibiotic resistance should continue to include judicious use of antibiotics. Disease caused by Streptococcus pneumoniae, the leading cause of severe bacterial respiratory illness and

From April 2009 through March 2010, during the pandemic (H1N1) 2009 outbreak, ≈8.2 million prescriptions for influenza neuraminidase-inhibiting antiviral drugs were filled in the United States. We estimated the number of hospitalizations likely averted due to use of these antiviral medications. After adjusting for prescriptions that were used for prophylaxis and personal stockpiles, as well as for patients who did not complete their drug regimen, we estimated the filled prescriptions prevented ≈8,400–12,600 hospitalizations (on the basis of median values). Approximately 60% of these prevented hospitalizations were among adults 18–64 years of age, with the remainder almost equally divided between children 0–17 years of age and adults >65 years of age. Public health officials should consider these estimates an indication of success of treating patients during the 2009 pandemic and a warning of the need for renewed planning to cope with the next pandemic.

Background. The Government of Nepal is interested in preventing congenital rubella syndrome (CRS). Surveillance data were analyzed and studies conducted to assess the burden of rubella and CRS and aid in developing a rubella vaccination strategy. Methods. (1) Analysis of rubella cases reported through measles surveillance, 2004 - 2009; (2) in 2008, rubella seroprevalence among women 15 to 39 years of age was evaluated; and (3) in 2009, children attending a school for the deaf were examined for ocular defects associated with CRS. Results. From 2004-2009, there were 3,710 confirmed rubella cases and more than 95% of these cases were less than 15 years of age. Of 2,224 women of childbearing age (WCBA) tested for anti-rubella IgG, 2,020 (90.8%) were seropositive. Using a catalytic infection model, approximately 1,426 infants were born with CRS (192/100,000 live births) in 2008. Among 243 students attending a school for the deaf, 18 (7.4%) met the clinical criteria for CRS. Conclusions. Rubella and CRS were documented as significant public health problems in Nepal. A comprehensive approach is necessary, including introducing rubella vaccine in the routine program, assuring immunity among WCBA, strengthening routine immunization, integrating rubella surveillance with measles casebased surveillance, and establishing CRS surveillance.

OBJECTIVE: We sought to determine the accuracy of cancer registry data regarding the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) status of patients with non-Hodgkin's lymphoma (NHL). METHODS: We used the population-based San Diego/Orange County cancer registry to identify 392 patients with HIV-related NHL diagnosed 1994-1999. After matching for age, sex, race, period of NHL diagnosis, and hospital type, we were able to find 324 corresponding patients among the remaining 4,863 NHL patients diagnosed 1994-1999 (who did not have HIV infection according to cancer registry records). We sought to review these patients' charts at 41 hospitals with 15 separate institutional review boards to determine if the HIV serostatus from the cancer registry was correct. We performed a forward conditional multivariate logistic regression to determine characteristics associated with a false positive HIV status. RESULTS: The false positive rate was 8% while the false negative rate was 3%. The positive predictive value was 93% while the negative predictive value was 97%. Compared to correctly identified patients, false positives were more likely to be > or =50 years old, female, and treated with chemotherapy and less likely to be single with high grade or extranodal disease. CONCLUSION: Using cancer registry data to identify AIDS-related NHL is a valid research practice.

Highly active retroviral therapy (HAART) has been in widespread use in the United States since 1996. We sought to determine how the use of HAART influenced survival among patients with acquired immunodeficiency syndrome (AIDS) and primary central nervous system (CNS) non-Hodgkin's lymphoma (NHL). We used the population-based San Diego and Orange County cancer registry to identify 94 patients with both AIDS and CNS NHL diagnosed 1994-1999, of whom 31 were diagnosed 1996-1999. We performed Kaplan-Meier analyses to compare survival between patients who received HAART at NHL diagnosis or thereafter versus untreated patients and Cox proportional hazard models for adjusted survival. Among the patients diagnosed with NHL in 1996-1999, seven (23%) were taking HAART at the time of NHL diagnosis. Median survival was eight months for those who received HAART at the time of lymphoma diagnosis or after, versus one month for untreated patients. HAART, radiation therapy, and better performance status were associated with improved survival. We conclude that HAART prolongs survival in AIDS-related CNS NHL.

BACKGROUND The authors sought to determine whether the availability of highly active antiretroviral therapy (HAART) coincided with changes in the epidemiology of acquired immunodeficiency syndrome (AIDS)-related non-Hodgkin lymphoma (NHL). METHODS Cancer registry data from 1988–2000 were linked with AIDS registry data from 1981 to July 2003 for San Diego County to identify 537 AIDS-NHL patients. By using the total number of patients with AIDS who were alive as of July 1 annually as the AIDS population denominator, the average annual incidence of NHL was estimated among patients with AIDS for the pre-HAART period (1988–1995) and post-HAART period (1996–2000). The chi-square test was used to compare proportions, and a Cox proportional hazards model was used to compare survival between the pre-HAART and post-HAART periods. RESULTS The incidence of NHL decreased from 29.6 per 1000 person-years pre-HAART to 6.5 per 1000 person-years post-HAART. The proportion of patients who had NHL of central nervous system (CNS) origin decreased from 28% pre-HAART to 17% post-HAART. Among patients with systemic NHL, 54% received chemotherapy pre-HAART, and 72% received chemotherapy post-HAART. The percentage of intermediate-grade NHL increased from 33% pre-HAART to 49% post-HAART, and the percentage of high-grade NHL decreased from 38% to 19%, respectively. A diagnosis of human immunodeficiency virus infection preceding the NHL diagnosis and Stage IV NHL were associated with worse survival, whereas a diagnosis of NHL in the post-HAART period and chemotherapy were associated with better survival. The median survival was 4 months pre-HAART and 9 months post-HAART. CONCLUSIONS Since the introduction of HAART, there has been a decrease in the incidence of systemic and CNS NHL among patients with AIDS. Among patients with systemic, AIDS-related NHL, there has been decreased high-grade histology, increased use of chemotherapy, and improved survival. Cancer 2006. © 2005 American Cancer Society.

Background. Morbidity due to Buruli ulcer disease (BUD), a cutaneous infection caused by Mycobacterium ulcerans, has been increasingly recognized in rural West Africa. The source and mode of transmission remain unknown.Methods. To identify BUD risk factors, we conducted a case-control study in 3 BUD-endemic districts in Ghana. We enrolled case patients with clinically diagnosed BUD and obtained skin biopsy specimens. M. ulcerans infection was confirmed by at least I of the following diagnostic methods: histopathologic analysis, culture, polymerase chain reaction, and Ziehl-Neelsen staining of a lesion smear. We compared characteristics of case patients with confirmed BUD with those of age- and community-matched control subjects using conditional logistic regression analysis.Results. Among 121 case patients with confirmed BUD, leg lesions (49%) or arm lesions (36%) were common. Male case patients were significantly more likely than female case patients to have lesions on the trunk (25% vs. 6%; P = .009). Multivariable modeling among 116 matched case-control pairs identified wading in a river as a risk factor for BUD (odds ratio [OR], 2.69; 95% confidence interval [Cl], 1.27-5.68; P = .0096). Wearing a shirt while farming (OR, 0.27; 95% Cl, 0.11-0.70; P = .0071), sharing indoor living space with livestock (OR, 0.36; 95% Cl, 0.15-0.86; P = .022), and bathing with toilet soap (OR, 0.41; 95% Cl, 0.19-0.90; P = .026) appeared to be protective. BUD was not significantly associated with penetrating injuries (P = .14), insect bites near water bodies (P = .84), bacille Calmette-Guerin vaccination (P = .33), or human immunodeficiency virus infection (P = .99).Conclusions. BUD is an environmentally acquired infection strongly associated with exposure to river areas. Exposed skin may facilitate transmission. Until transmission is better defined, control strategies in BUD-endemic areas could include covering exposed skin.

Objective: We sought to determine if the introduction of highly active antiretroviral therapy (HAART) corresponded with changes in anal squamous cell cancer rates among men with AIDS Study: We linked cancer registry data from 1988-2000 and AIDS registry data from 1981-July/2003 for San Diego County. We defined 1991-1995 and 1996-2000 as the pre- and post-HAART periods, respectively. Results: The annual incidence of invasive anal cancer increased from zero per 100,000 men with AIDS aged 25 to 64 years (95% confidence interval [CI], 0-226) in 1991 to 224 per 100,000 (95% CI, 102-425) in the year 2000. Pre-HAART, the average annual incidence of invasive anal cancer was 49 per 100,000 men with AIDS aged 25 to 64 years (95% CI, 16-114) versus 144 per 100,000 (95% CI, 93-212) post-HAART. The relative risk of invasive anal cancer among men with AIDS compared with men without known HIV/AIDS was 98 (95% CI, 36-264) pre-HAART and 352 (95% CI, 186-669) post-HAART. The increased incidence of anal cancer among men with AIDS resulted in an increase in the overall rate of anal cancer among men in San Diego County. Conclusions: The rising incidence of anal cancer among men with AIDS may be related to increased longevity with HAART and the consequent increased time at risk for the development of malignancy and/or the result of greater use of cytologic screening.

Helicobacter pylori is the primary cause of peptic ulcer disease and an etiologic agent in the development of gastric cancer. H. pylori infection is curable with regimens of multiple antimicrobial agents, and antimicrobial resistance is a leading cause of treatment failure. The Helicobacter pylori Antimicrobial Resistance Monitoring Program (HARP) is a prospective, multicenter U.S. network that tracks national prevalence rates of H. pylori antimicrobial resistance. Of 347 clinical H. pylori isolates collected from December 1998 through 2002, 101 (29.1%) were resistant to one antimicrobial agent, and 17 (4.8%) were resistant to two or more antimicrobial agents. Eighty-seven (25.1%) isolates were resistant to metronidazole, 45 (12.9%) to clarithromycin, and 3 (0.9%) to amoxicillin. On multivariate analysis, black race was the only significant risk factor (p < 0.01, hazard ratio 2.04) for infection with a resistant H. pylori strain. Formulating pretreatment screening strategies or providing alternative therapeutic regimens for high-risk populations may be important for future clinical practice.

(MRSA) infection presented to the emergency room with pain and significant swelling at the site of a dog bite on his left forearm. He had been bitten 2 weeks earlier by a friend’s dog, and the bite had punctured the skin. He also had red streaking on the skin of the left arm from the wrist to the elbow, and he reported feeling “feverish” and having night sweats.3At first, the bite had seemed to improve, then swelling and pain had developed and in-creased. He reported this to his primary care physician, along with the information that he had previously had an anaphylactic reaction to penicillin and a cephalosporin. His physi-cian, considering a penicillin allergy, started him on ciprofloxacin (Cipro) plus clindamy-cin (Cleocin). The patient took this for 5 days, but without improvement. The appear-ance of the red streaking on his left forearm prompted his presentation to our emergency room.■

Colorectal cancer screening beginning at age 50 is recommended for all Americans considered at “average” risk for the development of colorectal cancer either with flexible sigmoidoscopy and fecal occult blood testing (FOBT) or with colonoscopy. Patients who elect flexible sigmoidoscopy and FOBT undergo full colonoscopy only if left-sided neoplasia is detected or if the FOBT is positive. Unfortunately in blacks and whites most right-sided colorectal lesions are unaccompanied by left-sided sentinel lesions, which leads some to prefer colonoscopic screening in these patients. The topography of colorectal cancer in Asians and Latinos is unavailable. We used 1988–1995 California Cancer Registry data to determine the topography of 105,906 consecutive colorectal cancers among Asian, black, Latino, and white patients. We found that the proportion of colorectal cancer distal to the splenic flexure and therefore detectable by flexible sigmoidoscopy varied by ethnicity: Asian (71%) > Latino (63%) > white (57%) > black (55%); P < 0.001. These differences were significant after adjusting for age and sex. The risk of distal disease relative to whites was 1.61 in Asians, 1.15 in Latinos, and 0.82 in blacks ( P < 0.001). Flexible sigmoidoscopy detects a higher proportion of colorectal cancers in Asians and Latinos than in whites or blacks. Further study is needed to assess whether the topography of benign colorectal neoplasia parallels that of malignant disease. Colorectal screening recommendations may need to incorporate racial and ethnic differences in colorectal neoplasia topography.

The incidence of breast cancer in the U.S. is lower among Hispanic women than non-Hispanic white women. However, population-based studies show that Hispanic women are more likely to be diagnosed at a later stage than non-Hispanic whites. We aimed to determine whether: 1) a lower proportion of breast cancer was diagnosed at early vs. late stages in Hispanic compared to non-Hispanic white women from 1988-93 in San Diego County, and 2) lower income is related to later stage at diagnosis for both groups. All incident cases of breast cancer in San Diego County from the California Cancer Registry (10,161 cases) were stratified by 'early' (in situ or localized) or 'late' (regional or distant) stage, and by race/ethnicity. Annual average age-adjusted incidence rates/100,000 (AAIR) were calculated. Incidence rate ratios (IRR) (AAIR for early stages divided by AAIR for late stages) were used as a surrogate of early detection. AAIRs for early and late stage disease were significantly higher for non-Hispanic whites (89.3, 42.3) than Hispanic women (46.7, 27.2). The IRR was significantly higher for non-Hispanic whites than Hispanics, (2.11 vs 1.72, p = 0.01). This difference was greatest among women under 50 years old (IRR difference 0.63), and not apparent for women 65 or older (IRR difference 0.06). There was also an association between increasing census tract per capita income and higher rates of early stage disease among non-Hispanic whites but not Hispanics. Results suggest that Hispanic women and lower income women should be targeted for early detection.

BACKGROUND It is suspected that young patients with adenocarcinoma have a more aggressive form of disease and therefore a poorer prognosis than older patients. METHODS A retrospective cohort study used the population-based tumor registries of Orange, San Diego, and Imperial Counties. Cases (patients age ≤40 years with gastric carcinoma) were compared with controls (patients age >40 years with gastric carcinoma). RESULTS The overall, age-adjusted incidence rate of gastric carcinoma was 10.2/100,000. Approximately 5.5% of 3,020 cases occurred in patients age 70 years had an independent increased risk of dying from all causes in comparison with young patients (relative risk = 1.46; P = 0.01). CONCLUSIONS Young gastric carcinoma patients have adverse clinical and pathologic features in comparison with older patients. In this study, young age was not found to be an independent predictor of overall survival. Cancer 1998;83:25-33. © 1998 American Cancer Society.

A case of pneumonia due to Legionella bozemanii--only the 20th culture-proven case reported so far--progressed with cavitation 9 days after the initiation of intravenous therapy with erythromycin. Review of all 20 reported cases revealed a similar propensity toward radiographic progression (25%) and cavitation (25%) during therapy. A slow response to long courses of erythromycin was the rule (35% of cases). In two instances, long courses of intravenous erythromycin failed and the patient died. Pleural effusion was reported in 60% of patients, including two with empyema. Overall mortality was high (40%). Although mortality was only 21% among patients who lived long enough to receive adequate courses of erythromycin, all three such patients who died had received erythromycin alone. Combination therapy with erythromycin and rifampin proved more effective in terms of survival. Infections due to non-pneumophila Legionella may be overlooked because of the organisms' special serological and culture requirements.

This study examines the estimated risk of bladder cancer associated with various occupations among 1,465 cases identified in Orange County, California, during 1984-1988. The annual age-adjusted incidence rate per 100,000 population in Orange County was similar to that of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute: 25.7 in males and 6.2 in females. Cases were compared with a sample of Orange County residents relative to broad category of current occupation, adjusted for age and cigarette smoking. The estimated relative risks were significant for males in machine trades (relative risk (RR) = 2.69, 95% confidence interval (CI) 1.24-5.82) and processing occupations (RR = 5.77, 95% CI 1.43-23.27) and for females in machine trades (RR = 8.34, 95% CI 1.14-61.17) and homemakers (RR = 5.37, 95% CI 2.40-11.99) as compared with individuals of the same sex in professional, technical, and managerial occupations.

Treating infections is one of the greatest successes in medicine, but it may be too easy to prescribe antibiotics. This report reviews U.S. outpatient antibiotic use in 2010.

Little is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection.To describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001.Cross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records.Health complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2).The anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P.001), and significantly reduced health-related quality-of-life indices compared with US referent populations. Eight survivors (53%) had not returned to work since their infection. Comparing disease manifestations, inhalational survivors reported significantly lower overall physical health than cutaneous survivors (mean scores, 30 vs 41; P =.02). Available medical records could not explain the persisting health complaints.The anthrax survivors continued to report significant health problems and poor life adjustment 1 year after onset of bioterrorism-related anthrax disease.

Objective : To determine whether a single session of PNF stretching using the hold-relax technique on the diagonal of extension, abduction and internal rotation was more effective at increasing hip adductor flexibility than passive stretching in a horizontal plane in sedentary individuals. Materials and Method : A single blind cross-over design, with the evaluator being blinded was utilized. A total of sixty-four students from the University of the West Indies participated in the study. Each subject had one leg exposed to three passive stretches with a 10 second hold for each stretch. The other leg was placed on the PNF diagonal of extension, abduction, and internal rotation and three repetitions of the hold-relax technique applied. Abduction range of motion was measured using standard goniometric procedures before and immediately after stretching. Results : Both PNF and static stretching produced a significant increase in flexibility (mean change of 9.95 o ± 6.7o and 10.9o± 6.8o respectively, p < 0.001). The results of the t -test showed no difference in the mean change in flexibility when the two techniques were compared (p = 0.41). Conclusion : Passive stretching in a horizontal plane and PNF stretching using the hold-relax technique on a diagonal are equally effective at increasing adductor flexibility in sedentary individuals.

ContextLittle is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection.ObjectiveTo describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001.Design, Setting, and ParticipantsCross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records.Main Outcome MeasuresHealth complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2).ResultsThe anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P

Human APOBEC3G (hA3G), a member of the AID/APOBEC family of deaminases, is a restriction factor for human immunodeficiency virus (HIV). In the absence of the viral Vif protein hA3G is packaged into virions and during reverse transcription in a recipient cell it deaminates cytosines, leading to G → A hypermutation and inactivation of the viral DNA. Unlike humans, who carry seven APOBEC3 genes, mice only carry one, mA3. Thus the role of mA3 in restriction of retroviral infection could be studied in mA3 −/− knockout mice, where the gene is inactivated. M-MuLV-infected mA3 −/− mice showed substantially higher levels of infection at very early times compared to wild-type mice (ca. 2 logs at 0–10 days), particularly in the bone marrow and spleen. Restriction of M-MuLV infection was studied ex vivo in primary bone marrow-derived dendritic cells (BMDCs) that express or lack mA3, using an M-MuLV-based retroviral vector expressing enhanced jellyfish green fluorescent protein (EGFP). The results indicated that mA3 within the virions as well as mA3 in the recipient cell contribute to resistance to infection in BMDCs. Finally, M-MuLV-infected mA3 +/+ mice developed leukemia more slowly compared to animals lacking one or both copies of mA3 although the resulting disease was similar (T-lymphoma). These studies indicate that mA3 restricts replication and pathogenesis of M-MuLV in vivo.

FAMILIAL dysautonomia is a rare congenital disorder that occurs primarily in Jewish children.1 The more striking manifestations of the disease include reduced or absent tearing, transient skin blotching, profuse sweating, abnormal swallowing reflex and instability of temperature control. Postural hypotension is a regular finding in this syndrome although the blood pressure may rise during excitement. Riley2 has suggested that the many manifestations of familial dysautonomia may result from a singleenzyme defect. Since autonomie dysfunction is so prominent in this disorder, a defect in catechol amine metabolism may be involved. The excretion rates of catechol amine catabolites, homovanillic (HVA) and vanillyl-mandelic . . .