Factors associated with triptan use in episodic migraine: results from the American Migraine Prevalence and Prevention Study

Background.— Though triptans are considered the standard of acute therapy for migraine attacks with headache‐related disability, they are used by the minority of potentially eligible persons. Understanding the socio‐demographic and headache features that predict triptan use may help to clarify barriers to optimal treatment. Objective.— To assess the sociodemographic and headache features associated with triptan use in a US population sample of persons with episodic migraine. Methods.— The American Migraine Prevalence and Prevention Study (AMPP) is a longitudinal study conducted in a representative sample of US headache sufferers. Episodic migraineurs (n = 11,388) who provided treatment data in 2005 were included in the current analyses. We assessed factors associated with triptan use through univariate and multivariate analyses. Multivariate analyses were adjusted for sociodemographic factors, headache‐related disability, cutaneous allodynia, depression, and preventive headache medication use. Results.— Among persons with episodic migraine, 18.31% reported current use of triptans for acute headache treatment. In univariate analyses, triptan use was most common in midlife (ages 30‐59), among females, and was more common in Caucasians than in African Americans. Triptan use increased with headache frequency, headache‐related disability and allodynia, but decreased among persons with depression. In multivariate analyses, female gender, Caucasian race, age 40‐49, higher levels of education (college or higher), annual household income of ≥$40,000, having health insurance, the presence of cutaneous allodynia, greater headache‐related disability, and preventive medication use for migraine were significantly associated with triptan use. Conclusions.— Less than 1 in 5 persons with migraine in the United States who were respondents to this survey used triptans for acute headache treatment over the course of a year. Several markers of severe headache, including disability and allodynia, were associated with increased triptan use. Groups less likely to get triptans included males, African Americans, older adults, and the uninsured. Predictors of use provide insight into groups with unmet treatment needs.     

AIDS-MEDICOLEGAL ASPECTS

AIDS/HIV Positivity has been the most widely debated disease of this century. Reasons for this are manifold, viz-the non-availability of cure and consequent 100% mortality of a full blown case; its mode of transmission-homosexual and heterosexual activities; widespread occurrence amongst ‘main liners’; and patients receiving blood and blood products etc. These aspects have created a dreaded halo around AIDS as well as social stigma. Even the medical community is not exempt from these problems. Unfortunately, legislatures around the world, more so in India, have lagged behind in clarifying many legal issues involved by not enacting specific laws pertaining to AIDS. Consequently many legal & ethical doubts arise in the minds of doctors when confronted with a case of AIDS either in a live patient or in a dead body. In addition, the disease being incurable & 100% fatal, makes it essential to adopt effective preventive measures which in turn need thorough knowledge of social aspects of the epidemic. Certain medicolegal, and ethical aspects of the problem of AIDS are recapitulated in this article for the benefit of the medical community.KEY WORDS: Access, AIDS, Confidentiality     

Differential Access to Digital Communication Technology: Association with Health and Health Survey Recruitment within an African-American Underserviced Urban Population

Digital communication technologies (DCT), such as cell phones and the internet, have begun to replace more traditional technologies even in technology-poor communities. We characterized access to DCT in an underserved urban population and whether access is associated with health and study participation. A general probability community sample and a purposive high-turnover housing sample were recruited and re-interviewed after 3 months. Selected characteristics were compared by sample type and retention. Associations between DCT access and self-reported health were examined using multivariable logistic regression. Of 363 eligible individuals, 184 (general community = 119; high-turnover housing = 65) completed the baseline survey. Eighty-four percent of respondents had a cell phone and 62% had ever texted. Ever use of the internet was high (69%) overall, but frequency and years of internet use were higher in the general community sample. Self-reported fair or poor health was more common for residents of cell phone–only households and those with less frequent internet use. Technology use was similar for those retained and not retained. Overall, access to DCT was high in this underserved urban population but varied by sample type. Health varied significantly by DCT use, but study retention did not. These data have implications for incorporating DCT into health-related research in urban populations.     

Optimizing targeted therapeutic development: Analysis of a colorectal cancer patient population with the BRAFV600E mutation

BRAF^V600E mutations are found in 10% of colorectal cancers (CRCs). The low frequency of this mutation therefore makes it a challenging target for drug development, unless subsets of patients with higher rates of BRAF^V600E can be defined. Knowledge of the concordance between primary–metastasis pairs and the impact of BRAF^V600E on outcome would also assist in optimal drug development. We selected primary CRCs from 525 patients (stages I–IV) evenly matched for age (<70 and ≥70), gender and tumor location (right, left and rectum), and 81 primary–metastasis pairs. BRAF^V600E, KRAS mutation and microsatellite instability (MSI) were determined and correlated with clinical features and patient outcomes. In multivariate analyses, increasing patient age (p = 0.04), female gender (p = 0.0005) and right‐sided tumor location (p < 0.0001) were independently associated with BRAF^V600E. The prevalence of BRAF^V600E was considerably higher in older (age > 70) females with KRAS wild‐type right‐sided colon cancers (50%) compared to the unselected cohort (10%). BRAF^V600E was associated with inferior overall survival in metastatic CRC (HR = 2.02; 95% CI 1.26–3.26), particularly evident in patients treated with chemotherapy, and is independent of MSI status. BRAF status was concordant in all primary tumors and matched metastases (79 wild‐type pairs and two mutant pairs). Clinicopathological and molecular features can identify CRC patients with a higher prevalence of BRAF^V600E. Patients with BRAF^V600E wild‐type primary tumor do not appear to acquire the mutation in their metastases, and BRAF^V600E is associated with poorer outcomes in metastatic patients. Our findings are timely and will help inform the rational development of BRAF^V600E inhibitors in CRC.     

Introducing geriatric health in medical training in Ajman,United Arab Emirates: A co-curricular approach

Background

Medical students’ knowledge and understanding of the elderly will affect the quality of care to the rising population of older adults which points to a need to identify geriatric health training methods appropriate for the region and curriculum. Therefore the study assessed the effect of a co- curricular introductory workshop on knowledge regarding geriatric health and attitude towards the elderly among fourth year medical students in a medical university

Method

A quasi-experimental before-after study, with control was conducted at Gulf Medical College among 60 medical students from discipline-based curriculum in year IV during May-June 2010 of whom 16 had opted (attendees) to undergo the introductory course, a five day workshop of 10 hours duration. Pre- and post-testing used self-administered questionnaires for demographic variables: age, gender, nationality, close contact with older people; a quiz on old people’s health, and Kogan’s Old People Scale (KOPS) for attitude. The difference in scores on quiz and KOPS were compared for the attendees and 26 non-attendees who participated in both pre and post testing.

Results

The attendees group had 38% male and 62% female participants and the non-attendees group had 21% and 79% respectively. The groups were not significantly different in age, sex, nationality and close contact with the elderly. The scores on the quiz and KOPS showed no statistically significant difference between the two groups before or after the workshop. Almost all the participants evaluated the workshop very positively especially the interaction with healthy elderly and inmates of old people’s home.

Conclusion

A 10-hour introductory co-curricular workshop made no significant change in the knowledge on geriatric health or attitude of fourth year medical students though they reported it as a very enriching experience. A reflective report may have been a better assessment tool and the impact on their clinical practice cannot be predicted.     

Improving progression-free and overall survival in patients with cancer: a potential role for bisphosphonates

INTRODUCTION: Bisphosphonates are a well-established therapy for patients with multiple myeloma or bone metastases from advanced cancers and are used routinely to delay the onset and reduce the risk of skeletal-related events. Emerging evidence indicates that they also may provide additional anticancer benefits. These developments warrant reappraisal of their role in patients with cancer and reevaluation of optimal therapeutic regimens. AREAS COVERED: This article reviews the evidence of the anticancer activity of bisphosphonates in patients with solid tumors or multiple myeloma. The underlying mechanisms of the anticancer activity of bisphosphonates are elucidated from preclinical and translational data that show that bisphosphonates suppress tumor growth and survival, inhibit tumor-mediated angiogenesis, or stimulate host anticancer immune response. These data also provide insights into the potential for therapeutic combinations. Preclinical and clinical data relating to the anticancer effects of bisphosphonates are reviewed by cancer type. EXPERT OPINION: Future trials of bisphosphonates in cancer patients will explore the underlying mechanism of the anticancer benefit in greater detail and attempt to examine critically the potential clinical benefit in individual cancer types in early/advanced disease.     

Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study

Background

The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women.

Methods

Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively.

Findings

Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation.

Interpretation

Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

     

Metastasis and bone loss: Advancing treatment and prevention

Tumor metastasis to the skeleton affects over 400,000 individuals in the United States annually, more than any other site of metastasis, including significant proportions of patients with breast, prostate, lung and other solid tumors. Research on the bone microenvironment and its role in metastasis suggests a complex role in tumor growth. Parallel preclinical and clinical investigations into the role of adjuvant bone-targeted agents in preventing metastasis and avoiding cancer therapy-induced bone loss have recently reported exciting and intriguing results. A multidisciplinary consensus conference convened to review recent progress in basic and clinical research, assess gaps in current knowledge and prioritize recommendations to advance research over the next 5 years. The program addressed three topics: advancing understanding of metastasis prevention in the context of bone pathophysiology; developing therapeutic approaches to prevent metastasis and defining strategies to prevent cancer therapy-induced bone loss. Several priorities were identified: (1) further investigate the effects of bone-targeted therapies on tumor and immune cell interactions within the bone microenvironment; (2) utilize and further develop preclinical models to study combination therapies; (3) conduct clinical studies of bone-targeted therapies with radiation and chemotherapy across a range of solid tumors; (4) develop biomarkers to identify patients most likely to benefit from bone-targeted therapies; (5) educate physicians on bone loss and fracture risk; (6) define optimal endpoints and new measures of efficacy for future clinical trials; and (7) define the optimum type, dose and schedule of adjuvant bone-targeted therapy.     

Anticancer properties of zoledronic acid

Zoledronic acid effectively reduces/delays skeletal-related events in patients with metastatic disease or skeletal-related cancers. Emerging data suggest that zoledronic acid may also exhibit anticancer properties. Zoledronic acid ± anticancer therapies in animal models inhibits soft-tissue tumor growth, decreases tumor cell proliferation, increases apoptosis, inhibits angiogenesis, alters tumor-associated macrophage function, and enhances immune surveillance. Data from in vitro and pilot studies suggest that zoledronic acid inhibits tumor cell dissemination in bone marrow, and early clinical data show that it may improve disease-related outcomes. Ongoing studies will further elucidate the role of zoledronic acid in cancer patients.