Faculty Bibliography

BACKGROUND: Menopausal hormone therapy (MHT) reportedly increases the risk of cognitive decline in women over age 65 y. It is unknown whether similar risks exist for recently postmenopausal women, and whether MHT affects mood in younger women. The ancillary Cognitive and Affective Study (KEEPS-Cog) of the Kronos Early Estrogen Prevention Study (KEEPS) examined the effects of up to 4 y of MHT on cognition and mood in recently postmenopausal women. METHODS AND FINDINGS: KEEPS, a randomized, double-blinded, placebo-controlled clinical trial, was conducted at nine US academic centers. Of the 727 women enrolled in KEEPS, 693 (95.3%) participated in the ancillary KEEPS-Cog, with 220 women randomized to receive 4 y of 0.45 mg/d oral conjugated equine estrogens (o-CEE) plus 200 mg/d micronized progesterone (m-P) for the first 12 d of each month, 211 women randomized to receive 50 mug/d transdermal estradiol (t-E2) plus 200 mg/d m-P for the first 12 d of each month, and 262 women randomized to receive placebo pills and patches. Primary outcomes included the Modified Mini-Mental State examination; four cognitive factors: verbal learning/memory, auditory attention/working memory, visual attention/executive function, and speeded language/mental flexibility; and a mood measure, the Profile of Mood States (POMS). MHT effects were analyzed using linear mixed-effects (LME) models, which make full use of all available data from each participant, including those with missing data. Data from those with and without full data were compared to assess for potential biases resulting from missing observations. For statistically significant results, we calculated effect sizes (ESs) to evaluate the magnitude of changes. On average, participants were 52.6 y old, and 1.4 y past their last menstrual period. By month 48, 169 (24.4%) and 158 (22.8%) of the 693 women who consented for ancillary KEEPS-Cog were lost to follow-up for cognitive assessment (3MS and cognitive factors) and mood evaluations (POMS), respectively. However, because LME models make full use all available data, including data from women with missing data, 95.5% of participants were included in the final analysis (n = 662 in cognitive analyses, and n = 661 in mood analyses). To be included in analyses, women must have provided baseline data, and data from at least one post-baseline visit. The mean length of follow-up was 2.85 y (standard deviation [SD] = 0.49) for cognitive outcomes and 2.76 (SD = 0.57) for mood outcomes. No treatment-related benefits were found on cognitive outcomes. For mood, model estimates indicated that women treated with o-CEE showed improvements in depression and anxiety symptoms over the 48 mo of treatment, compared to women on placebo. The model estimate for the depression subscale was -5.36 x 10-2 (95% CI, -8.27 x 10-2 to -2.44 x 10-2; ES = 0.49, p < 0.001) and for the anxiety subscale was -3.01 x 10-2 (95% CI, -5.09 x 10-2 to -9.34 x 10-3; ES = 0.26, p < 0.001). Mood outcomes for women randomized to t-E2 were similar to those for women on placebo. Importantly, the KEEPS-Cog results cannot be extrapolated to treatment longer than 4 y. CONCLUSIONS: The KEEPS-Cog findings suggest that for recently postmenopausal women, MHT did not alter cognition as hypothesized. However, beneficial mood effects with small to medium ESs were noted with 4 y of o-CEE, but not with 4 y of t-E2. The generalizability of these findings is limited to recently postmenopausal women with low cardiovascular risk profiles. TRIAL REGISTRATION: ClinicalTrials.gov NCT00154180 and NCT00623311.

BACKGROUND: Variation in periodontal terminology can affect the diagnosis and treatment plan as assessed by practicing general dentists in the Practitioners Engaged in Applied Research and Learning (PEARL) Network. General dentists participating in the PEARL Network are highly screened, credentialed, and qualified and may not be representative of the general population of dentists. METHODS: Ten randomized case presentations ranging from periodontal health to gingivitis, to mild, moderate, and severe periodontitis were randomly presented to respondents. Descriptive comparisons were made between these diagnosis groups in terms of the treatment recommendations following diagnosis. RESULTS: PEARL practitioners assessing periodontal clinical scenarios were found to either over- or under-diagnose the case presentations, which affected treatment planning, while the remaining responses concurred with respect to the diagnosis. The predominant diagnosis was compared with that assigned by two practicing periodontists. There was variation in treatment based on the diagnosis for gingivitis and the lesser forms of periodontitis. CONCLUSION: Data suggests that a lack of clarity of periodontal terminology affects both diagnosis and treatment planning, and terminology may be improved by having diagnosis codes, which could be used to assess treatment outcomes. CLINICAL IMPLICATIONS: This article provides data to support best practice for the use of diagnosis coding and integration of dentistry with medicine using ICD-10 terminology.

RATIONALE: Phenytoin (Dilantin((R)); DPH) is used to treat epilepsy but causes estrogen agonist-antagonist-like side effects. We investigated the interaction of phenytoin with estrogen receptors (ERs) alpha and beta by computational molecular docking, ER competition binding, transcriptional assays, and biological actions, comparing outcomes with estradiol (E2), estrone (E1), and tamoxifen (TMX). EXPERIMENTAL: (1) The DPH docking to 3-dimensional crystal structures of the ERalpha ligand-binding domain (LBD) showed a high degree of structural complementarity (-57.15 calculated energy units, approximating kcal/mol) with the ligand-binding pocket, including a contact at leucine (L540) in helix 12. Estrogen receptor beta showed slightly less favorable interactions (-54.27 kcal/mol), without contacting L450. Estradiol, E1, and TMX contact points with ERalpha and ERbeta do not include L450. (2) Cellular actions: Incubation of cells transfected with ERalpha or ERbeta and a luciferase promoter phenytoin was several orders weaker than E2 as an agonist through ERalpha and had no effect through ERbeta. However, phenytoin at clinical concentrations (10(-11) to 10(-6) mol/L) powerfully antagonized action of E2 on ERalpha-expressing cells. Similarly, phenytoin at clinically effective concentrations marginally induced alkaline phosphatase by ERalpha- and ERbeta-expressing endometrial cancer cells but at doses well below clinical effectiveness blocked E2-induced alkaline phosphatase. (3) ER competition: In Scatchard plots comparing phenytoin with 17beta-estradiol against endometrial cancer cell cytosol E2-alone more effectively displaced labeled E2 than phenytoin, but phenytoin was approximately equimolar effective to E2 in inhibiting E2's displacement of the radiolabel, further confirming that phenytoin is a strong E2 antagonist. CONCLUSIONS: At clinically effective concentrations, phenytoin is a strong ERalpha cell antagonist but a many-fold weaker agonist. Although it interacts with ERbeta LBD residues, phenytoin has no effects on ERbeta-only expressing cells. Docking studies indicate phenytoin interacts with the ERalpha LBD at the hinge of helix 12 and could thereby interfere with the entry of other ER ligands or with the mobility of helix 12, either of which actions could explain phenytoin's antagonism of ER-mediated E2 actions. Our results suggest an explanation for the broad profile of phenytoin's actions and raise possibilities for the use of phenytoin or congeners in the clinical management of ERalpha-dependent conditions.

Healthcare systems should be transparent and easy to use and considered a joint venture between the various stakeholders with the goal of improving the diagnosis, treatment and clinical outcomes to control nations' rising costs of healthcare. The stakeholders are many including an educational component, practitioners, payers, government and industry providing the treatment and medications. All of these variables and more contribute to cost escalation. Within this complex framework is the nations' abiliy to provide some level of basic care for public health assurance of its populace possibly through the concept of 'person-centricity'. The Practitioners Engaged in Applied Learning & Research (PEARL) Network was conceived through government funding and has evolved into a not-for-profit private enterprise. The PEARL Network is a hybrid network incorporating the benefits of an academic practice based research network into a practice based translational network with the principles of conducting pharmaceutical level clinical studies for regulatory submission. PEARL incorporates the philosophy of 'person-centricity' and operationalizes it conducting 'person-centric clinical trials.&rsqu

A person-centric clinical trial is inclusive of both the investigator and the person and as such represents point-of-use data generated at the practice level and encompasses both health and disease. Raising the clinical encounter to a research encounter and providing an infrastructure to support a level of quality assurance creates a synergy for efficiency for healthcare delivery. The interface of translational studies and clinical research poses an opportunity, whereby person-centricity can support transparency, facilitate informed consent, improve safety, enhance recruitment and compliance, improve dissemination of results, implement change and help close the translational gap. The model represents robust clinical data from persons of record allowing for improved interpretation of drug/device side-effects and for regulatory reviewers to expedite the approval process.