[Palliative care in patients with left ventricular assist devices: systematic review]

Hintergrund

Bei terminal herzinsuffizienten Patienten gewinnt die Implantation von Linksherzunterstützungssystemen (LVAD) als Therapieoption zunehmend an Bedeutung. Diese Systeme werden als Überbrückung bis zu einer Herztransplantation (BTT) oder als definitive Therapie (DT) eingesetzt. Sie können die Lebensqualität verbessern und die Lebenszeit verlängern. Trotzdem bleibt die Prognose besonders bei DT oder bei Wechsel von BTT zu DT mit Blick auf die Lebenszeit und auftretende Komplikationen ungünstig. Bisher ist ungeklärt, ob eine LVAD-Implantation eine Indikation für eine frühzeitige Integration von Palliativmedizin darstellt.

Ziel der Arbeit

Erfassung der aktuellen Studienlage über den Einfluss einer palliativmedizinischen Behandlung bei LVAD-Patienten.

Material und Methoden

Im Mai 2020 wurde eine systematische Literaturrecherche in 6 verschiedenen Datenbanken durchgeführt.

Ergebnisse

Von den 491 Treffern der Literaturrecherche wurden 21 Arbeiten in diese Übersichtsarbeit eingeschlossen. Durch die frühzeitige Integration der Palliativmedizin vor LVAD-Implantation erhöhte sich die Anzahl der Patienten mit vorausschauender Versorgungsplanung und Vorsorgeinstrumenten. Außerdem zeigte sich ein positiver Einfluss auf das familiäre Umfeld, das Symptommanagement und die Umstände des Versterbens. Es gibt verschiedene Formate für die Integration palliativmedizinischer Konzepte in die LVAD-Therapie.

Diskussion

Die frühzeitige und kontinuierliche Einbindung der Palliativmedizin im Verlauf einer LVAD-Therapie kann die Behandlungsqualität verbessern. Die Ausarbeitung von spezifischen Handlungsempfehlungen ist in Abhängigkeit vom Therapieziel (BTT oder DT) sinnvoll. Empfohlen werden Schulungen für Palliativmediziner und LVAD-Spezialisten.

Identification of clinically useful predictive genetic variants in pachyonychia congenita

BACKGROUND

Pachyonychia congenita (PC) refers to a group of autosomal dominant disorders caused by mutations in five keratin genes (KRT16,KRT6A,KRT17,KRT6B or KRT6C). Current disease classification is based on the gene harbouring disease-causing variants.

AIMS

We harnessed the International Pachyonychia Congenita Research Registry (IPCRR) containing both clinical and molecular data on patients with PC worldwide, to identify genetic variants predicting disease severity.

METHODS

We ascertained 815 individuals harbouring keratin mutations registered in the IPCRR. We looked for statistically significant associations between genetic variants and clinical manifestations in a subgroup of patients carrying mutations found in at least 10% of the cohort. Data were analysed using χ² and Kruskal-Wallis tests.

RESULTS

We identified five mutations occurring in at least 10% of the patients registered in the IPCRR. The KRT16 p.L132P mutation was significantly associated with younger age of onset, presence of palmar keratoderma oral leucokeratosis and a higher number of involved nails. By contrast, the KRT16 p.N125S and p.R127C mutations resulted in a milder phenotype featuring a decreased number of involved nails and older age of onset. Patients carrying the p.N125S mutation were less likely to develop palmar keratoderma while p.R127C was associated with an older age of palmoplantar keratoderma onset. Moreover, the KRT17 p.L99P mutation resulted in an increased number of involved fingernails and patients demonstrating 20-nail dystrophy, while the opposite findings were observed with KRT17 p.N92S mutation.

CONCLUSIONS

We have identified novel and clinically useful genetic predictive variants in the largest cohort of patients with PC described to date.

Screening For Bone Marrow Cellularity Changes in Cynomolgus Macaques in Toxicology Safety Studies Using Artificial Intelligence Models

Many compounds affect the cellularity of hematolymphoid organs including bone marrow. Toxicologic pathologists are tasked with their evaluation as part of safety studies. An artificial intelligence (AI) tool could provide diagnostic support for the pathologist. We looked at the ability of a deep-learning AI model to evaluate whole slide images of macaque sternebrae to identify and enumerate bone marrow hematopoietic cells. The AI model was trained and able to differentiate the hematopoietic cells from the other sternebrae tissues. We compared the model to severity scores in a study with decreased hematopoietic cellularity. The mean cells/mm² from the model was lower for each increase in severity score. The AI model was trained by 1 pathologist, providing proof of concept that AI model generation can be fast and agile, without the need of a cross disciplinary team and significant effort. We see great potential for the role of AI-based bone marrow screening.

Geospatial Distribution and Predictors of Mortality in Hospitalized Patients With COVID-19: A Cohort Study

BACKGROUND

The global coronavirus disease 2019 (COVID-19) pandemic offers the opportunity to assess how hospitals manage the care of hospitalized patients with varying demographics and clinical presentations. The goal of this study was to demonstrate the impact of densely populated residential areas on hospitalization and to identify predictors of length of stay and mortality in hospitalized patients with COVID-19 in one of the hardest hit counties internationally.

METHODS

This was a single-center cohort study of 1325 sequentially hospitalized patients with COVID-19 in New York between March 2, 2020, to May 11, 2020. Geospatial distribution of study patients' residences relative to population density in the region were mapped, and data analysis included hospital length of stay, need and duration of invasive mechanical ventilation (IMV), and mortality. Logistic regression models were constructed to predict discharge dispositions in the remaining active study patients.

RESULTS

The median age of the study cohort (interquartile range [IQR]) was 62 (49-75) years, and more than half were male (57%) with history of hypertension (60%), obesity (41%), and diabetes (42%). Geographic residence of the study patients was disproportionately associated with areas of higher population density (r s = 0.235; P = .004), with noted "hot spots" in the region. Study patients were predominantly hypertensive (MAP > 90 mmHg; 670, 51%) on presentation with lymphopenia (590, 55%), hyponatremia (411, 31%), and kidney dysfunction (estimated glomerular filtration rate < 60 mL/min/1.73 m2; 381, 29%). Of the patients with a disposition (1188/1325), 15% (182/1188) required IMV and 21% (250/1188) developed acute kidney injury. In patients on IMV, the median (IQR) hospital length of stay in survivors (22 [16.5-29.5] days) was significantly longer than that of nonsurvivors (15 [10-23.75] days), but this was not due to prolonged time on the ventilator. The overall mortality in all hospitalized patients was 15%, and in patients receiving IMV it was 48%, which is predicted to minimally rise from 48% to 49% based on logistic regression models constructed to project disposition in the remaining patients on ventilators. Acute kidney injury during hospitalization (odds ratioE, 3.23) was the strongest predictor of mortality in patients requiring IMV.

CONCLUSIONS

This is the first study to collectively utilize the demographics, clinical characteristics, and hospital course of COVID-19 patients to identify predictors of poor outcomes that can be used for resource allocation in future waves of the pandemic.

[Cooperation between intensive care and palliative care : The status quo in German Comprehensive Cancer Centers]

Hintergrund

Die interdisziplinäre Zusammenarbeit zwischen Intensivmedizin und Palliativmedizin kann die Versorgungsqualität verbessern. Das Ausmaß dieser Zusammenarbeit ist aber bisher kaum untersucht.

Ziel der Arbeit

Es sollten die angebotenen und in Anspruch genommenen palliativmedizinischen Unterstützungsangebote auf den Intensivstationen deutscher onkologischer Spitzenzentren erfasst werden.

Material und Methoden

Durchgeführt wurde eine quantitativ-qualitative, deskriptive Umfrage an den 16 von der Stiftung Deutsche Krebshilfe geförderten Zentren. Die im quantitativen Teil erfragten Häufigkeiten werden als Mittelwert und Median mit den jeweiligen Streumaßen dargestellt, während die im qualitativen Teil erhobenen Triggerfaktoren mit einer Inhaltsanalyse nach Mayring ausgewertet wurden.

Ergebnisse

Von Juli bis August 2017 konnten Angaben aus 15 von 16 onkologischen Spitzenzentren (94 %) erfasst werden. Im Jahr 2016 wurden im Median 33 Intensivpatienten (Min. 0, Max. 100) palliativmedizinisch vorgestellt und 9 Patienten (Min. 1, Max. 30) auf eine Palliativstation verlegt. Regelmäßige intensivmedizinisch-palliativmedizinische Visiten sowie ein Screening-Tool zur Einbindung der spezialisierten Palliativmedizin sind an zwei onkologischen Spitzenzentren implementiert. Anhand von 23 genannten Triggern, die auf der Intensivstation eine palliativmedizinische Mitbehandlung ausgelöst haben, lassen sich nach qualitativer Analyse die drei Kategorien „Entscheidung und Einstellung des Teams“, „Zustand des Patienten“ und „Wunsch von Patienten und Angehörigen“ ableiten.

Diskussion

Trotz eines verfügbaren Angebots werden palliativmedizinische Ressourcen in den intensivmedizinischen Abteilungen der onkologischen Spitzenzentren immer noch selten genutzt. In die tägliche Routine integrierte Angebote wie Screening-Tools oder gemeinsame Visiten könnten die Ausnutzung der angebotenen palliativmedizinischen Ressourcen erhöhen und die Versorgungsqualität verbessern.

Evaluating the impact of long-term exposure to fine particulate matter on mortality among the elderly

Many studies link long-term fine particle (PM2.5) exposure to mortality, even at levels below current U.S. air quality standards (12 micrograms per cubic meter). These findings have been disputed with claims that the use of traditional statistical approaches does not guarantee causality. Leveraging 16 years of data-68.5 million Medicare enrollees-we provide strong evidence of the causal link between long-term PM2.5 exposure and mortality under a set of causal inference assumptions. Using five distinct approaches, we found that a decrease in PM2.5 (by 10 micrograms per cubic meter) leads to a statistically significant 6 to 7% decrease in mortality risk. Based on these models, lowering the air quality standard to 10 micrograms per cubic meter would save 143,257 lives (95% confidence interval, 115,581 to 170,645) in one decade. Our study provides the most comprehensive evidence to date of the link between long-term PM2.5 exposure and mortality, even at levels below current standards.

0768 Time Course Of Improvement In Excessive Daytime Sleepiness And Cataplexy During Treatment With Pitolisant In Patients With Narcolepsy

Introduction

This analysis evaluated the efficacy of pitolisant over time in three 7- to 8-week, randomized, placebo-controlled studies of adults with narcolepsy.

Methods

Patients in all 3 studies (HARMONY-1, HARMONY-1bis, HARMONY-CTP) experienced excessive daytime sleepiness (EDS) at study baseline; patients in HARMONY-CTP also experienced ≥3 cataplexy attacks/week. Pitolisant was titrated to a maximum dose of 35.6 mg/day (HARMONY-1, HARMONY-CTP) or 17.8 mg/day (HARMONY-1bis). Change from baseline in mean Epworth Sleepiness Scale (ESS) score (3 studies) and mean weekly rate of cataplexy (WRC; 1 study) was compared for pitolisant versus placebo.

Results

In the higher-dose HARMONY-1 (pitolisant, n=31; placebo, n=30) and HARMONY-CTP (pitolisant, n=54; placebo, n=51) studies, ESS score improvement was significantly greater with pitolisant versus placebo beginning at Week 2 (LS mean difference, -2.8; P=0.015) and Week 3 (LS mean difference, -2.0; P=0.005), respectively. In the lower-dose HARMONY-1bis study (pitolisant, n=66; placebo, n=32), significant separation from placebo was first observed at Week 7 (LS mean difference, -2.3; P=0.044). At end-of-treatment, LS mean difference in ESS score change from baseline was -3.1 (P=0.022) in HARMONY-1, -3.4 (P&lt;0.001) in HARMONY-CTP, and -2.2 (P=0.030) in HARMONY-1bis. In HARMONY-CTP, LS mean WRC with pitolisant was 11.7 at baseline, 4.6 at end-of-treatment, and 5.1 after a 1-week, placebo-washout period. Improvement in WRC was significantly greater with pitolisant versus placebo beginning at Week 2 (LS mean difference, -5.3; P=0.004) and continued through end-of-treatment (LS mean difference, -6.2; P&lt;0.001); there was no evidence of rebound cataplexy after placebo-washout (LS mean difference, -4.9; P=0.027).

Conclusion

During pitolisant treatment, improvement in EDS occurred sooner (within first few weeks) and was more robust in studies that permitted titration to the maximum recommended dose (35.6 mg/day). The rate of cataplexy attacks decreased early during treatment, with no evidence of rebound when pitolisant was withdrawn.

Support

Bioprojet Pharma and Harmony Biosciences, LLC.

A 6-month, Randomized, Placebo-controlled, Double Blind Trial of Ziprasidone Plus a Mood Stabilizer in Subjects With Bipolar I Disorder

Background:

The objective of this study was to evaluate the efficacy and safety of ziprasidone adjunctive to a mood stabilizer for the maintenance treatment of bipolar mania.

Methods:

Male and female subjects with bipolar I disorder with MRS 3 14 were enrolled. Subjects achieving ≥ 8 consecutive weeks of stability with open-label ziprasidone (80-160 mg/d) and lithium or divalproex were randomized into the 6-month double-blind maintenance period, to ziprasidone + mood stabilizer or placebo + mood stabilizer. The primary and key secondary end points were the time to intervention for a mood episode, and time to discontinuation for any reason, respectively. Inferential analysis was performed using a Kaplan-Meier product-limit estimator (Log-rank test).

Results:

127 and 112 subjects were randomized to and treated in the ziprasidone and placebo groups, respectively. The time to intervention for a mood episode was significantly different, favoring ziprasidone (p = 0.0104). 19.7% and 32.4% of ziprasidone and placebo subjects, respectively, required intervention for a mood episode. Time to discontinuation for any reason was significantly different (p = 0.0047), favoring ziprasidone. Among treatment-emergent adverse events occurring in the double-blind period, the only event occurring more frequently in the ziprasidone group than in the placebo group (≥ 5%) was tremor (6.3% vs 3.6%, respectively).

Conclusions:

These results demonstrate that ziprasidone is an effective, safe, and well-tolerated adjunctive treatment with a mood stabilizer for long-term maintenance treatment of bipolar mania.

Evaluation of a Chemiluminescence Method for Measuring Alkaline Phosphatase Activity in WholeMilk of Multiple Species and Bovine Dairy Drinks: Interlaboratory Study

Alkaline phosphatase (ALP) is a ubiquitous enzyme in milk with timetemperature destruction similar to that of certain pathogens destroyed in pasteurization. Measurement of ALP to indicate proper pasteurization is a common practice. Recently the public health level for ALP was decreased to 350 mU/L, a level below the sensitivity of older colorimetric ALP methods. This study was conducted within the structure of the International Dairy Federation and the International Organization for Standardization to evaluate the reproducibility of the chemiluminescence method (Charm PasLite) for ALP at 50, 100, 350, and 500 mU/L in whole milk of multiple species to meet new regulations in the United States and proposed regulations in the European Union (EU). Fifteen laboratories from 8 countries evaluated bovine, goat, sheep, and buffalo milk, bovine skim milk, 20% fat cream, and 2% fat chocolate milk. At ALP levels of 350 and 500 mU/L, the average relative standard deviation for repeatability (RSDr) was 7.5%, and the average relative standard deviation of reproducibility was (RSDR) 15%. For ALP at 100 and 50 mU/L, the average RSDr values were 10.5 and 12.6%, respectively, and the average RSDR values were 18 and 25%, respectively. The limit of detection was 20 mU/L. Results are comparable to those obtained with other enzymatic photo-activated system methods such as the fluorometric method. Results indicate that the method is suitable for measuring ALP in the milk of multiple species and in dairy drinks at U.S. and proposed EU levels.

Assessing Adverse Health Effects of Long-Term Exposure to Low Levels of Ambient Air Pollution: Phase 1

INTRODUCTION

This report provides a summary of major findings and key conclusions supported by a Health Effects Institute grant aimed at "Assessing Adverse Health Effects of Long-Term Exposure to Low Levels of Ambient Pollution." Our study was designed to advance four critical areas of inquiry and methods development.

METHODS

First, our work focused on predicting short- and long-term exposures to ambient PM2.5 mass (particulate matter ≤ 2.5μm in aerodynamic diameter) and ozone (O3) at high spatial resolution (1 km × 1 km) for the continental United States during the period 2000-2012 and linking these predictions to health data. Second, we developed new causal inference methods for exposure-response (ER) that account for exposure error and adjust for measured confounders. We applied these methods to data from the New England region. Third, we applied standard regression methods using Medicare claims data to estimate health effects that are associated with short- and long-term exposure to low levels of ambient air pollution. We conducted sensitivity analyses to assess potential confounding bias due to lack of extensive information on behavioral risk factors in the Medicare population using the Medicare Current Beneficiary Survey (MCBS) (nationally representative sample of approximately 15,000 Medicare enrollees per year), which includes abundant data on individual-level risk factors including smoking. Finally, we have begun developing tools for reproducible research - including approaches for data sharing, record linkage, and statistical software.

RESULTS

Our HEI-funded work has supported an extensive portfolio of analysis and the development of statistical methods that can be used to robustly understand the health effects of long- and short-term exposure to low levels of ambient air pollution. This report provides a high-level overview of statistical methods, data analysis, and key findings, as grouped into the following four areas: (1) Exposure assessment and data access; (2) Epidemiological studies of ambient exposures to air pollution at low levels; (3) Methodological contributions in causal inference; and (4) Open science research data platform.

CONCLUSION

Our body of work, advanced by HEI, lends extensive evidence that short- and long-term exposure to PM2.5 and O3 is harmful to human health, increasing the risks of hospitalization and death, even at levels that are well below the National Ambient Air Quality Standards (NAAQS).

Implementation of an antibody characterization procedure and application to the major ALS/FTD disease gene C9ORF72

Antibodies are a key resource in biomedical research yet there are no community-accepted standards to rigorously characterize their quality. Here we develop a procedure to validate pre-existing antibodies. Human cell lines with high expression of a target, determined through a proteomics database, are modified with CRISPR/Cas9 to knockout (KO) the corresponding gene. Commercial antibodies against the target are purchased and tested by immunoblot comparing parental and KO. Validated antibodies are used to definitively identify the most highly expressing cell lines, new KOs are generated if needed, and the lines are screened by immunoprecipitation and immunofluorescence. Selected antibodies are used for more intensive procedures such as immunohistochemistry. The pipeline is easy to implement and scalable. Application to the major ALS disease gene C9ORF72 identified high-quality antibodies revealing C9ORF72 localization to phagosomes/lysosomes. Antibodies that do not recognize C9ORF72 have been used in highly cited papers, raising concern over previously reported C9ORF72 properties.

Characterization of an evolutionarily conserved calcitonin signaling system in a lophotrochozoan, the Pacific oyster (Crassostrea gigas)

In Protostoma, the diuretic hormone 31 (DH31) signaling system was long considered as the orthologue of the chordate calcitonin (CT) signaling system. Using the Pacific oyster (Crassostrea gigas) transcriptomic database GigaTON (http://ngspipelines-sigenae.toulouse.inra.fr/), we characterized seven G-protein-coupled receptors (GPCRs) named Cragi-CTR1/7 and phylogenetically related to chordate CT receptors (CTRs) and to protostome DH31 receptors. Two CT Precursors (Cragi-CTP1 and Cragi-CTP2) containing two CT-type peptides and encoded by two distinct genes with a similar organization were also characterized. These oyster neuropeptides (Cragi-CT1/2) exhibit the two N-terminal paired cysteine residues and except CTP2 derived peptide (Cragi-CTP2dp) the C-terminal proline-amide motif typical of deuterostome CT-type peptides. All mature Cragi-CTs but Cragi-CTP2dp were detected in visceral ganglion (VG) extracts using mass spectrometry. Cell-based assays revealed that the formerly characterized oyster receptors Cg-CTR and Cragi-CTR2 were specifically activated by Cragi-CT1b and Cragi-CT2, respectively. This activation does not require the co-expression of receptor activity-modifying proteins (RAMPs). Thus, the oyster CT signaling appears functionally more closely related to the vertebrate CT/CTR signaling than to the (Calcitonin Gene Related Peptide) CGRP/CLR signaling. Gene expression profiles in different adult tissues and in oysters acclimated to brackish water suggest the potential implication of both Cg-CT-R/Cragi-CT1b and Cragi-CTR2/Cragi-CT2 in water and ionic regulations, though with apparently opposite effects. The present study represents the first comprehensive characterization of a functional CT-type signaling system in a protostome and provides evidence for its evolutionarily ancient origin and its early role in osmotic homeostasis.

Emergence of a cholecystokinin/sulfakinin signalling system in Lophotrochozoa

Chordate gastrin/cholecystokinin (G/CCK) and ecdysozoan sulfakinin (SK) signalling systems represent divergent evolutionary scenarios of a common ancestral signalling system. The present article investigates for the first time the evolution of the CCK/SK signalling system in a member of the Lophotrochozoa, the second clade of protostome animals. We identified two G protein-coupled receptors (GPCR) in the oyster Crassostrea gigas (Mollusca), phylogenetically related to chordate CCK receptors (CCKR) and to ecdysozoan sulfakinin receptors (SKR). These receptors, Cragi-CCKR1 and Cragi-CCKR2, were characterised functionally using a cell-based assay. We identified di- and mono-sulphated forms of oyster Cragi-CCK1 (pEGAWDY(SO₃H)DY(SO₃H)GLGGGRF-NH₂) as the potent endogenous agonists for these receptors. The Cragi-CCK genes were expressed in the visceral ganglia of the nervous system. The Cragi-CCKR1 gene was expressed in a variety of tissues, while Cragi-CCKR2 gene expression was more restricted to nervous tissues. An in vitro bioassay revealed that different forms of Cragi-CCK1 decreased the frequency of the spontaneous contractions of oyster hindgut. Expression analyses in oysters with contrasted nutritional statuses or in the course of their reproductive cycle highlighted the plausible role of Cragi-CCK signalling in the regulation of feeding and its possible involvement in the coordination of nutrition and energy storage in the gonad. This study confirms the early origin of the CCK/SK signalling system from the common bilaterian ancestor and delivers new insights into its structural and functional evolution in the lophotrochozoan lineage.

Characterization of a tachykinin signalling system in the bivalve mollusc Crassostrea gigas

Although tachykinin-like neuropeptides have been identified in molluscs more than two decades ago, knowledge on their function and signalling has so far remained largely elusive. We developed a cell-based assay to address the functionality of the tachykinin G-protein coupled receptor (Cragi-TKR) in the oyster Crassostrea gigas. The oyster tachykinin neuropeptides that are derived from the tachykinin precursor gene Cragi-TK activate the Cragi-TKR in nanomolar concentrations. Receptor activation is sensitive to Ala-substitution of critical Cragi-TK amino acid residues. The Cragi-TKR gene is expressed in a variety of tissues, albeit at higher levels in the visceral ganglia (VG) of the nervous system. Fluctuations of Cragi-TKR expression is in line with a role for TK signalling in C. gigas reproduction. The expression level of the Cragi-TK gene in the VG depends on the nutritional status of the oyster, suggesting a role for TK signalling in the complex regulation of feeding in C. gigas.