Utility of state-level influenza disease burden and severity estimates to investigate an apparent increase in reported severe cases of influenza A(H1N1) pdm09 - Arizona, 2015-2016

The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015-2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015-2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015-2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.

Maternal pre-pregnancy obesity and child neurodevelopmental outcomes: a meta-analysis

This review examined evidence of the association between maternal pre-pregnancy overweight/obesity status and child neurodevelopmental outcomes. PubMed and PsycINFO databases were systematically searched for empirical studies published before April 2017 using keywords related to prenatal obesity and children's neurodevelopment. Of 1483 identified papers, 41 were included in the systematic review, and 32 articles representing 36 cohorts were included in the meta-analysis. Findings indicated that compared with children of normal weight mothers, children whose mothers were overweight or obese prior to pregnancy were at increased risk for compromised neurodevelopmental outcomes (overweight: OR = 1.17, 95% CI [1.11, 1.24], I²  = 65.51; obese: OR = 1.51; 95% CI [1.35, 1.69], I²  = 79.63). Pre-pregnancy obesity increased the risk of attention deficit-hyperactivity disorder (OR = 1.62; 95% CI [1.23, 2.14], I²  = 70.15), autism spectrum disorder (OR = 1.36; 95% CI [1.08, 1.70], I²  = 60.52), developmental delay (OR = 1.58; 95% CI [1.39, 1.79], I²  = 75.77) and emotional/behavioural problems (OR = 1.42; 95% CI [1.26, 1.59], I²  = 87.74). Given the current obesity prevalence among young adults and women of childbearing age, this association between maternal obesity during pregnancy and atypical child neurodevelopment represents a potentially high public health burden.

Ski and snowboard school programs: Injury surveillance and risk factors for grade-specific injury

The objective of our study was to evaluate incidence rates and profile of school program ski and snowboard-related injuries by school grade group using a historical cohort design. Injuries were identified via Accident Report Forms completed by ski patrollers. Severe injury was defined as those with ambulance evacuation or recommending patient transport to hospital. Poisson regression analysis was used to examine the school grade group-specific injury rates adjusting for risk factors (sex, activity, ability, and socioeconomic status) and accounting for the effect of clustering by school. Forty of 107 (37%) injuries reported were severe. Adolescents (grades 7-12) had higher crude injury rates (91 of 10 000 student-days) than children (grades 1-3: 25 of 10 000 student-days; grades 4-6: 65 of 10 000 student-days). Those in grades 1-3 had no severe injuries. Although the rate of injury was lower in grades 1-3, there were no statistically significant grade group differences in adjusted analyses. Snowboarders had a higher rate of injury compared with skiers, while higher ability level was protective. Participants in grades 1-3 had the lowest crude and adjusted injury rates. Students in grades 7-12 had the highest rate of overall and severe injuries. These results will inform evidence-based guidelines for school ski/snowboard program participation by school-aged children.

The impact of new national guidance for the public health management of enteric fever in England

OBJECTIVES

New guidance was published in England in February 2012 to support the public health management of enteric fever and reduce the risks of secondary transmission. The new guidance was evaluated to assess: STUDY DESIGN: Quantitative and qualitative evaluation of the implementation of new public health guidance.

METHODS

A qualitative review of all non-travel-related cases from February 2010 to January 2014 to compare the risk of secondary transmission before and after the guidance introduction; an audit of clearance sampling for each case and their contacts reported in London from February 2012-January 2015 to compare with a previous London audit; and an online user survey in November 2014.

RESULTS

The proportions of non-travel cases reported before and after the introduction of the new guidance were similar, 6% in 2010-2012 compared to 7% in 2012-2014 (P = 0.33). There was a 32% reduction in the number of clearance samples required for cases and the estimated period of exclusion from work or school was reduced from 54 days to 16 days. Compliance in case clearance improved from 53% to 90% and contact screening compliance improved from 42% to 80%. The targeted screening of contacts led to a significantly higher positive yield (3.6% from 1.5%, P = 0.003). All symptomatic co-travellers presented to a healthcare professional, suggesting that screening could be restricted to those in risk groups for transmission. Feedback from users highlighted additional areas, such as management of large organised groups of co-travellers and those diagnosed abroad, which has informed the update of the national guidance.

CONCLUSIONS

The new guidance has not led to an increase in secondary transmission of enteric fever in England and findings have been used to inform an update of the guidance. The new guidance also represents a reduced burden of investigation and thus a likely reduced cost to patients, healthcare professionals, laboratories and environmental health officers.

PD-L1 Prevents the Development of Autoimmune Heart Disease in Graft-versus-Host Disease

Effector memory T cells (T_EM) are less capable of inducing graft-versus-host disease (GVHD) compared with naive T cells (T_N). Previously, in the TS1 TCR transgenic model of GVHD, wherein TS1 CD4 cells specific for a model minor histocompatibility Ag (miHA) induce GVHD in miHA-positive recipients, we found that cell-intrinsic properties of TS1 T_EM reduced their GVHD potency relative to TS1 T_N Posttransplant, TS1 T_EM progeny expressed higher levels of PD-1 than did TS1 T_N progeny, leading us to test the hypothesis that T_EM induce less GVHD because of increased sensitivity to PD-ligands. In this study, we tested this hypothesis and found that indeed TS1 T_EM induced more severe skin and liver GVHD in the absence of PD-ligands. However, lack of PD-ligands did not result in early weight loss and colon GVHD comparable to that induced by TS1 T_N, indicating that additional pathways restrain alloreactive T_EM TS1 T_N also caused more severe GVHD without PD-ligands. The absence of PD-ligands on donor bone marrow was sufficient to augment GVHD caused by either T_EM or T_N, indicating that donor PD-ligand-expressing APCs critically regulate GVHD. In the absence of PD-ligands, both TS1 T_EM and T_N induced late-onset myocarditis. Surprisingly, this was an autoimmune manifestation, because its development required non-TS1 polyclonal CD8⁺ T cells. Myocarditis development also required donor bone marrow to be PD-ligand deficient, demonstrating the importance of donor APC regulatory function. In summary, PD-ligands suppress both miHA-directed GVHD and the development of alloimmunity-induced autoimmunity after allogeneic hematopoietic transplantation.

Letrozole may be a valuable maintenance treatment in high-grade serous ovarian cancer patients

OBJECTIVES

Endocrine therapy is used as maintenance in estrogen receptor (ER) positive breast cancers and has been proposed in low-grade serous ovarian cancers (LGSOC). Here we examine a rationale for its use as maintenance in high-grade serous ovarian cancers (HGSOC).

METHODS

We accessed the TCGA PANCAN dataset to evaluate the expression of ESR1. ESR1 expression data on all cancers (n=8901) and HGSOC (n=527) were followed by investigation of ER expression via immunohistochemistry (IHC) (n=4071). The same was performed in an independent cohort for matched primary and recurrent HGSOC (n=80). Finally, newly diagnosed ER+ HGSOC patients were offered a maintenance therapy with Letrozole.

RESULTS

ESR1 was strongly expressed in similar levels in HGSOC as in breast cancer. We found a strong ER expression via IHC in both the primary and matched recurrent HGSOC, particularly in the Platinum-resistant subgroup. The additional use of Letrozole as maintenance treatment was associated with a significantly prolonged recurrence free interval (after 24months 60% when taking Letrozole versus 38.5% in the control group; p=0.035; RFS: IC₅₀ reached by one subject versus 13.2months). This effect was also present in patients treated additionally with Bevacizumab; 20.8% of patients had no recurrence after 12months compared to 87.5% when taking Letrozole in addition to Bevacizumab (p=0.026).

CONCLUSIONS

Primary HGSOC have a slightly higher ESR1 than and a similar ER expression breast cancer where aromatase inhibitor maintenance is routine for decades. Here we demonstrate evidence for the usefulness of Letrozole in HGSOC, particularly in patients with chemotherapy resistance or residual disease.

The Effect of Brassica Vegetable Consumption on Caffeine Metabolism in Humans

Ten healthy volunteers were used in two studies investigating the effect of short-term Brassica consumption on caffeine metabolism. In the first study volunteers were given three Brassica-containing meals, the last one 3 h prior to caffeine administration. In the second study volunteers were given two Brassica-containing meals and then fasted overnight before caffeine administration.

In both studies the mean plasma half-life of caffeine was reduced by approximately 20% following a Brassica diet, suggesting that Brassica vegetables stimulate caffeine metabolism.

When caffeine was given 3 h after the last meal, plasma caffeine concentrations over 6 h, were increased by up to 27% on the Brassica diet compared to controls. This may be due to a transient increased permeability of the intestine to caffeine, immediately following Brassica consumption. This effect was not seen in the second study where there was a 12-h period between the last meal and caffeine administration.

There was large interindividual variation in the effect of the Brassica diet on caffeine metabolism.

Wasted septal work in left ventricular dyssynchrony: a novel principle to predict response to cardiac resynchronization therapy

Aims

Cardiac resynchronization therapy (CRT) in heart failure is limited by many non-responders. This study explores whether degree of wasted left ventricular (LV) work identifies CRT responders.

Methods and results

Twenty-one patients who received CRT according to guidelines were studied before and after 8 ± 3 months. By definition, segments that shorten in systole perform positive work, whereas segments that lengthen do negative work. Work was calculated from non-invasive LV pressure and strain by speckle tracking echocardiography. For each myocardial segment and for the entire LV, wasted work was calculated as negative work in percentage of positive work. LV wall motion score index (WMSI) was assessed by echocardiography. Response to CRT was defined as ≥15% reduction in end-systolic volume (ESV). Responder rate to CRT was 71%. In responders, wasted work for septum was 117 ± 102%, indicating more negative than positive work, and decreased to 14 ± 12% with CRT (P < 0.01). In the LV free wall, wasted work was 19 ± 16% and showed no significant change. Global LV wasted work decreased from 39 ± 21 to 17 ± 7% with CRT (P < 0.01). In non-responders, there were no significant changes. In multiple linear regression analysis, septal wasted work and WMSI were the only significant predictors of ESV reduction (β = 0.14, P = 0.01; β = 1.25, P = 0.03). Septal wasted work together with WMSI showed an area under the curve of 0.86 (95% confidence interval 0.71–1.0) for CRT response prediction.

Conclusion

Wasted work in the septum together with WMSI was a strong predictor of response to CRT. This novel principle should be studied in future larger studies.

Use of arsenic trioxide in a hemodialysis-dependent patient with relapsed acute promyelocytic leukemia

Arsenic trioxide has been established for use in both relapsed and front-line treatment of acute promyelocytic leukemia. Dose adjustments are recommended to be considered in severe renal impairment although dosage reduction guidelines are not provided. In addition, toxicities of arsenic are significant. The use of arsenic trioxide has not been well studied in dialysis patients and there is a paucity of data in the literature to support the use in such a situation. We describe an 81-year-old relapsed acute promyelocytic leukemia hemodialysis-dependent patient with a pre-existing cardiac condition who was treated with 10 mg arsenic trioxide three times weekly after dialysis. These findings provide support along with the marginal amount of currently published data for an arsenic trioxide dosing regimen in hemodialysis patients.

Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

Chordomas at High Prevalence in the Captive Population of the Endangered Perdido Key Beach Mouse (Peromyscus polionotus trissyllepsis)

The Perdido Key beach mouse (Peromyscus polionotus trissyllepsis) is a critically endangered subspecies of the oldfield mouse. The captive population, currently maintained by 3 Florida zoos, is entirely derived from just 3 wild-caught ancestor mice. Necropsy and histopathology revealed chordoma of the vertebral column in 38 of 88 (43%) mice. The tumors were locally expansile and invasive masses of large physaliferous (vacuolated) cells with small, round, hyperchromatic nuclei, similar to the "classic" form of chordomas described in humans. Primary tumors rarely contained small amounts of bone and cartilaginous matrix, characteristic of the "chondroid" form. Neoplastic cells contained abundant granules positive by the periodic acid-Schiff reaction. Brachyury and cytokeratin AE1/AE3 were detected in neoplastic cells by immunohistochemistry, but uncoupling protein 1 was not identified. Primary tumors occurred along the entire vertebral column--cervical, 5 of 38 (13%); thoracic, 16 (42%); lumbar, 13 (34%); and sacral, 10 (26%)--and 10 (26%) mice had multiple primary masses. Metastases to the lungs were noted in 13 of the 38 (34%) mice. Mice diagnosed with chordomas postmortem ranged from 424 to 2170 days old, with a mean of 1399 days. The prevalence of chordoma was not significantly different between males (n = 23 of 50; 46%) and females (n = 15 of 38; 39%).

Association between right ventricular dysfunction and restrictive lung disease in childhood cancer survivors as measured by quantitative echocardiography

BACKGROUND

Restrictive lung disease is a complication in childhood cancer survivors who received lung-toxic chemotherapy and/or thoracic radiation. Left ventricular dysfunction is documented in these survivors, but less is known about right ventricular (RV) function. Quantitative echocardiography may help detect subclinical RV dysfunction. The aim of this study was to assess RV function quantitatively in childhood cancer survivors after lung-toxic therapy.

PROCEDURES

We identified records of 33 childhood cancer survivors who (1) were treated with lung-toxic therapy and/or radiation, (2) were cancer-free for ≥ one year after therapy, and (3) had pulmonary function tests and echocardiograms from their most recent follow-up visit.

RESULTS

Participants' mean age was 11.6 ± 4.5 years at cancer diagnosis and 23 ± 8.6 years at evaluation. The most common diagnosis was lymphoma/leukemia (n = 27). Twenty-nine subjects had anthracycline exposure. Eleven of the 33 subjects demonstrated restrictive pulmonary impairment (total lung capacity 3.69 ± 1.5 L [69.3 ± 22.4% predicted]). Among quantitative measures of RV function, isovolumetric acceleration (IVA), a measure of contractility, was significantly lower in the group with restrictive lung disease (2.42 ± 0.56 vs. 1.83 ± 0.78 m/sec(2); P < 0.05). There was a trend towards lower tissue Doppler derived S' and tricuspid annular plane systolic excursion in the group with restrictive lung disease. Subjects with restrictive lung disease were found to have ≥ 2 abnormal parameters (P < 0.01).

CONCLUSION

IVA may detect early RV dysfunction in childhood cancer survivors with restrictive lung disease. Our findings require confirmation in a larger study population and validation by cardiac MRI.

Promoting resilience and wellbeing through an outdoor intervention designed for Aboriginal adolescents

INTRODUCTION

Aboriginal people in Canada (First Nations, Inuit and Métis) have a lower health status compared to the Canadian population. There is a particular concern about the mental health and wellbeing of First Nations adolescents living on reserves. Interventions following principles of outdoor education and adventure therapy appear to be an appropriate fit for this population. These approaches have proven effective in non-Aboriginal populations, yet there is very little evidence on the efficacy of these types of program for Aboriginal adolescents. The primary purpose of this study was to evaluate the impact of an outdoor adventure leadership experience (OALE) on the resilience and wellbeing of First Nations adolescents from one reserve community. The secondary purposes were to explore whether this impact was sustainable, and whether there were any intervening factors that may have influenced the impact.

METHODS

The collaborative research team used a mixed-method design to evaluate the 10-day OALE for adolescents from Wikwemikong Unceded Indian Reserve in northern Ontario, Canada. The main outcome assessed was resilience, measured by self-report, using the 14-Item Resilience Scale (RS-14). Several other exploratory measures assessed other aspects of health and well-being. The questionnaire package was administered at three different time periods: (T1) one day before the OALE; (T2) one month after the OALE; and (T3) one year after the OALE. The Mental Component Score (MCS) of the SF-12v2 was used to confirm any changes in resilience. Open-ended questions were appended to the questionnaire at the 1-year point to identify any intervening factors that may have impacted any changes in resilience and wellbeing. The primary analysis compared mean RS-14 scores at T1 with those at T2. Responses to the open-ended questions were analyzed using content analysis.

RESULTS

Over two summers (2009 and 2010), 73 youth 12-18 years of age from Wikwemikong participated in a standardized 10-day OALE program. This represented 15% of the on-reserve population of adolescents in this age range. Survey responses from 59 (80.8%) participants were available for analysis at T1, compared to 47 (64.4%) at T2 and 33 (45.2%) at T3. The mean RS-14 score was 73.65 at baseline, and this improved 3.40 points (p=0.011) between T1 and T2. However, the resilience scores at T3 (1 year post-OALE) had a mean of 74.19, indicating a return back to pre-OALE levels. The mean MCS score at T1 was 48.23 and it improved over the subsequent two time periods. Several intervening factors reported at T3 may have influenced the decrease in resilience scores from T2 to T3. These included changes in family living situation, death in the family, and other life stressors that occurred over the course of the year.

CONCLUSIONS

Outcome scores from this study provide a unique glimpse into the self-reported health and wellbeing for adolescents within one First Nations community in Canada. The OALE program was beneficial in promoting resilience for adolescents in Wikwemikong over the short-term. Future studies are necessary to assess whether the OALE (or similar outdoor type interventions) are effective within other communities.