Connected diagnostics: linking digital rapid diagnostic tests and mobile health wallets to diagnose and treat brucellosis in Samburu, Kenya

BACKGROUND

Despite WHO guidelines for testing all suspected cases of malaria before initiating treatment, presumptive malaria treatment remains common practice among some clinicians and in certain low-resource settings the capacity for microscopic testing is limited. This can lead to misdiagnosis, resulting in increased morbidity due to lack of treatment for undetected conditions, increased healthcare costs, and potential for drug resistance. This is particularly an issue as multiple conditions share the similar etiologies to malaria, including brucellosis, a rare, under-detected zoonosis. Linking rapid diagnostic tests (RDTs) and digital test readers for the detection of febrile illnesses can mitigate this risk and improve case management of febrile illness.

METHODS

This technical advance study examines Connected Diagnostics, an approach that combines the use of point-of-care RDTs for malaria and brucellosis, digitally interpreted by a rapid diagnostic test reader (Deki Reader) and connected to mobile payment mechanisms to facilitate the diagnosis and treatment of febrile illness in nomadic populations in Samburu County, Kenya. Consenting febrile patients were tested with RDTs and patient diagnosis and risk information were uploaded to a cloud database via the Deki Reader. Patients with positive diagnoses were provided digital vouchers for transportation to the clinic and treatment via their health wallet on their mobile phones.

RESULTS

In total, 288 patients were tested during outreach visits, with 9% testing positive for brucellosis and 0.6% testing positive for malaria. All patients, regardless of diagnosis were provided with a mobile health wallet on their cellular phones to facilitate their transport to the clinic, and for patients testing positive for brucellosis or malaria, the wallet funded their treatment. The use of the Deki Reader in addition to quality diagnostics at point of care also facilitated geographic mapping of patient diagnoses in relation to key risk areas for brucellosis transmission.

CONCLUSIONS

This study demonstrates that the Connected Dx approach can be effective even when addressing a remote, nomadic population and a rare disease, indicating that this approach to diagnosing, treatment, and payment for healthcare costs is feasible and can be scaled to address more prevalent diseases and conditions in more populous contexts.

Faecal Calprotectin and Magnetic Resonance Enterography in Ileal Crohn's Disease: Correlations Between Disease Activity and Long-Term Follow-Up

BACKGROUND AND AIMS

Magnetic resonance enterography [MRE] is the gold standard for assessing ileal inflammation in Crohn's disease [CD]. The aim of the present study was to correlate faecal calprotectin [FC] to MRE via a simple score in an exclusive ileal cohort with long-term follow-up for association with time to surgery or biologic therapy.

METHODS

In total, 150 MRE studies with matched FC [±30 days] were identified from the Edinburgh FC Register [2008-12; n = 18138]. Scans were re-read blinded to clinical data, independently, by two expert gastrointestinal radiologists, to generate a simple MRE score [range 0-10] from assessment of the worst intestinal segment plus total disease extent.

RESULTS

In total, 119 MRE scans were evaluated from 104 patients with ileal CD [L1 or L3 with panproctocolectomy]. Receiver operating characteristic analysis showed an area under the curve of 0.77 [0.67-0.87, p < 0.0001] for FC and MRE score >1, with an optimal cut-off of 145 μg/g for severe inflammation on MRE with 69.3% [57.6-79.5] sensitivity and 71.4% [53.7-85.4] specificity. Long-term follow-up over a median [interquartile range] of 2086 days [1786-2353] revealed FC ≥ 145 μg/g was associated with reduced biologic-free survival until 3 years following MRE, whereas MRE score [severe vs absent] was associated with reduced surgery- and biologic-free survival throughout follow-up. Backwards stepwise logistic regression revealed that length of ileal disease (odds ratio [OR] 3.8, 1.1-13.2, p = 0.034) and increased bowel wall thickness at MRE [OR 4.2, 1.6-10.7, p < 0.0001] or female sex [OR 5.2, 1.5-18.7, p = 0.011] increased the risk of biologic use or surgery, respectively.

CONCLUSIONS

FC correlates well with MRE assessment of ileal CD with MRE parameters associated with long-term biologic- and surgery-free remission.

Haplotype Analysis of β-Thalassaemia Major and Carriers with Filipino β°-Deletion in Sabah, Malaysia

Objective

The Filipino β°-deletion has been reported as a unique mutation in East Malaysia with a severe phenotype due to the complete absence of β-globin chain synthesis. In this study, the haplotype patterns of the β-globin gene cluster were used to relate the human genetic variation to this specific β-thalassaemia mutation.

Methods

The 376 study subjects included 219 β-thalassaemia major (β-TM) patients with homozygous Filipino β°-deletion and 157 carriers with heterozygous Filipino β°-deletion from 10 government hospitals in different regions of Sabah. Genomic DNA was isolated from whole blood using silica membrane based DNA purification protocol. Polymerase chain reaction restriction fragment length polymorphism analysis (PCR-RFLP) was conducted on five markers within the β-globin gene cluster to construct the haplotype patterns.

Results

Four haplotypes (Haplotype I–IV) were identified with Haplotype I as the predominant haplotype with the highest frequency of 0.98, followed by Haplotype II, III and Haplotype IV with 0.02. Haplotype I was strongly linked with the Filipino β°-deletion among the indigenous population.

Conclusion

Haplotype I as the predominant haplotype suggests the patients with the Filipino β°-deletion in Sabah have a similar origin.

Clinical Significance of BCL2, C-MYC, and BCL6 Genetic Abnormalities, Epstein-Barr Virus Infection, CD5 Protein Expression, Germinal Center B Cell/Non-Germinal Center B-Cell Subtypes, Co-expression of MYC/BCL2 Proteins and Co-expression of MYC/BCL2/BCL6 Proteins in Diffuse Large B-Cell Lymphoma: A Clinical and Pathological Correlation Study of 120 Patients

Background: Clinical significance of germinal center B-cell (GCB) and non-GCB sub-categorization, expression of MYC, BCL2, BCL6, CD5 proteins and Epstein Barr virus encoded RNA (EBER) positivity in diffuse large B-cell lymphoma (DLBCL) remain controversial. Could these biomarkers accurately identify high risk DLBCL patients? Are MYC, BCL2 and BCL6 proteins expression feasible as baseline testing to predict c-Myc, BCL2 or BCL6 gene rearrangements? Aims: To investigate prognostic values of GCB/non-GCB sub-categorization, Double Protein Expression Lymphoma (DPL), Triple Protein Expression Lymphoma (TPL), positivity of CD5 protein and EBER in patients with DLBCL disease. To evaluate correlation between BCL2 , c-Myc and BCL6 gene rearrangements with BCL2, MYC and BCL6 proteins expression. Methods: Diagnostic tissue samples of 120 DLBCL patients between January 2012 to December 2013 from four major hospitals in Malaysia were selected. Samples were subjected to immunohistochemical staining, fluorescent in-situ hybridization (FISH) testing, and central pathological review. Pathological data were correlated with clinical characteristics and treatment outcome. Results: A total of 120 cases were analysed. Mean age of diagnosis was 54.1 years ± 14.6, 64 were males, 56 were females, mean follow up period was 25 months (ranged from 1 to 36 months). Of the 120 cases, 74.2% were non-GCB whereas 25.8% were GCB, 6.7% were EBER positive, 6.7% expressed CD5 protein, 13.3% were DPL and 40% were TPL. The prevalence of c-Myc, BCL2, BCL6 gene rearrangements were 5.8%, 5.8%, and 14.2%, respectively; and 1.6% were Double Hit Lymphoma (DHL). EBER positivity, DPL, TPL, c-Myc gene rearrangement, BCL2 gene rearrangement, extra copies of BCL2 gene and BCL6 gene rearrangement were associated with shorter median overall survival (P<0.05). IPI score was the significant determinants of median overall survival in DPL and TPL (P<0.05). CD5 protein expression and GCB/non-GCB sub-categorization did not affect treatment outcome (P>0.05). Overall, c-Myc, BCL2 and BCL6 gene rearrangements showed weak correlation with expression of MYC, BCL2 and BCL6 proteins (P>0.05). Fluorescent in situ hybridization is the preferred technique for prediction of treatment outcome in DLBCL patients. Conclusion: c-Myc, BCL2, and BCL6 gene rearrangements, EBER expression, DHL, TPL and IPI score are reliable risk stratification tools. MYC, BCL2 and BCL6 proteins expression are not applicable as baseline biomarkers to predict c-Myc, BCL2, and BCL6 gene rearrangements.

Suppression of Wnt/β-catenin signaling by EGF receptor is required for hair follicle development

Mice that lack the epidermal growth factor receptor (EGFR) fail to develop a hair coat, but the mechanism responsible for this deficit is not completely understood. Here, we show that EGFR plays a critical role to attenuate wingless-type MMTV integration site family member (Wnt)/β-catenin signaling during postnatal hair follicle development. Genetic ablation of EGFR in mice resulted in increased mitotic activity in matrix cells, apoptosis in hair follicles, and impaired differentiation of epithelial lineages that form hair. EGFR is activated in wild-type hair follicle stem cells marked with SOX9 or NFATc1 and is essential to restrain proliferation and support stem cell numbers and their quiescence. We observed elevated levels of Wnt4, 6, 7b, 10a, 10b, and 16 transcripts and hyperactivation of the β-catenin pathway in EGFR knockout follicles. Using primary keratinocytes, we linked ligand-induced EGFR activation to suppression of nascent mRNA synthesis of Wnt genes. Overexpression of the Wnt antagonist sFRP1 in mice lacking EGFR demonstrated that elevated Wnts are a major cause for the hair follicle defects. Colocalization of transforming growth factor α and Wnts regulated by EGFR in stem cells and progeny indicates that EGFR autocrine loops control Wnts. Our findings define a novel mechanism that integrates EGFR and Wnt/β-catenin pathways to coordinate the delicate balance between proliferation and differentiation during development.

Abstract P2-13-06: Pancreatic nutrition program (PNP): A novel weight reduction program for breast cancer survivors

BACKGROUND: Breast cancer survivors have a high prevalence of metabolic dysfunction—characterized by high glucose and weight gain. Regardless of menopausal status, overweight and obese women are at increased risk for developing breast cancer and those who are diagnosed with breast cancer experience adverse cancer-related outcomes. The underlying principle of the Pancreatic Nutrition Program (PNP) is that bio-individualized healthy food choices—eating the correct foods and food combinations for an individual's body—can minimize fluctuations in insulin by keeping blood glucose regulated (70-100 mg/dL) and this will promote sustained weight loss, improved health, and quality of life. METHODS: The primary endpoint was change in body weight at 24 weeks post-PNP. The study was powered to detect a 10% loss of weight from baseline. Secondary endpoints included change in: glucose levels, insulin resistance, body composition, body chemistry, physical fitness, biological markers, quality of life, and compliance. Postmenopausal, non-diabetic breast cancer survivors (stages I-III) within 5 years of completion of treatment who had a body mass index of 25-33 kg/m2 were recruited. For the first 12 weeks, patients wore a glucometer (Abbott), which recorded glucose every 15 minutes continuously, and kept a food journal. During weekly meetings, glucometer data was reviewed with journal entries to identify food choices and combinations that would kept the subject's glucose levels between 70-100 mg/dL. At the end of the 12-weeks, the weekly meetings and glucometer were discontinued and patients were expected to maintain the PNP for an additional 12 weeks. Study endpoints were measured at baseline, 12-week and 24-week visits. RESULTS: Of the 21 patients enrolled in the study, 12 were non-Hispanic Caucasian, 5 were Hispanic, 2 were African-American, and 2 were Asian. The median age was 56 years (43-76 years). Twenty were estrogen-receptor positive, 18 progesterone-receptor positive, and 8 were HER2/neu positive. The mean body weight at baseline was 170.9 lbs (±20.4 lbs). Two patients dropped out prior to 12-weeks and 1 developed recurrent disease. Among the 18 eligible women who completed the first 12 weeks, the median weight loss at 12-weeks was 10.1 lbs (1.5-19.6 lbs). The median waist circumference lost was 2.5 inches (gain of 0.4 inches-loss of 5.5 inches). Among the women whose total cholesterol was above 200 mg/dL, 71% reduced their cholesterol below 200 mg/dL by 12-weeks. All women who had triglyceride levels above 150 mg/dL reduced their levels below 150 mg/dL by 12-weeks. Likewise, among women who were identified as being pre-diabetic based on fasting glucose or hemoglobin A1c levels, all were within normal range at 12-weeks. 6-month testing will be completed in August. Among the 15 women eligible for 6-month testing, 8 (53%) completed the testing. Of those, 7 (88%) maintained their positive results. CONCLUSIONS: Bio-individualized food choices based on glucose response combined with culturally-sensitive nutrition counseling may provide a feasible mechanism for sustainable weight loss in a population at high-risk of metabolic dysfunction. However, to increase adherence, a tapering strategy should be developed after the first 12-weeks of health counseling.

Citation Format: Clague DeHart J, Rosen C, Wong L, Moore S, Flores S, Salehian B, Mortimer J. Pancreatic nutrition program (PNP): A novel weight reduction program for breast cancer survivors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-13-06.

Renal transplantation outcomes following heart and heart-lung transplantation

BACKGROUND

Chronic kidney disease is a frequent complication following heart and combined heart-lung transplantation. The aim of this study was to analyse the outcome of a subsequent renal transplant in heart, lung and heart-lung transplantation recipients.

METHODS

All heart, lung and heart-lung transplant recipients who received a subsequent renal transplant over a 27-year period in a national heart and lung transplant centre were included in this study.

RESULTS

A total of 18 patients who had previously undergone heart (n = 6), lung (n = 7) and heart-lung (n = 5) transplantation received a renal transplant. The mean duration to development of end-stage kidney disease (ESKD) was 115 ± 45.9 months. The most common contributor to ESKD was calcineurin inhibitor nephrotoxicity. The 5-year patient survival and graft survival rates were 91.7 and 85.6%, respectively. The median creatinine level at the most recent follow-up was 123 μmol/L, IQR 90.8-147.5.

CONCLUSIONS

The overall outcome of renal transplantation following previous non-renal solid organ transplantation is excellent considering the medical complexity and co-morbidities of this patient population. Renal transplantation represents an important treatment option for ESKD in non-renal solid organ transplant recipients.

Abstract PD6-05: Identifying genetic vulnerabilities in cancers driven by defects in DNA-damage response

Although defects in cancer susceptibility genes within the DNA-damage response (DDR) machinery including BRCA1 and BRCA2 account for only 5-10% of all breast cancer cases, these defects are highly penetrant and significantly increase the risk of breast (60-80%) and also ovarian (35%) cancers [1]. Together with defects in the DNA-damage sensor ATM, apoptosis effector TP53, and PTEN and CDH1 with roles in regulation of DDR, these account for considerable proportions of sporadic breast (63%) and ovarian (85%) cancers. To compensate for these DDR defects and to avoid cell death triggered from a genomic catastrophe, cancer cells rewire their DDR network while also selecting (during clonal expansion) the optimal combination of oncogenic events. Deciphering these combinations of events would aid in mapping the vulnerabilities of cancer cells harbouring defects in DDR.

While there have been several studies screening for essentiality of genes across DDR-deficient cell-lines, the essential genes so identified are either restricted only to these cell-line models or are not frequently (over)expressed in cancers. Here, we observe that oncogenic events that are mutually exclusive to DDR defects in large proportions of cancers constitute the (clonally) selected combinations that are amenable to cancer-cell survival, and therefore by systematically mining for these events, we infer vulnerability genes that if targeted in conjunction with DDR defects could induce a genomic catastrophe and trigger cancer-cell death.

Using data from DNA copy-number and mRNA-expression profiles we infer vulnerability genes that are mutually exclusive to defects in six DDR genes ATM, BRCA1, BRCA2, CDH1, PTEN and TP53 across four cancers (total 3980 samples) – breast (2029), prostate (623), ovarian (828) and uterine (500) from The Cancer Genome Atlas. Interestingly, across the four cancers these vulnerability genes form the most combinations with BRCA2 (59.02%), followed by CDH1 (24.59%), PTEN (8.20%) and TP53 (8.19%) at p&lt;0.01 (1-hypergeometric test), whereas these show distinct patterns within the individual cancers: combinations dominated by CDH1 (90%) in breast, PTEN (78.38%) and BRCA2 (16.82%) in prostate, and BRCA1 (71.94%) and TP53 (16.21%) in ovarian cancers. Validation using GARP (Gene Activity Rank Profile)-score data from essentiality screens [2] from ten breast cancer cell lines (HCC1143, HCC1187, HCC1395, HCC1419, HCC1428, HCC1500, HCC1806, HCC1954, HCC38, MCF7) which harbour defects in at least one of the six DDR genes shows remarkable agreement between the GARP rankings and our inferred vulnerabilities. Our inferred genes are significantly enriched (p&lt;0.0001 X2 test) in the top quartile of the entire set of profiled (∼16000) essential genes in these screens. Moreover, Kaplan-Meier analysis using survival data from 1000 breast cancer patients shows considerable overexpression of these genes (e.g. TLK2 in 37% luminal cases) which correlates significantly (TLK2: p&lt;0.0006; Grade 3 hazard ratio 2.5) with poor prognosis. Experimental validation of these genes using single- and double knockout with DDR in breast cancer cell lines is currently underway.

[1] Liu & Srihari et al., Nucl Acids Res 2014, 42(10):6106-27.

[2] Marcotte et al., Cancer Discov 2012, 2(2):172-89.

Citation Format: Srihari S, Singla J, Wong L, Simpson PT, Khanna KK, Ragan MA. Identifying genetic vulnerabilities in cancers driven by defects in DNA-damage response. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD6-05.

Abstract P4-10-05: Changes in metabolic syndrome components in breast cancer patients receiving neoadjuvant or adjuvant chemotherapy

Purpose. We sought to determine the impact of (neo)adjuvant chemotherapy on metabolic syndrome (MetS) components and related anthropometric and metabolic biomarkers among premenopausal and postmenopausal early stage breast cancer patients.

Methods. Eighty-six women with early stage (I-III) breast cancer who were free from clinically diagnosed MetS (defined as 3 out of 5 components of MetS) and were planning to undergo chemotherapy, enrolled in the study. Participants were tested for MetS (blood pressure; BP, waist circumference; WC, fasting blood glucose; FBG, high-density lipoprotein cholesterol; HDL-C, and triglycerides; TG), anthropometrics (body weight; BW, percent body fat; BF, fat mass; FM), lipid profile (total cholesterol; TC, low-density lipoprotein cholesterol; LDL-C), glucose metabolism (insulin, homeostatic model- insulin resistance; HOMA-IR, glycosylated hemoglobin; HbA1c), and inflammation (C-reactive protein; CRP) within one week before and following the completion of chemotherapy. Fasting (12-hour) venous blood samples of the antecubital vein were drawn to measure glucose, insulin, lipid profile (TC, HDL-C, LDL-C, and TRI), HbA1c, and CRP. Blood samples were analyzed at the City of Hope Clinical Pathology Laboratory. Insulin resistance was calculated using the HOMA index: [(fasting glucose (mg/dL) x fasting insulin (mg/dL)/405]. Height, BW, and BP measurements were obtained by the nursing staff during pre-chemotherapy physical exams. Body composition (BF and FM) was measured using a portable hand-held bioelectrical impedance device (Omron®; Hoffman Estates, IL). WC was measured, using a fabric measuring tape, as the distance around the waist using the umbilicus as the reference point.

One-way analysis of covariance (ANCOVA) using SPSS version 18.0 was used to compare means adjusting for covariates such as age, race, type of chemotherapy, duration of chemotherapy, BMI at baseline, and menopausal status.

Results. The majority of the 86 women enrolled were Caucasian (44%) or Hispanic (30%), nonsmoking (96%), employed (84%), and well-educated (90%), with a mean age of 48.2 years. Women were most commonly undergoing Cytoxan/Adriamycin + Taxol (42%) or Taxotere/Cytoxan (36%) chemotherapy regimens, lasting on average 15.3 (±2.7) weeks. Overall the population was sedentary, averaging 7.2 (±5.8) minutes of physical activity/week.

Following chemotherapy, all MetS components and overall MetS score (out of 5) significantly increased (p&lt;0.01). Additionally, BW, BF, FM, lipids (TC, LDL), glucose metabolism (HOMA-IR, insulin, HbA1c), and inflammation (CRP) significantly increased (p&lt;0.01).

Conclusion. In women without MetS, (neo)adjuvant chemotherapy negatively altered MetS components, related anthropometrics, and biomarkers of glucose metabolism and inflammation, within 12 -18 weeks. Studies that test the impact of lifestyle interventions, such as diet and exercise, should be explored in this population of breast cancer patients to reduce the onset of MetS.

Citation Format: Dieli-Conwright CM, Wong L, Waliany S, Bernstein L, Salehian B, Mortimer JE. Changes in metabolic syndrome components in breast cancer patients receiving neoadjuvant or adjuvant chemotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-10-05.

Abstract P1-10-23: Bladder symptoms in women with newly diagnosed breast cancer

Background: Changes in bladder function are recognized effects of aging and menopause but have not generally been reported in women treated for breast cancer. We initiated a prospective trial to assess the impact of (neo) adjuvant therapy on women with early stage breast cancer.

Methods: Women with newly diagnosed invasive breast cancer who were to initiate (neo) adjuvant chemotherapy or endocrine therapy were approached for study participation. At baseline a urinalysis, urine culture, and self assessment quality of life questionnaires were completed. The Urogenital Distress Inventory (UDI-6) assesses bladder symptoms and the Incontinence Impact Questionnaire (IIQ-7) assesses the impact of bladder symptoms on quality of life. Three months after initiation of (neo)adjuvant therapy, the quality of life questionnaires were repeated. We report the results of the pretreatment questionnaires.

Results: Between February and June, 2015, forty-nine women with newly diagnosed breast cancer were enrolled on study. The median age was 54 (Range 25-78); 21 were premenopausal and 28 postmenopausal. Twenty nine (59%) were treated in the adjuvant setting; 12 with chemotherapy and 17 with endocrine therapy. Twenty patients, (41%) were treated in the neoadjuvant setting with chemotherapy. Prior to initiation of therapy, " Frequent urination" was reported in 38 (65%), " Leakage related to urgency" in 5 ( 10%), " Leakage with physical activity" in 32 (55%) and "Small amounts of leakage" in 32 (55%). Bladder symptoms impacted the ability to perform household chores in 8 (16%), Physical recreation in 10 (20%), social activities in 9 (18%), and Emotional health in 5 (10%).

Conclusions: Symptoms of bladder dysfunction are common in women with newly diagnosed breast cancer even before therapy is initiated.

Citation Format: Wong L, Chung C, Flores S, Mortimer J. Bladder symptoms in women with newly diagnosed breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-23.

Yoga for Self-Care and Burnout Prevention Among Nurses

The promotion of self-care and the prevention of burnout among nurses is a public health priority. Evidence supports the efficacy of yoga to improve physical and mental health outcomes, but few studies have examined the influence of yoga on nurse-specific outcomes. The purpose of this pilot-level randomized controlled trial was to examine the efficacy of yoga to improve self-care and reduce burnout among nurses. Compared with controls ( n = 20), yoga participants ( n = 20) reported significantly higher self-care as well as less emotional exhaustion and depersonalization upon completion of an 8-week yoga intervention. Although the control group demonstrated no change throughout the course of the study, the yoga group showed a significant improvement in scores from pre- to post-intervention for self-care ( p < .001), mindfulness ( p = .028), emotional exhaustion ( p = .008), and depersonalization ( p = .007) outcomes. Implications for practice are discussed.

Mitigation of organic laser damage precursors from chemical processing of fused silica

Increases in the laser damage threshold of fused silica have been driven by the successive elimination of near-surface damage precursors such as polishing residue, fractures, and inorganic salts. In this work, we show that trace impurities in ultrapure water used to process fused silica optics may be responsible for the formation of carbonaceous deposits. We use surrogate materials to show that organic compounds precipitated onto fused silica surfaces form discrete damage precursors. Following a standard etching process, solvent-free oxidative decomposition using oxygen plasma or high-temperature thermal treatments in air reduced the total density of damage precursors to as low as <50 cm(-2). Finally, we show that inorganic compounds are more likely to cause damage when they are tightly adhered to a surface, which may explain why high-temperature thermal treatments have been historically unsuccessful at removing extrinsic damage precursors from fused silica.

Unusual cause of iatrogenic anterior open bite after bilateral sagittal split mandibular advancement osteotomy

We describe a case of anterior open bite after bilateral sagittal split mandibular advancement osteotomy. The discrepancy in height between the proximal and distal segments at the osteotomy sites damaged the soft tissue and caused bony interferences. Removal of the maxillary third molars and bilateral removal of bony interferences of the distal segments using a bur led to full resolution and a good orthognathic outcome on follow-up.

PCR-based identification of adriatic specimen of three scorpionfish species (Scorpaenidae, Teleostei)

The identification of three scorpionfish species, the black scorpionfish (Scorpaena porcus Linnaeus, 1758), the large-scaled scorpionfish (S. scrofa Linnaeus, 1758) and the small red scorpionfish (S. notata Rafinesque, 1810) is possible in adults by morphometry, but often problematic in juveniles due to their similar phenotypes. To develop a molecular species identification tool, first, we have analyzed the genetic similarity of the three species by a PCR-based 'blind method' that amplified bands from various locations of the genome. We found high levels of nucleotide similarity between S. porcus and S. scrofa, whereas S. notata showed a higher level of divergence from the other two species. Then, we have searched these patterns for differences between the genomes of Adriatic specimen of these three species and identified several species-specific products in two of them. For the third one a species-specific primer pair amplifying from the 16S ribosomal DNA was designed. One marker for each species was cloned, sequenced and converted into Sequence Characterized Amplified Region (SCAR) markers amplified by specific primer pairs. The SCAR markers amplified robust bands of limited variability from the target species, while no or only occasional weak products were obtained from the other two, proving that they can be used for molecular identification of these three species. These markers can help the conservation and future analysis of these three species as well as their possible selection programs for aquaculture purposes.

Comparative gastrointestinal safety of bisphosphonates in primary osteoporosis: a network meta-analysis

We completed a network meta-analysis of published papers to compare bisphosphonate gastrointestinal safety. We found that zoledronic acid had the highest chance of causing gastrointestinal adverse events. Etidronate had the highest chance of discontinuation due to an adverse event. No difference was found for serious adverse events.

INTRODUCTION

Bisphosphonates are first-line treatment for osteoporosis. Gastrointestinal (GI) adverse events (AE) are the primary reason for non-adherence. Little is known about the comparative GI safety of bisphosphonates.

PURPOSE

Leverage published clinical trial data to examine the comparative GI safety of bisphosphonates.

METHODS

We completed a systematic review of all English-language clinical trials that assessed bisphosphonate safety and/or efficacy in primary osteoporosis through to 2012. Randomized, blinded, and controlled studies were eligible. The primary outcome was any GI-related AE. Subanalyses were completed for upper GI symptoms, serious GI, nausea, esophageal-related events, and discontinuation due to AE. A Bayesian-based network meta-analysis was completed to allow for indirect comparisons. Results were reported as the probability that a specific drug had the highest number of events.

RESULTS

We identified 50 studies: 32 alendronate, 12 risedronate, 5 etidronate, and 7 zoledronic acid. Zoledronic acid had the highest probability of having the highest number of any GI AE (91%) and nausea (70%). Etidronate (70%) and zoledronic acid (28%) had the highest probability of having the greatest attrition due to AE. Etidronate had the highest probability (56%) of having the greatest number of upper GI symptoms among oral bisphosphonates.

CONCLUSION

Zoledronic acid had the highest probability of causing the greatest number of GI AE, possibly related to nausea. These results question the assumption that annual zoledronic acid will translate into better adherence. Little difference was found between alendronate and risedronate for serious AE. More research into real-world implications of the comparative safety of bisphosphonates is needed.

High fluence laser damage precursors and their mitigation in fused silica

The use of any optical material is limited at high fluences by laser-induced damage to optical surfaces. In many optical materials, the damage results from a series of sources which initiate at a large range of fluences and intensities. Much progress has been made recently eliminating silica surface damage due to fracture-related precursors at relatively low fluences (i.e., less than 10 J/cm(2), when damaged by 355 nm, 5 ns pulses). At higher fluence, most materials are limited by other classes of damage precursors which exhibit a strong threshold behavior and high areal density (>10(5) cm(-2)); we refer to these collectively as high fluence precursors. Here, we show that a variety of nominally transparent materials in trace quantities can act as surface damage precursors. We show that by minimizing the presence of precipitates during chemical processing, we can reduce damage density in silica at high fluence by more than 100 times while shifting the fluence onset of observable damage by about 7 J/cm(2). A better understanding of the complex chemistry and physics of cleaning, rinsing, and drying will likely lead to even further improvements in the damage performance of silica and potentially other optical materials.

Evaluation of butyrate-induced production of a mannose-6-phosphorylated therapeutic enzyme using parallel bioreactors

Bioreactor process changes can have a profound effect on the yield and quality of biotechnology products. Mannose-6-phosphate (M6P) glycan content and the enzymatic catalytic kinetic parameters are critical quality attributes (CQAs) of many therapeutic enzymes used to treat lysosomal storage diseases (LSDs). Here, we have evaluated the effect of adding butyrate to bioreactor production cultures of human recombinant β-glucuronidase produced from CHO-K1 cells, with an emphasis on CQAs. The β-glucuronidase produced in parallel bioreactors was quantified by capillary electrophoresis, the catalytic kinetic parameters were measured using steady-state analysis, and mannose-6-phosphorylation status was assessed using an M6P-specific single-chain antibody fragment. Using this approach, we found that butyrate treatment increased β-glucuronidase production up to approximately threefold without significantly affecting the catalytic properties of the enzyme. However, M6P content in β-glucuronidase was inversely correlated with the increased enzyme production induced by butyrate treatment. This assessment demonstrated that although butyrate dramatically increased β-glucuronidase production in bioreactors, it adversely impacted the mannose-6-phosphorylation of this LSD therapeutic enzyme. This strategy may have utility in evaluating manufacturing process changes to improve therapeutic enzyme yields and CQAs.

Myomectomy: technique and current indications

Uterine fibroids are the commonest benign tumor of the female genital tract. They affect a significant proportion of reproductive aged women and while some women are asymptomatic, fibroids can cause excessive menstrual bleeding, pelvic pressure, and adversely affect reproductive outcomes. Myomectomy is the most suitable surgical option for women who desire preservation of their fertility potential. However, only a selected group of women of childbearing age will benefit from a myomectomy. Furthermore, the consequences of myomectomy on reproductive function have remained controversial. The purpose of this paper is to review the main surgical approaches for myomectomy - hysteroscopic resection, laparoscopic myomectomy and open myomectomy (by laparotomy) - and discuss evidence-based indications for myomectomy in women with fibroids, especially with regards to its impact on reproductive outcomes. A critical review of the literature pertaining to the surgical approaches of myomectomy and the indications for myomectomy was performed, focusing on their impact on fertility and reproductive outcomes. Myomectomy is useful for the treatment of symptomatic fibroids and in selected women with infertility. Symptomatic submucosal fibroids are classically treated by hysteroscopic resection. Symptomatic intramural and subserosal fibroids may be treated by myomectomy, either by laparotomy or laparoscopy depending on their number and size. Prophylactic myomectomy is not recommended for preventing obstetrical complications or the risk of leiomyosarcoma. Although fibroids can have a negative effect on fertility, only the removal of submucosal fibroids has been consistently shown to improve spontaneous fertility or outcomes of assisted reproduction technology.

Assessment of online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS): a strategic study

The Internet is a powerful method of acquiring and sharing information. In marketing and business, online visibility is vital for publicity and the reputation of an organisation. To our knowledge, the importance of such visibility in medicine in general, and in Oral and Maxillofacial Surgery (OMFS) services in the UK, has not previously been investigated. We aimed to provide a better understanding of the way that patients use the Internet by asking 450 patients to complete a questionnaire when they attended outpatient OMFS departments at 2 centres. We also assessed the online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and investigated the correlation between the strength of online visibility and professional reputation. Results from the self-administered, anonymous, validated questionnaires showed that 82% of patients agreed that the Internet was a powerful source of information, and two-thirds associated online visibility with a good reputation. However, the perceived online visibility of the BAOMS was poor (2%). This study mirrors findings in business publications, and confirms the link between online visibility and professional reputation. It also shows that there is a gap between patients' perceptions and the level of uptake of professional resources. We propose various strategies to bridge this gap and to promote the online visibility and professional reputation of the BAOMS and of OMFS services in the UK.

High temperature luminescence of Dy3+ in crystalline silicon in the optical communication and eye-safe spectral regions

We report on photoluminescence in the 1.3 and 1.7 μm spectral ranges in silicon doped with dysprosium. This is attributed to the Dy3+ internal transitions between the second Dy3+ excited state and the ground state, and between the third Dy3+ excited state and the ground state. Luminescence is achieved by Dy implantation into Si substrates codoped with boron, to form dislocation loops, and show a strong dependence on fabrication process. The spectra consist of several sharp lines with the strongest emission at 1736 nm, observed up to 200 K. No Dy3+ luminescence is observed in samples without B codoping, showing the paramount importance of dislocation loops to enable the Dy emission.

Altered adhesion receptor expression impairs recruitment of aged T cell to the nasal mucosa in response to influenza virus infection. (P5085)

Influenza viruses cause significant annual illness and death in the elderly with recurrent seasonal epidemics and sporadic devastating pandemics. CD8 T cells are crucial for resolving influenza virus infection, can protect from divergent viruses, and are highly correlated with protection in the elderly. Due to its anatomical location, the nasal-associated lymphoid tissue (NALT) is crucial for the induction of the immune response, yet little is known regarding the requirements for optimal immunity at this mucosal site. We demonstrated that the number of antiviral CD8 T cells in the NALT was reduced in the aged. Phenotypic analyses of nasal T cells revealed that the carbohydrate-dependent rolling receptors L-Selectin, P-Selectin glycoprotein ligand-1, and CD44 were differentially expressed on aged T cells. We addressed the hypothesis that the reprogramming of adhesion receptor expression in the aged functionally impacts the migration of virus-specific CD8 T cells to the infected nasal mucosa. We demonstrated that rolling receptors, especially L-Selectin, were crucial for CD8 T cell recruitment to the NALT. Thus, the differential adhesion receptor expression profile on aged CD8 T cells may provide a mechanism that contributes to defective mucosal immunity in the elderly and our provides crucial information for novel strategies for improved nasal vaccines.