Hypophosphataemic osteomalacia due to cadmium exposure in the silver industry

Chronic heavy metal exposure and the health hazards that ensue are important public-health problems. We highlight the occurrence of hypophosphataemic osteomalacia due to chronic cadmium exposure in the silver industry in India. Three silversmiths presented similarly with clinical, biochemical and radiological evidence of hypophosphataemic osteomalacia. Considering their occupation, their blood samples were screened for heavy metals and were found to have toxic levels of cadmium. They were initiated on neutral phosphate and calcitriol. On follow-up, they reported significant reduction in severity of symptoms. It is essential to maintain a high index of suspicion in diagnosing this condition. A thorough knowledge of the occupational background of patients, as well as ambient conditions at the workplace is of utmost importance in contemplating the possibility of such rare occurrences. Moreover, regulatory agencies and policy makers ought to survey the silver industry and ensure that the metals used are within permissible safe limits of exposure.

Improvement in depression with oestrogen treatment in women with schizophrenia

Women with schizophrenia are often noted to suffer with comorbid depression. Many studies have shown associations between fluctuating oestrogen levels in the brain and mental illness. This study investigates the effect of oestradiol treatment on comorbid depressive symptoms in women with schizophrenia. This study is an 8-week, three-arm, double-blind, randomised-controlled trial. The 180 female participants were aged between 18 and 45, with schizophrenia and ongoing symptoms of psychosis Positive and Negative Syndrome Scale (PANSS) score > 60 despite a stable dose of antipsychotic medication. Depressive symptoms were assessed using Montgomery Asberg Depression Scale (MADRS) with a mean score of 73.77 at baseline. Participants received transdermal oestradiol 200 μg or transdermal oestradiol 100 μg or an identical placebo patch. The a priori outcome measure was the change in PANSS score measured at baseline and days 7, 14, 28 and 56, but in this study, we focused on the change in MADRS score at the same time points. Data were analysed by using Quade's rank analysis of covariance (ANCOVA) (Huitema 1980) with baseline MADRS score as a covariate. We found a fluctuating but overall trend towards improvement of comorbid depressive symptoms in women with schizophrenia taking transdermal oestrogen 200 mcg compared with oestrogen 100 mcg or placebo. The stronger 'antidepressant' effect of 200 mcg transdermal oestradiol was found at day 28 (p = 0.03). Our study suggests that adjunctive oestradiol treatment for depression may be a promising treatment for women with comorbid depression and schizophrenia.

Do virtual renal clinics improve access to kidney care? A preliminary impact evaluation of a virtual clinic in East London

Background

Early identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease.

The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care.Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice.

Methods

We describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices.

Results

Prior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices.

Conclusions

‘Virtual’ specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.

P37 Do all notochordal lesions require proton beam radiotherapy? A case series of ecchordosis physaliphora

Objectives

Ecchordosis physaliphora (EP) is a benign, usually asymptomatic, notochord tumour but may also present with a spontaneous CSF fistula. Differentiating EP from its more aggressive counterpart, chordoma is challenging but important as the clinical course and management differ significantly, with the latter requiring proton beam radiotherapy. This case series aims to further inform this discussion.

Design

Case series.

Subjects

Patients with suspected EP from 2015–2018.

Methods

Retrospective analysis.

Results

Six patients were identified. Four presented with suspected CSF leak. MRI revealed a T1-hypointense and T2-hyperintense clival lesion without enhancement. CT showed pneumocephalus, a clival defect and no mass lesion. All underwent endoscopic endonasal repair of CSF fistula with biopsy. Histology revealed physaliphorous cells with no mitoses; immunohistochemistry confirmed notochord origin (EMA, S100, CD10 and/or MNF116) and low proliferation index. In 2 patients, EP was found incidentally on imaging and these lesions have remained static on follow-up.

Conclusions

In the absence of a clival mass, notochord remnant lesions with benign histopathology can be treated as EP and patients can avoid radiotherapy. The diagnosis of EP, however, remains challenging as no distinctive histopathological marker exists to differentiate it from chordoma and until a genetic or immunohistochemical marker is identified, the diagnosis rests solely on the presence or absence of a mass on imaging.

Raloxifene as a treatment for cognition in women with schizophrenia: the influence of menopause status

Cognitive impairments cause significant functional issues for people with schizophrenia, often emerging before the onset of hallucinations, delusions and other psychosis symptoms. Current pharmacological treatments do not target cognitive dysfunction. Several lines of evidence support the beneficial effects of estrogens on cognition. Raloxifene hydrochloride, a selective estrogen receptor modulator, has been associated with cognitive improvements in healthy postmenopausal women and in schizophrenia, although findings are inconsistent. Using pooled data from two clinical trials, the aim of the current study was to compare the efficacy of 120 mg/day adjunctive raloxifene to placebo for 12 weeks on cognitive performance in women with schizophrenia who were stratified by menopause status (pre-menopausal; peri-menopausal or post-menopausal). A total of sixty-nine participants with a diagnosis of schizophrenia or schizoaffective disorder were included. Cognition was assessed at baseline and study end using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results indicated that after stratifying for menopause status (strata) and adjusting for endogenous hormone levels (estrogen, progesterone, follicle stimulating hormone and luteinising hormone), semantic fluency, picture naming and list recognition change from baseline scores for the raloxifene group differed significantly from the placebo group. The findings from the current study highlight the importance of considering menopause status when interpreting the effects of hormonal treatments.

Menstrual cycle irregularity and menopause status influence cognition in women with schizophrenia

Cognitive impairments are a core feature of schizophrenia and contribute significantly to functional complications. Current pharmacological treatments do not ameliorate cognitive dysfunction and the aetiology of cognitive impairments are poorly understood. Hormones of the hypothalamic-pituitary-gonadal (HPG) axis that regulate reproductive function have multiple effects on the development, maintenance and function of the brain and have been suggested to also influence cognition. The aim of the current study was to investigate how HPG axis hormones effect cognition, specifically exploring the influence of menopause status and menstrual cycle irregularity on cognitive performance in women with schizophrenia. The data for the present study represents pooled baseline data from three clinical trials. Two hundred and forty female participants with a diagnosis of schizophrenia or schizoaffective disorder were included in the analysis. Cognition was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status. Hormone assays for serum sex steroids and pituitary hormones (including estradiol, progesterone, luteinising hormone and follicle-stimulating hormone) were conducted and women were classified as postmenopausal; perimenopausal; premenopausal/reproductive, further classified into regular and irregular menstrual cycles. To model a comparison of cognitive performance for i) perimenopausal; ii) post-menopausal women and iii) reproductive aged women with irregular cycles to reproductive aged women with regular cycles a semiparametric regression model (generalised additive mode) was fitted. The results revealed that in females with schizophrenia, menstrual cycle irregularity predicted significantly poorer cognitive performance in the areas of psychomotor speed, verbal fluency and verbal memory. Perimenopause was not associated with cognitive changes and the post-menopausal period was associated with poorer visuospatial performance. This study provides evidence to associate reproductive hormones with cognitive dysfunction in schizophrenia.

Lyme Disease Surveillance in New York State: an Assessment of Case Underreporting

Despite the mandatory nature of Lyme disease (LD) reporting in New York State (NYS), it is believed that only a fraction of the LD cases diagnosed annually are reported to public health authorities. Lack of complete LD case reporting generally stems from (i) lack of report of provider-diagnosed cases where supportive laboratory testing is not ordered or results are negative (i.e. provider underreporting) and (ii) incomplete case information (clinical laboratory reporting only with no accompanying clinical information) such that cases are considered 'suspect' and not included in national and statewide case counts (i.e. case misclassification). In an attempt to better understand LD underreporting in NYS, a two-part study was conducted in 2011 using surveillance data from three counties. Case misclassification was assessed by obtaining medical records on suspect cases and reclassifying according to the surveillance case definition. To assess provider underreporting, lists of patients for whom ICD-9-CM code 088.81 (LD) had been used were reported to NYS Department of Health (NYSDOH). These lists were matched to the NYSDOH case reporting system, and medical records were requested on patients not previously reported; cases were then classified according to the case definition. When including both provider underreporting and case misclassification, approximately 20% (range 18.4-24.6%) more LD cases were identified in the three-county study area than were originally reported through standard surveillance. The additional cases represent a minimum percentage of unreported cases; the true percentage of unreported cases is likely higher. Unreported cases were more likely to have a history of erythema migrans (EM) rash and were more likely to be young paediatric cases. Results of the study support the assertion that LD cases are underreported in NYS. Initiatives to increase reporting should highlight the importance of reporting clinically diagnosed EM and be targeted to those providers most likely to diagnose LD, specifically providers treating paediatric patients.

Abstract P6-08-22: Frequency of equivocal Her2-test results after revision of the ASCO/CAP guidelines in a real-world setting. Results of a prospective cross-sectional study of primary breast cancers in Germany

Background

In 2013 the ASCO/CAP Guidelines for HER2 testing were updated and revised to improve the accuracy of Her2 testing and its utility as a predictive marker in breast cancer. In this prospective cross-sectional study, we assessed the proportion of Her2 positive and equivocal cases in a real-world setting in Germany. Patients' characteristics and tumor biological factors were evaluated. Furthermore, we analyzed the effect of the updated recommendations on the clinical management.

Methods

This IRB approved prospective analysis included patients with primary breast cancer. Patients with primary stage IV and recurrent breast cancer were excluded. Data was collected from 2012-2017 in six certified breast centers using a personal questionnaire and data from the patients' medical records.

Results

2705 primary breast cancer cases were analyzed. The groups consisted of 320(11.8%) TNBC, 1956 (72.31%) luminal breast cancer patients and 381 (14.08%)Her2 positive cancer patients. 18 (1%) patients were classified as equivocal. 30 patients did not meet the criteria of any of these groups. No significant difference was seen in positive lymph node status between all groups. Tumor size at diagnosis was larger for TNBC compared to the other groups. 81,9% of all TNBC, 65.1% of the Her2 type, 44.2% of the luminal type and 44.44% (8/18) of the equivocal cases were grade 3 tumors. 3 cases with unresolved Her2 status were diagnosed in 2013 and 6 cases in 2016. 17/18 equivocal cases were hormone receptor positive, 1/18 was hormone receptor negative. In 12/18 cases adjuvant or neoadjuvant chemotherapy was recommended. Trastuzumab was recommended in 9/18 of the cases. 2/18 patients were BRCA mutation carriers. 2/18 received an oncologic treatment for another cancer prior to their breast cancer diagnosis. 1/18 patient received primary endocrine therapy with an aromatase inhibitor. 6/18 patients had a positive family history for breast cancer.

Conclusions

Our study indicates that the 2013 ASCO/CAP update does not affect the overall Her2 positivity rate in breast cancer. Although the proportion of tests and retests increased, only few unresolved cases remained. Despite the fact that the benefit of anti-Her2 directed therapy in equivocal cases is unproven, oncologists were more likely to recommend Trastuzumab, if chemotherapy was indicated for high risk breast cancer. There are numerous factors that could explain equivocal findings. Interestingly, a significant number of our patients presented endogenous or exogenous risk factors for chromosomal aberrations that might be responsible for unresolved Her2 cases.

Citation Format: Kuehnle E, Wulf S, Kristina L, Iris S, Stefanie N, Alexander M, Jutta J, Thomas N, Momme A, Peter H, Thilo D-B, Tjoung-Won P-S. Frequency of equivocal Her2-test results after revision of the ASCO/CAP guidelines in a real-world setting. Results of a prospective cross-sectional study of primary breast cancers in Germany [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 P6-08-22.

Troponin-T as a biomarker in neonates with perinatal asphyxia

BACKGROUND

Troponin-T is a commonly used cardiac biomarker, which could be useful in perinatal asphyxia. We aimed to analyze troponin-T concentrations in asphyxiated neonates and to correlate the concentrations with clinical outcomes.

METHODS

Data were collected from electronic medical records of neonates diagnosed with perinatal asphyxia over a period of four years.

RESULTS

There were 63 neonates with moderate to severe encephalopathy, in whom serial troponin-T concentrations had been done on days 1, 3, and 7. 53 (84%) asphyxiated infants had troponin-T concentration >100 pg/ml at 2-4 h of life.The difference in troponin-T concentrations between moderate and severe encephalopathy was not statistically significant (173 vs. 263 pg/ml, p value 0.40). The difference in the concentrations at 72 hours between cooled and non-cooled neonates was not significant (48.5 vs. 62.5 pg/ml, p value 0.22). Troponin-T concentration was significantly higher in babies with hypotensive shock and hepatic injury, but not acute kidney injury. There was no significant correlation between troponin-T and the extent of resuscitation needed.Troponin-T concentration on day 1 of life was significantly higher in babies who died than who survived (407 vs. 168 pg/ml, p value 0.03). ROC curve for troponin-T to predict mortality had an area under the curve (AUC) of 0.803; the best cut-off value (190 pg/ml) had 82% sensitivity and 80% specificity.

CONCLUSION

There was no significant difference in troponin-T concentrations between cooled and non-cooled neonates. Troponin-T concentration had a good predictive accuracy for mortality before discharge.

Assessing diagnostic coding practices among a sample of healthcare facilities in Lyme disease endemic areas: Maryland and New York - A Brief Report

The value of using diagnostic codes in Lyme disease (LD) surveillance in highly endemic states has not been well studied. Surveys of healthcare facilities in Maryland (MD) and New York (NY) regarding coding practices were conducted to evaluate the feasibility of using diagnostic codes as a potential method for LD surveillance. Most respondents indicated that their practice utilized electronic medical records (53%) and processed medical/billing claims electronically (74%). Most facilities were able to search office visits associated with specific ICD-9-CM and CPT codes (74% and 73%, respectively); no discernible differences existed between the healthcare facilities in both states. These codes were most commonly assigned by the practitioner (82%), and approximately 70% of respondents indicated that these codes were later validated by administrative staff. These results provide evidence for the possibility of using diagnostic codes in LD surveillance. However, the utility of these codes as an alternative to traditional LD surveillance requires further evaluation.

Estimation of tile drainage contribution to streamflow and nutrient loads at the watershed scale based on continuously monitored data

Nitrogen losses from artificially drained watersheds degrade water quality at local and regional scales. In this study, we used an end-member mixing analysis (EMMA) together with high temporal resolution water quality and streamflow data collected in the 122 km² Otter Creek watershed located in northeast Iowa. We estimated the contribution of three end-members (groundwater, tile drainage, and quick flow) to streamflow and nitrogen loads and tested several combinations of possible nitrate concentrations for the end-members. Results indicated that subsurface tile drainage is responsible for at least 50% of the watershed nitrogen load between April 15 and November 1, 2015. Tiles delivered up to 80% of the stream N load while providing only 15-43% of the streamflow, whereas quick flows only marginally contributed to N loading. Data collected offer guidance about areas of the watershed that should be targeted for nitrogen export mitigation strategies.

Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

BACKGROUND

Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting.

METHODS

The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707).

FINDINGS

Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80).

INTERPRETATION

Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care.

FUNDING

The National Health and Medical Research Council of Australia.

Advanced Methods for Dose and Regimen Finding During Drug Development: Summary of the EMA/EFPIA Workshop on Dose Finding (London 4-5 December 2014)

Inadequate dose selection for confirmatory trials is currently still one of the most challenging issues in drug development, as illustrated by high rates of late‐stage attritions in clinical development and postmarketing commitments required by regulatory institutions. In an effort to shift the current paradigm in dose and regimen selection and highlight the availability and usefulness of well‐established and regulatory‐acceptable methods, the European Medicines Agency (EMA) in collaboration with the European Federation of Pharmaceutical Industries Association (EFPIA) hosted a multistakeholder workshop on dose finding (London 4–5 December 2014). Some methodologies that could constitute a toolkit for drug developers and regulators were presented. These methods are described in the present report: they include five advanced methods for data analysis (empirical regression models, pharmacometrics models, quantitative systems pharmacology models, MCP‐Mod, and model averaging) and three methods for study design optimization (Fisher information matrix (FIM)‐based methods, clinical trial simulations, and adaptive studies). Pairwise comparisons were also discussed during the workshop; however, mostly for historical reasons. This paper discusses the added value and limitations of these methods as well as challenges for their implementation. Some applications in different therapeutic areas are also summarized, in line with the discussions at the workshop. There was agreement at the workshop on the fact that selection of dose for phase III is an estimation problem and should not be addressed via hypothesis testing. Dose selection for phase III trials should be informed by well‐designed dose‐finding studies; however, the specific choice of method(s) will depend on several aspects and it is not possible to recommend a generalized decision tree. There are many valuable methods available, the methods are not mutually exclusive, and they should be used in conjunction to ensure a scientifically rigorous understanding of the dosing rationale.