Inflammatory cytokines in type 2 diabetes mellitus as facilitators of hypercoagulation and abnormal clot formation

BACKGROUND

The global burden of type 2 diabetes mellitus (T2DM), together with the presence of cardiovascular risk in this population, is reaching pandemic levels. A prominent feature of T2DM is chronic and systemic inflammation, with the accompanying presence of circulating and dysregulated inflammatory biomarkers; which in turn is associated with abnormal clot formation.

METHODS

Here, we investigate the correlation between abnormal blood clotting, using thromboelastography (TEG), clot ultrastructure using scanning electron microscopy (SEM) and the presence of a dysregulated inflammatory cytokine profile, by examining various circulating biomarkers.

RESULTS

Our results show that many biomarkers, across TEG, cytokine and lipid groups, were greatly dysregulated in the T2DM sample. Furthermore, our T2DM sample's coagulation profiles were significantly more hypercoagulable when compared to our heathy sample, and ultrastructural analysis confirmed a matted and denser clot structure in the T2DM sample.

CONCLUSIONS

We suggest that dysregulated circulating molecules may in part be responsible for a hypercoagulable state and vascular dysfunction in the T2DM sample. We propose further that a personalized approach could be of great value when planning treatment and tracking the patient health status after embarking on a treatment regimes, and that looking to novel inflammatory and vascular biomarkers might be crucial.

Dentinogenesis imperfecta in Osteogenesis imperfecta type XI in South Africa: a genotype-phenotype correlation

BACKGROUND

The maxillofacial and dental manifestations of Osteogenesis imperfecta (OI) have significant implications in terms of management. Although the occurrence of abnormal dentine in some forms of OI is well documented, there is scant information on the association of abnormal dentine in the Black African persons with phenotypic OI III and genotypic OI XI in South Africa.

METHODS

This was a cross-sectional analytic study. A series of 64 Black South African individuals with a confirmed phenotypic diagnosis of OI III, ages ranging from 3 months to 29 years, were assessed clinically, radiographically, and at a molecular level.

RESULTS

A total number of 64 saliva samples were analyzed and 3 DNA variations were identified in exon 5 of the FKBP10 gene. The homozygous mutation, c.[831dupC]; [831dupC], was identified in 23 affected persons who had no clinically obvious features of DI in their primary and secondary teeth. Radiologically, mild features of DI were evident in 10 persons in whom radiographic images were obtained and were given a Clinical-radiological score of 2. A compound heterozygous mutation, c. [831delC]; [831dupC], was identified in three siblings. An intraoral examination of these affected persons revealed no clinically apparent features of DI in their primary and secondary teeth. Due to the lack of radiological facilities, the presence or absence of DI could not be confirmed or negated. A second compound heterozygous mutation, c.[831dupC]; [1400-4C>G], was identified in a female of 29 years belonging to the Xhosa linguistic group. Her teeth appeared clinically normal but it was not possible to obtain radiographs. In 37 affected individuals, no disease-causing mutations were identified.

CONCLUSION

Black African individuals in SA with the homozygous mutation in the FKBP10 gene have clinically unaffected teeth yet exhibited radiographic features of DI to varying degrees. This characterization is suggestive of a relationship between the genetic abnormality and the clinical manifestations of DI. The authors suggest that this diagnosis must include teeth that are clinically and/or radiologically aberrant, and should not exclude the presence of other, milder, dentinal aberrations associated with OI. There was no correlation between severity of OI and DI in this cohort of individuals.

Communication Skills Training for Surgical Residents: Learning to Relate to the Needs of Older Adults

BACKGROUND

It is vital for physicians and surgeons to communicate successfully with older adults, who will constitute one-fifth of the US population by 2030. Older adults often perceive themselves as stigmatized and powerless in healthcare settings. Effective communication leads to better patient compliance and satisfaction, which is now a component of Medicare hospital reimbursement and physician and surgeon compensation from hospitals and networks.

OBJECTIVE

To increase orthopaedic surgery resident understanding of the unique needs of older adults in order to maintain effective and sensitive communication with this vulnerable population.

DESIGN

A two-part training program (ongoing for 8 years) comprised of: 1) small-group interactive didactic sessions on aging issues; and 2) workshop demonstrations given by the residents to a group of older adults, followed by a Question & Answer session. Residents were assessed using a 22-item pre-post questionnaire covering medical knowledge of aging, attitudes toward older adults, and personal anxiety about aging. Older adult participants were surveyed for perceptions of residents' sensitivity toward them.

SETTING

Hospital for Special Surgery in New York City, a specialized urban academic center, with a 5-year Orthopedic Surgery Residency program.

PARTICIPANTS

70 PGY3 residents, for whom the program is a requirement, and 711 older adult participants recruited from a community convenience sample.

RESULTS

Older adult participants: Of 711 participants, 672 (95%) responded; 96% strongly agreed/agreed that the residents had demonstrated sensitivity toward them. Residents: Of 70 residents, 35 (50%) were assessed. Mean knowledge scores increased significantly (p ≤ 0.001); five of nine attitude items (p ≤ 0.05) and one of four anxiety items improved significantly (p ≤ 0.001).

CONCLUSIONS

Significant change was seen in residents' attitudes and anxiety levels toward older adults, attributes that are usually deep seated and hard to change. Residents moved along the Accreditation Council for Graduate Medical Education Milestones continuum for three core competencies.

Febrile illness in Asia: gaps in epidemiology, diagnosis and management for informing health policy

BACKGROUND

Increasing evidence is becoming available on the aetiology and management of fevers in Asia; the importance of these fevers has increased with the decline in the incidence of malaria.

AIMS

To conduct a narrative review of the epidemiology and management of fevers in South and South-East Asia and to highlight gaps in our knowledge that impair evidence-based health policy decisions.

SOURCES

A narrative review of papers published since 2012 on developments in fever epidemiology, diagnosis and treatment in South and South-East Asia. The papers that the authors felt were pivotal, from their personal perspectives, are discussed.

CONTENT

We identified 100 studies. Among the 30 studies (30%)-including both children and adults-that investigated three or more pathogens, the most frequently reported fever aetiology was dengue (reported by 15, 50%), followed by leptospirosis (eight, 27%), scrub typhus (seven, 23%) and Salmonella serovar Typhi (six, 20%). Among four studies investigating three or more pathogens in children, dengue and Staphylococcus aureus were the most frequent, followed by non-typhoidal Salmonella spp, Streptococcus pneumoniae, Salmonella serovar Typhi, and Orientia tsutsugamushi. Increased awareness is needed that rickettsial pathogens are common but do not respond to cephalosporins, and that alternative therapies, such as tetracyclines, are required.

IMPLICATIONS

Many key gaps remain, and consensus guidelines for study design are needed to aid comparative understanding of the epidemiology of fevers. More investment in developing accurate and affordable diagnostic tests for rural Asia and independent evaluation of those already on the market are needed. Treatment algorithms, including simple biomarker assays, appropriate for empirical therapy of fevers in different areas of rural Asia should be a major aim of fever research. Enhanced antimicrobial resistance (AMR) surveillance and openly accessible databases of geography-specific AMR data would inform policy on empirical and specific therapy. More investment in innovative strategies facilitating infectious disease surveillance in remote rural communities would be an important component of poverty reduction and improving public health.

Hereditary dentine dysplasias: terminology in the context of osteogenesis imperfecta

Hereditary dentine dysplasias (HDD) such as dentinogenesis imperfecta (DI) and dentine dysplasia (DD) are a group of genetic conditions characterised by an abnormal dentine structure due to disturbances in the formation, composition, or organisation of the dentine matrix. Either the primary or both primary and secondary dentition are affected to varying degrees. These disorders result from mutations in the genes encoding the major protein constituents of dentine, notably collagens and phosphoproteins. The clinical and radiological features of the hereditary dentine dysplasias (HDD) are relevant to clinical dentistry, in particular osteogenesis imperfecta (OI) which is a well-known heterogeneous genetic disorder. OI is currently the focus of considerable academic attention and involvement of the teeth is a frequent and variable manifestation. In this analysis, the literature related to the classification, clinical features, and molecular pathogenesis of heritable structural tooth diseases affecting dentine formation is reviewed. The definition, history of the terminology and the development of the current classification is outlined and discussed in detail with the aim to address semantic confusion that has arisen in the literature on HDD and to provide clarity on the use of appropriate terminology in the context of OI.

The Context of Sexual Decisions and Intrapersonal and Interpersonal Factors Related to Sexual Initiation Among Female Military-Dependent Youth

Despite the sizable population of military-dependent youth (MDY) in the United States and the military stressors they experience (e.g., relocations, parental deployment), little is known about MDY's sexual behavior, especially about the perceived role that military stressors play in their sexual decisions, such as the decision to initiate sex. We conducted 25 semistructured, in-depth interviews with sexually experienced female MDY aged 15 to 19 years to (a) describe MDY's general perceptions of military life and (b) identify intrapersonal and interpersonal characteristics related to MDY's sexual initiation, including the perceived impact of military stressors. We analyzed life history grids and transcripts to identify common and unique themes across participants' experiences. Most participants reported having positive experiences related to military life, and most did not believe that military stressors influenced their decision to initiate sex. Common intrapersonal and interpersonal characteristics related to sexual initiation were having an older first sexual partner, being in a dating relationship, receiving sexual health education prior to their first sexual experience, and discussing sex with a parent prior to their first sexual experience. These intrapersonal and interpersonal characteristics should be considered when developing sexual health programs for MDY, which should focus on building supportive peer and parental relationships.

Evaluation of an assessment system for professionalism amongst dental students

INTRODUCTION

Dental professionalism is an essential requirement to practice dentistry that covers both abilities and personal qualities. Therefore, a programme of assessment that promotes personal and professional development throughout the undergraduate dental education course is needed. This study aimed to develop and validate a system to assess dental students' professionalism based on a previously developed conceptual framework.

METHODS

Using the framework, an assessment programme was designed to encourage students to reflect on and explain their observed behaviours with appropriate feedback. The programme was panel-tested and then administered to a cohort of senior dental students. Internal reliability criterion validity and construct validity were evaluated quantitatively, whilst the usefulness of the programme was evaluated qualitatively.

RESULTS

Mean of student, staff and agreed grades was similar, and there were no floor or ceiling effects. All item-total correlations were >0.6 and Cronbach's alpha = 0.95 indicating acceptable internal reliability. All items correlated significantly with global ratings indicating good criterion validity. All hypothesized correlations were significant, and grades were not related to age or gender. Qualitative data produced three themes: assessment process, educational value and suggestions for improvement.

CONCLUSION

The assessment programme has good internal reliability and validity and suggests that basing an assessment system around the explicit theoretical model is a valuable educational tool.

Autism Spectrum Disorder, Developmental and Psychiatric Features in 16p11.2 Duplication

The 16p11.2 duplication (BP4-BP5) is associated with Autism Spectrum Disorder (ASD), although significant heterogeneity exists. Quantitative ASD, behavioral and neuropsychological measures and DSM-IV diagnoses in child and adult carriers were compared with familial non-carrier controls, and to published results from deletion carriers. The 16p11.2 duplication phenotype ranges widely from asymptomatic presentation to significant disability. The most common diagnoses were intellectual disability, motor delays and Attention Deficit Hyperactivity Disorder in children, and anxiety in adults. ASD occurred in nearly 20 % of child cases, but a majority of carriers did not show the unique social features of ASD. The 16p11.2 duplication phenotype is characterized by wider variability than the reciprocal deletion, likely reflecting contributions from additional risk factors.

Why on earth did I buy that? A study of regretted appliance purchases

If targets to reduce greenhouse gas emissions and thereby tackle climate change are to be achieved, it will be necessary to reduce both embodied energy costs (e.g. in terms of producing and manufacturing the products and services that society consumes) and operational energy costs. Reducing the number of purchases that people regret could be a first step in changing the overall dynamic of consumption patterns. This research looks at some potentially adverse effects of consumption on well-being (e.g. negative emotions), applying social practice theory to give insights into why people make purchases that they feel negatively about. This paper draws from: (i) findings of a national survey of over 2000 respondents which found that 53% of adults had reported regretting purchasing an electrical device at some point, and that 23% regretted making such a purchase within the past year; and (ii) a series of walking interviews around people's homes that provide detailed insights into the nature and extent of regretted purchases of electrical goods (e.g. resentment at built-in obsolescence, frustration at the pace of technological change). By combining the qualitative and quantitative data, we develop a typology of regretted consumption and explore the underlying factors that lead to such purchases. The paper concludes with a discussion of the policy implications of this research.This article is part of the themed issue 'Material demand reduction'.

Vaccination to improve the persistence of CD19CAR gene-modified T cells in relapsed pediatric acute lymphoblastic leukemia

Trials with second generation CD19 chimeric antigen receptors (CAR) T-cells report unprecedented responses but are associated with risk of cytokine release syndrome (CRS). Instead, we studied the use of donor Epstein-Barr virus-specific T-cells (EBV CTL) transduced with a first generation CD19CAR, relying on the endogenous T-cell receptor for proliferation. We conducted a multi-center phase I/II study of donor CD19CAR transduced EBV CTL in pediatric acute lymphoblastic leukaemia (ALL). Patients were eligible pre-emptively if they developed molecular relapse (>5 × 10-4) post first stem cell transplant (SCT), or prophylactically post second SCT. An initial cohort showed poor expansion/persistence. We therefore investigated EBV-directed vaccination to enhance expansion/persistence. Eleven patients were treated. No CRS, neurotoxicity or graft versus host disease (GVHD) was observed. At 1 month, 5 patients were in CR (4 continuing, 1 de novo), 1 PR, 3 had stable disease and 3 no response. At a median follow-up of 12 months, 10 of 11 have relapsed, 2 are alive with disease and 1 alive in CR 3 years. Although CD19CAR CTL expansion was poor, persistence was enhanced by vaccination. Median persistence was 0 (range: 0-28) days without vaccination compared to 56 (range: 0-221) days with vaccination (P=0.06). This study demonstrates the feasibility of multi-center studies of CAR T cell therapy and the potential for enhancing persistence with vaccination.

Wavelet-based scaling indices for breast cancer diagnostics

Mammography is routinely used to screen for breast cancer. However, the radiological interpretation of mammogram images is complicated by the heterogeneous nature of normal breast tissue and the fact that cancers are often of the same radiographic density as normal tissue. In this work, we use wavelets to quantify spectral slopes of breast cancer cases and controls and demonstrate their value in classifying images. In addition, we propose asymmetry statistics to be used in forming features, which improve the classification result. For the best classification procedure, we achieve approximately 77% accuracy (sensitivity=73%, specificity=84%) in classifying mammograms with and without cancer. Copyright © 2017 John Wiley & Sons, Ltd.

Abstract P4-02-05: Test-retest fidelity of FDG SUVmax in bone and non-boney metastatic breast cancer lesions in local area network PET/CT scanners

Background: Metabolic activity in lesions, measured by FDG-PET, is often used for assessing tumor aggressiveness and response to therapy. Patients may be scanned on different machines, so quantitative measurements should be reproducible. Reducing SUV variability in PET machines throughout a local network can aid in monitoring patient response to therapy and increase access to clinical trials.

Methods: Eighteen female patients with advanced or metastatic breast cancer underwent paired FDG PET/CT test-retest studies with 1-15 days between scans, and without interim change in treatment. Ten patients were studied in the same scanner and 8 patients were studied in 2 different scanners. Five different PET/CT scanners were used (2 GE DSTE, 2 Siemens (BioGraph 6 and mCT), 1 Philips Ingenuity TF). Each PET/CT scanner was calibrated using NIST-traceable reference sources to characterize and reduce variability. All of the images were interpreted by two separate reviewers. SUVmax values in lesions, corresponding normal tissue, and normal liver were collected. Linear mixed models with random intercept (patient effects) were fitted to compare differences in log(|SUVmax % difference|+.01) in multiple lesions per patient.

Results: SUVmax was assessed in a total of 130 lesions (75 bone). The median number of lesions per patient was 5 (range 1-17). Average SUVmax ranged from 1.0 to 18.2 (mean±SD = 6.0±3.2). The median SUVmax difference was 0.4 (8%) for 47 lesions imaged twice in the same scanner, and was 0.6 (13%) for 83 lesions imaged in two different scanners. In a multivariable linear mixed effects model, SUVmax for different scanners within the same institution did not differ more than for the same scanner (p=0.39), but repeat scans with different scanners and site personnel at had an average of 78% greater percentage difference in SUVmax than for the same scanner (p=0.009). In the same model, the average percent difference in SUVmax for bone lesions was estimated as 30% lower than for other sites (p=0.06, 95% confidence interval 0-50%). Examining normal liver uptake, the median SUVmean was 2.5 (range 1.9-3.1) with an median 6.5% difference between measurements (range 1.1%-23.7%) that did not appear to differ based on scanners used for repeat measurements (p=0.47).

Conclusions: The variability in quantitative FDG SUVmax between scans is modest, suggesting reliable reproducibility in appropriately calibrated settings. In our study, bone lesions had somewhat higher fidelity than other tumor sites. Additional studies will address variability in other cancer types. Careful calibration and monitoring of PET/CT scanners, and consistent imaging protocols are necessary in clinical trials that utilize quantitative PET/CT imaging in order to confidently interpret results.

Research Support: NIH grant U01-CA148131 and NCI-SAIC Contract 24XS036-004.

Citation Format: Linden HM, Peterson LM, Kurland B, Roberts T, Specht J, Shields AT, Novakova A, Christopfel R, Byrd D, Muzi M, Mankoff DA, Kinahan P. Test-retest fidelity of FDG SUVmax in bone and non-boney metastatic breast cancer lesions in local area network PET/CT scanners [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-02-05.