Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases

BACKGROUND

A large number of observational epidemiological studies have reported generally positive associations between circulating mass and activity levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular diseases. Few studies have been large enough to provide reliable estimates in different circumstances, such as in different subgroups (e.g., by age group, sex, or smoking status) or at different Lp-PLA2 levels. Moreover, most published studies have related disease risk only to baseline values of Lp-PLA2 markers (which can lead to substantial underestimation of any risk relationships because of within-person variability over time) and have used different approaches to adjustment for possible confounding factors.

OBJECTIVES

By combination of data from individual participants from all relevant observational studies in a systematic 'meta-analysis', with correction for regression dilution (using available data on serial measurements of Lp-PLA2), the Lp-PLA2 Studies Collaboration will aim to characterize more precisely than has previously been possible the strength and shape of the age and sex-specific associations of plasma Lp-PLA2 with coronary heart disease (and, where data are sufficient, with other vascular diseases, such as ischaemic stroke). It will also help to determine to what extent such associations are independent of possible confounding factors and to explore potential sources of heterogeneity among studies, such as those related to assay methods and study design. It is anticipated that the present collaboration will serve as a framework to investigate related questions on Lp-PLA2 and cardiovascular outcomes.

METHODS

A central database is being established containing data on circulating Lp-PLA2 values, sex and other potential confounding factors, age at baseline Lp-PLA2 measurement, age at event or at last follow-up, major vascular morbidity and cause-specific mortality. Information about any repeat measurements of Lp-PLA2 and potential confounding factors has been sought to allow adjustment for possible confounding and correction for regression dilution. The analyses will involve age-specific regression models. Synthesis of the available observational studies of Lp-PLA2 will yield information on a total of about 15 000 cardiovascular disease endpoints.

Progressive MS Alliance Industry Forum: Maximizing Collective Impact To Enable Drug Development

The Progressive MS Alliance Industry Forum describes a new approach to address barriers to developing treatments for progressive multiple sclerosis (MS). This innovative model promises to facilitate robust collaboration between industry, academia, and patient organizations and accelerate research towards the overarching goal of developing safe and effective treatments for progressive MS.

Impact of concomitant medication use on belimumab efficacy and safety in patients with systemic lupus erythematosus

Practicing physicians have requested efficacy and safety data for belimumab, when used with specific systemic lupus erythematosus (SLE) medications. This was a post hoc analysis of pooled efficacy and safety data from patients who received belimumab 10 mg/kg plus standard of care (SoC) or placebo (SoC) in two Phase III, randomized trials, BLISS-52 and BLISS-76. Patients were categorized into four groups based on baseline concomitant medication usage: steroids only; antimalarials (AM) only; steroids + AM; or steroids + AM + immunosuppressants (IS). The primary endpoint was the SLE Responder Index (SRI) at Week 52. SRI over time and individual SRI components were secondary endpoints. Time to first flare and changes in concomitant medications were exploratory endpoints. Safety was assessed using adverse event (AE) reporting. Across 834 patients, steroids + AM was the largest group (n = 346, 41.5%) and AM only was the smallest (n = 77, 9.2%). Disease duration was shortest in the steroids + AM group (5.7 years vs 6.4–7.1 years); SELENA-SLEDAI scores were similar across groups. At Week 52, the percentage of SRI responders was greatest in the steroids + AM group for belimumab 10 mg/kg (59%) compared with placebo (44%); treatment response and SRI component improvements were also observed across other groups. The probability of experiencing an SLE flare was reduced in the steroids-only group for patients who received belimumab 10 mg/kg compared with placebo (64.3% vs 78.1%; hazard ratio 0.64; 95% confidence interval: 0.42–0.96). There was little or no change in daily AM or IS dose in any group. For all groups, there was a general decrease in steroid dose over time; a quarter to a third of patients experienced decreased steroid doses at Week 52. The overall safety profile was similar across treatment arms and concomitant medication groups, with the exception of serious AEs in the steroids + AM group (belimumab 10 mg/kg 16%, placebo 8%). The efficacy and safety of belimumab in combination with SoC was demonstrated for various groupings of steroids, AM and IS. These findings may improve the understanding of the safety and efficacy of adding belimumab to different treatments.

Guidelines for the diagnosis, prevention and management of chemical- and radiation-induced cystitis

Objective

Haemorrhagic cystitis (HC) is a relatively common complication of chemotherapy and radiotherapy to the pelvic area, but can be a challenging condition to treat, particularly since there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.

Materials and methods

A comprehensive literature search was undertaken to evaluate the evidence for the diagnosis, prevention and management of cancer treatment-induced HC.

Results

Recommendations and a proposed management algorithm for the diagnosis, prevention and treatment of HC, as well as the management of intractable haematuria, have been developed based on the expert opinion of the multidisciplinary consensus panel following a comprehensive review of the available clinical data.

Conclusion

These guidelines are relevant and applicable to current clinical practice and will help clinicians optimally define and manage this potentially serious condition.

Outcome measures for multiple sclerosis clinical trials: relative measurement precision of the Expanded Disability Status Scale and Multiple Sclerosis Functional C omposite

We compared the relative measurement precision (RMP) of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functio nal C omposite (MSFC) for discriminating between groups of patients known to differ in their extent of multiple sclerosis (MS). A total of 133 patients were rated with the EDSS and MSFC and had magnetic resonance imaging (MRI) scans. Patients were grouped on the basis of MRI appearances (T1- and T2-weighted lesion loads, parenchymal and ventricular fractions - T1LL, T2LL, PF, VF, respectively) and RMP was determined using the method of group differences. For each MRI parameter, the total sample was arranged in ascending order of magnitude and divided into two, three, four and five similar sized groups. For each division (two, three, four or five groups), EDSS and MSFC scores for the groups were compared using parametric (paired samples t-tests, one-way A NOVA) and nonparametric (Wilcoxon’s rank-sum test, Kruskal -Wallis analysis of variance) statistical methods and RMP was estimated. The EDSS and MSFC were correlated substantially (r = -0.64). Relative to the MSFC, the EDSS had inferior measurement precision regardless of the number of groups into which the total sample was divided, or the statistical method. However, the RMP of the EDSS compared with the MSFC varied from 2% to 86%. Results suggest the MSC F is better than the EDSS for detecting differences between groups of patients, defined by these MRI markers of MS. However, the finding that both scales correlated weakly with MRI markers, indicated that they are limited as predicto rs of MS patho logy as defined by MRI. A n explanatio n for this well-established clinical -MRI paradox is that rating scales and MRI measure fundamentally different manifestations of MS.

Abstract P5-13-01: Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study)

Background: The OPPORTUNE Study randomized postmenopausal patients (pts) to receive 2-week preoperative treatment with anastrozole (ANA) plus pictilisib ("ANA+PIC" arm) or ANA alone. Patients had newly diagnosed, operable, ER+, HER2- invasive breast cancer of ≥1 cm size. The primary outcome at interim analysis (n=70) revealed that the addition of PIC significantly increased the anti-proliferative response to ANA as measured by reduction in Ki67 immunohistochemistry (IHC). Multivariate analyses suggested benefit of PIC for patients with luminal B disease (Schmid et al. SABCS 2014).

Methods: RNA expression analysis of ∼800 breast cancer-related genes was performed on patients analyzed at the interim analysis, including 14 (ANA) and 20 (ANA+PIC) patients with matched pre- and post- treatment paired tumour samples using the nCounter platform (NanoString). Differential expression of individual genes by arm was assessed using paired and moderated t-tests and statistical significance assessed through false discovery rate (FDR). Ingenuity Pathway Analysis (IPA) of differentially expressed transcripts identified pathways of relevance. Protein expression was analyzed by reverse protein array ( RPPA) in pre- and post-treatment samples.

Results: In an unsupervised analysis, down-regulation of genes associated with ER signaling was observed in patients who received single-agent ANA and ANA+PIC, which included genes that regulate the cell cycle, cell death, survival, growth and proliferation and known ER target genes (e.g., PGR, GREB1). In addition, transcripts related to growth factor signaling pathway appeared to be specifically modulated in the ANA+PIC arm, possibly via the upregulation of the expression of RTK ligands. There were no clear changes in PI3K-related phosphoproteins (e.g., AKT, S6, 4E-BP1) in the post-treatment samples by RPPA. However, known PI3K-regulated genes, IRS2 and PIK3IP1, were upregulated in the post-treatment samples and a composite PI3K gene expression signature score (O'Brien et al. 2010) was reduced in both study arms following treatment. This PI3K signature was associated with pre-treatment luminal B status (n=27) and, consistent with this finding, the baseline PI3K gene signature score in the ANA arm, but not the ANA+PIC arm, was inversely associated with the decrease in post treatment Ki67. The tumor immune microenvironment was analyzed though the use of composite gene sets. In our initial observations, analysis of pre- and post-treatment samples showed that 2-week treatment with ANA resulted in a modest increase in transcripts associated with multiple immune signatures, which was further enhanced by the addition of PIC.

Conclusions: Gene expression analysis of pre- and post-treatment samples in the OPPORTUNE study demonstrates on-target inhibition of ER and PI3K signaling networks. The analysis of additional paired samples is in progress to further assess if 2-weeks of treatment with a regimen containing an AI in patients with early breast cancer impacts the tumor immune microenvironment.

Citation Format: Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). [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 P5-13-01.

Abstract OT2-03-03: Women's triple-negative, first-line treatment: Improving outcomes in triple-negative breast cancer using molecular triaging and diagnostic imaging to guide neoadjuvant therapy

BACKGROUND:

In triple negative breast cancer (TNBC), pathologic compete response/residual cancer burden-0 (pCR/RCB-0) or minimal residual disease (RCB-I) following neoadjuvant chemotherapy (NACT) is associated with a good prognosis. This is in contrast to extensive residual disease (RCB-II-III) which carries approximately a 50% chance of recurrence. These patients have a particularly poor prognosis as there are currently no targeted agents to salvage chemoresistant disease. It is important to predict pCR in order to direct responsive disease toward standard NACT and non-responsive disease (NRD) to therapy on clinical trials.

TRIAL DESIGN:

The use of genomic signatures (JAMA, 2011; 305:1873-81) and imaging to predict response to NACT will be validated, and the clinical impact of selecting patients with predicted NRD for targeted therapy on clinical trial will be determined. Patients will undergo primary tumor biopsy for molecular profiling and will be randomized 2:1 to know the results versus not (control). Following that, all patients will receive 4 cycles of anthracycline-based NACT, with imaging used for response assessment. Patients with molecular/imaging criteria for NRD will be offered enrollment on a clinical trial based upon molecular profiling or based upon physician/patient choice (control).

INCLUSION CRITERIA:

Tumor size ≥1.5 cm diameter; TNBC by standard assays; ≥18 years of age; LVEF ≥50%; adequate organ and bone marrow function

EXCLUSION CRITERIA:

Stage IV disease; invasive cancer within 5 years; excisional biopsy of the primary tumor; features that limit response assessment by imaging; unfit for taxane and/or antracycline regimens; prior anthracycline therapy; ≥grade II neuropathy; Zubrod performance status of ≥2; history of serious cardiac events

PRIMARY AIM:

- Prospectively determine the impact of a molecular diagnostic/imaging platform in patients with localized invasive TNBC

SECONDARY AIMS:

- Compare rates of clinical trial enrollment

- Evaluate disease free survival in the experimental arms compared to control standard NACT

- Perform integrated biomarker analyses and identify therapeutic targets for resistant disease

STATISTICAL METHODS:

A maximum of 360 patients will be randomized (2:1)using a group sequential design with one-sided O'Brien-Fleming boundaries, with two equally spaced binding interim tests for futility and superiority and one final test, having an overall Type I error .05 and power .80 to detect an improvement in pCR/RCB-I from 50% to 64%.

Citation Format: Mitri ZI, Ueno NT, Yang W, Valero V, Litton JK, Murthy RK, Ibrahim NK, Arun BK, Mittendorf EA, Hunt KK, Meric-Bernstam F, Thompson A, Piwnica-Worms H, Tripathy D, Symmans F, Moulder-Thompson S. Women's triple-negative, first-line treatment: Improving outcomes in triple-negative breast cancer using molecular triaging and diagnostic imaging to guide neoadjuvant therapy. [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 OT2-03-03.

Abstract P3-14-07: Intra-cellular dsRNA receptor RIG-I: A ubiquitous novel target for treatment of chemotherapy drug resistant breast cancer

INTRODUCTION: Toll-like receptor 3 (TLR3), the cell surface receptor for double stranded RNA (dsRNA), expressed in ∼40% of advanced primary breast cancers (T2/T3/N+) has been shown to be an effective therapeutic target for synthetic dsRNA poly A:U in combination with radiation and adjuvant chemotherapy, producing a significant decrease in risk of metastatic relapse (HR 1.85-2.0; 1.03-3.89; Cancer Res;71:1607).

AIM: The present pre-clinical study aimed to explore the therapeutic potential of a ubiquitously expressed intracellular dsRNA receptor, retinoic-acid-inducible gene-I (RIG-I) - a cytoplasmic pathogen recognition receptor directed at pathogen-associated molecular pattern (PAMP) motifs to differentiate viral from cellular dsRNAs. We have shown Ampligen, poly I:C12U (a synthetic dsRNA polymer designed to rapidly degrade in vivo to prevent the toxicity of long dsRNA polymers such as poly I:C) is capable of entering cells in its fragmented dsRNA oligomeric form (<1–2 kb) optimal for activation of intra-cellular RIG-I (J Exp Med 2008;205:1601–1610).

METHODOLOGY & RESULTS: Preliminary experiments with Ampligen on several human breast cancer cell lines (MCF-7 & MDA-MB 453) and normal human mammary epithelial & fibroblast cell lines (HMEC & HFC) unexpectedly showed it to consistently cause a significant loss of cell viability (CellTiter-Glo Luminescent Cell Viability Assay) in p53-deficient drug resistant (5-FU/doxorubicin) MDA-MB 453 cell line in contrast to cell growth arrest (Guava cell Cycle Assay) in p53 wild type MCF-7 cancer and the two non-neoplastic cells lines. This selective effect was confirmed using syngeneic clones of MCF-7 breast cancer cells stably transfected with a dominant negative p53 construct or vector alone: p53-function blocked (DD1) vs p53-function active (EV1) MCF-7 cell lines, respectively (J Nucl Med 2006; 47:1525–1530), and shown to be associated with RIG-I specific mRNA induction (RT-PCR) and Type I interferon pathway activation both inhibited by BX795 (selective inhibitor of IRF3 activation and IFN-b production). Decitabine (DNA demethylating drug capable of intra-cellular generation of dsRNA through transcriptional activation of Alu retrotransposons - PNAS 2012; December 10: E89–E98 ) was next tested as an alternative source of intra-cellular dsRNA, and found to produce results similar to Ampligen on DD1 and EV1. Work is in progress to examine dose response and time-course relationships of the effects Ampligen or decitabine added singly or in combination with chemotherapeutic drug (e.g. doxorubicin) on DD1 and triple negative breast cancer cell lines such as MDA-MB 453 to explore potential therapeutically most effective protocols.

PROVISIONAL CONCLUSIONS: Intra-cellular dsRNA receptor RIG-I constitutively expressed in all cells offers a more ubiquitous target compared to TLR3 for the treatment of breast cancer. Ampligen and decitabine with their selective growth inhibitory effect on drug resistant p53-deficient breast cancer cell lines, merit testing as novel drugs for treatment of p53-deficient drug resistant breast cancer e.g. triple negative breast cancer frequently (∼70%) associated with drug resistance and altered p53 status.

Citation Format: Jasani B, Navabi N, Barrett-Lee P, Thompson A, Chester J, Mason M. Intra-cellular dsRNA receptor RIG-I: A ubiquitous novel target for treatment of chemotherapy drug resistant 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 P3-14-07.

Maximum upper esophageal sphincter (UES) admittance: a non-specific marker of UES dysfunction

BACKGROUND

Assessment of upper esophageal sphincter (UES) motility is challenging, as functionally, UES relaxation and opening are distinct. We studied novel parameters, UES admittance (inverse of nadir impedance), and 0.2-s integrated relaxation pressure (IRP), in patients with cricopharyngeal bar (CPB) and motor neuron disease (MND), as predictors of UES dysfunction.

METHODS

Sixty-six healthy subjects (n = 50 controls 20-80 years; n = 16 elderly >80 years), 11 patients with CPB (51-83 years) and 16 with MND (58-91 years) were studied using pharyngeal high-resolution impedance manometry. Subjects received 5 × 5 mL liquid (L) and viscous (V) boluses. Admittance and IRP were compared by age and between groups. A p < 0.05 was considered significant.

KEY RESULTS

In healthy subjects, admittance was reduced (L: p = 0.005 and V: p = 0.04) and the IRP higher with liquids (p = 0.02) in older age. Admittance was reduced in MND compared to both healthy groups (Young: p < 0.0001 for both, Elderly L: p < 0.0001 and V: p = 0.009) and CPB with liquid (p = 0.001). Only liquid showed a higher IRP in MND patients compared to controls (p = 0.03), but was similar to healthy elderly and CPB patients. Only admittance differentiated younger controls from CPB (L: p = 0.0002 and V: p < 0.0001), with no differences in either parameter between CPB and elderly subjects.

CONCLUSIONS & INFERENCES

The effects of aging and pathology were better discriminated by UES maximum admittance, demonstrating greater statistical confidence across bolus consistencies as compared to 0.2-s IRP. Maximum admittance may be a clinically useful determinate of UES dysfunction.

Comparative study of linear and curvilinear ultrasound probes to assess quadriceps rectus femoris muscle mass in healthy subjects and in patients with chronic respiratory disease

Introduction

Ultrasound measurements of rectus femoris cross-sectional area (RF_CSA) are clinically useful measurements in chronic obstructive pulmonary disease (COPD) and critically ill patients. Technical considerations as to the type of probe used, which affects image resolution, have limited widespread clinical application. We hypothesised that measurement of RF_CSA would be similar with linear and curvilinear probes.

Methods

Four studies were performed to compare the use of the curvilinear probe in measuring RF_CSA. Study 1 investigated agreement of RF_CSA measurements using linear and curvilinear probes in healthy subjects, and in patients with chronic respiratory disease. Study 2 investigated the intra-rater and inter-rater agreement using the curvilinear probe. Study 3 investigated the agreement of RF_CSA measured from whole and spliced images using the linear probe. Study 4 investigated the applicability of ultrasound in measuring RF_CSA during the acute and recovery phases of an exacerbation of COPD.

Results

Study 1 showed demonstrated no difference in the measurement of RF_CSA using the curvilinear and linear probes (308±104 mm² vs 320±117 mm², p=0.80; intraclass correlation coefficient (ICC)>0.97). Study 2 demonstrated high intra-rater and inter-rater reliability of RF_CSA measurement with ICC>0.95 for both. Study 3 showed that the spliced image from the linear probe was similar to the whole image RF_CSA (308±103.5 vs 263±147 mm², p=0.34; ICC>0.98). Study 4 confirmed the clinical acceptability of using the curvilinear probe during an exacerbation of COPD. There were relationships observed between admission RF_CSA and body mass index (r=+0.65, p=0.018), and between RF_CSA at admission and physical activity levels at 4 weeks post-hospital discharge (r=+0.75, p=0.006).

Conclusions

These studies have demonstrated that clinicians can employ whole and spliced images from the linear probe or use images from the curvilinear probe, to measure RF_CSA. This will extend the clinical applicability of ultrasound in the measurement of muscle mass in all patient groups.

A simple intervention to improve antibiotic treatment times for neutropenic sepsis

OBJECTIVES

Patients with suspected Neutropenic sepsis require rapid antibiotic administration, but despite extensive education, only 67% of patients received antibiotics within 60 minutes .

METHODS

A Neutropenic Sepsis Alert Card was created, as a Patient Specific Directive - this allows nurses to administer antibiotics to specific patients without prior medical review.

RESULTS

Since the intervention, 301 patients presented with suspected neutropenic sepsis. 277 patients (92%) received their first dose of intravenous antibiotics within 1 hour of arrival into hospital, compared to 95 out of 143 patients (67%) presenting between January and June of 2014 (p=0.036).

CONCLUSION

The Neutropenic Sepsis Alert Card can significantly improve door to antibiotic needle time for chemotherapy patients with suspected neutropenic sepsis. This intervention is inexpensive and easily replicable in other health care organisations.

The Cervical Spinal Canal Tapers Differently in Patients with Chiari I with and without Syringomyelia

BACKGROUND AND PURPOSE

The cause of syringomyelia in patients with Chiari I remains uncertain. Cervical spine anatomy modifies CSF velocities, flow patterns, and pressure gradients, which may affect the spinal cord. We tested the hypothesis that cervical spinal anatomy differs between Chiari I patients with and without syringomyelia.

MATERIALS AND METHODS

We identified consecutive patients with Chiari I at 3 institutions and divided them into groups with and without syringomyelia. Five readers measured anteroposterior cervical spinal diameters, tonsillar herniation, and syrinx dimensions on cervical MR images. Taper ratios for C1-C7, C1-C4, and C4-C7 spinal segments were calculated by linear least squares fitting to the appropriate spinal canal diameters. Mean taper ratios and tonsillar herniation for groups were compared and tested for statistical significance with a Kruskal-Wallis test. Inter- and intrareader agreement and correlations in the data were measured.

RESULTS

One hundred fifty patients were included, of which 49 had syringomyelia. C1-C7 taper ratios were smaller and C4-C7 taper ratios greater for patients with syringomyelia than for those without it. C1-C4 taper ratios did not differ significantly between groups. Patients with syringomyelia had, on average, greater tonsillar herniation than those without a syrinx. However, C4-C7 taper ratios were steeper, for all degrees of tonsil herniation, in patients with syringomyelia. Differences among readers did not exceed differences among patient groups.

CONCLUSIONS

The tapering of the lower cervical spine may contribute to the development of syringomyelia in patients with Chiari I.

Elevated BLyS levels in patients with systemic lupus erythematosus: Associated factors and responses to belimumab

Introduction

Patients with systemic lupus erythematosus (SLE) with B-lymphocyte stimulator (BLyS) levels ≥ 2 ng/mL are at increased risk of flare. A regression analysis was undertaken to identify routine clinical measures that correlate with BLyS ≥ 2 ng/mL. Efficacy and safety of belimumab 10 mg/kg were examined in patients with BLyS ≥ 2 ng/mL and < 2 ng/mL.

Methods

Data from BLISS-52 and -76 (N = 1684) were pooled post hoc. A univariate logistic regression was employed to identify factors predictive of baseline BLyS ≥ 2 ng/mL. Factors significant at the 0.05 level then entered a stepwise logistic regression as covariates. Efficacy endpoints included SLE responder index (SRI), ≥ 4-point reduction in Safety of Estrogens in Lupus National Assessment–Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) and risk of severe flare over 52 weeks. Adverse events (AEs) were analyzed for each treatment arm and BLyS subgroup.

Results

Baseline predictors of BLyS ≥ 2 ng/mL included positive anti-Smith (≥ 15 U/mL), low complement (C) 3 (< 900 mg/L), anti-double-stranded DNA (anti-dsDNA) 80–200 and ≥ 200 IU/mL, immunosuppressant usage, proteinuria, elevated C-reactive protein (CRP), and low total lymphocyte count for all patients. Belimumab 10 mg/kg led to significantly greater SRI responses over 52 weeks versus placebo in both BLyS subgroups, though treatment differences were numerically greater at Week 52 in the BLyS ≥ 2 ng/mL group (24.1%, p < 0.0001) compared with BLyS < 2 ng/mL (8.2%, p = 0.0158). Results were similar for ≥ 4-point reduction in SELENA-SLEDAI. Risk of severe flare over 52 weeks was significantly reduced with belimumab 10 mg/kg versus placebo in the BLyS ≥ 2 ng/mL group (p = 0.0002). AEs were similar across treatment arms and BLyS subgroups.

Conclusions

Positive anti-Smith, low C3, anti-dsDNA ≥ 80 IU/mL, immunosuppressant usage, proteinuria, elevated CRP, and low total lymphocyte count were predictors of BLyS ≥ 2 ng/mL. Monitoring these factors could identify patients with BLyS ≥ 2 ng/mL who are at risk of flare.

Investigating the widely held belief that men and women with learning disabilities receive poor quality healthcare when admitted to hospital: a single-site study of 30-day readmission rates

BACKGROUND

This study aims to use 30-day readmission rates to investigate the presumption that men and women with learning disabilities (LDs, known internationally as intellectual disabilities) receive poorer quality hospital care than their non-disabled peers.

METHOD

A 12-month retrospective audit was conducted using Hospital Episode Statistics (HES) at a single acute hospital in the East of England. This identified all in-patient admissions; admissions where the person concerned was recognised as having a LD; and all emergency readmissions within 30 days of discharge. Additionally, the healthcare records of all patients identified as having a LD and readmitted within 30 days as a medical emergency were examined in order to determine whether or not these readmissions were potentially preventable.

RESULTS

Over the study period, a total of 66 870 adults were admitted as in-patients, among whom 7408 were readmitted as medical emergencies within 30 days of discharge: a readmission rate of 11%. Of these 66 870 patients, 256 were identified as having a LD, with 32 of them experiencing at least one emergency readmission within 30 days: a readmission rate of 13%. When examined, the healthcare records pertaining to these 32 patients who had a total of 39 unique 30-day readmissions revealed that 69% (n = 26) of these readmissions were potentially preventable.

CONCLUSION

Although overall readmission rates were similar for patients with LDs and those from the general population, patients with LDs had a much higher rate of potentially preventable readmissions when compared to a general population estimate from van Walraven et al. This suggests that there is still work to be done to ensure that this patient population receives hospital care that is both safe and of high quality.

Self-Organizing Knotted Magnetic Structures in Plasma

We perform full-magnetohydrodynamics simulations on various initially helical configurations and show that they reconfigure into a state where the magnetic field lines span nested toroidal surfaces. This relaxed configuration is not a Taylor state, as is often assumed for relaxing plasma, but a state where the Lorentz force is balanced by the hydrostatic pressure, which is lowest on the central ring of the nested tori. Furthermore, the structure is characterized by a spatially slowly varying rotational transform, which leads to the formation of a few magnetic islands at rational surfaces. We then obtain analytic expressions that approximate the global structure of the quasistable linked and knotted plasma configurations that emerge, using maps from S^{3} to S^{2} of which the Hopf fibration is a special case. The knotted plasma configurations have a highly localized magnetic energy density and retain their structure on time scales much longer than the Alfvénic time scale.

Clinical and psychosocial outcomes of borderline personality disorder in childhood and adolescence: a systematic review

BACKGROUND

While there is a growing body of research on borderline personality disorder (BPD) in children and adolescents, controversy remains regarding the validity and diagnosis of the disorder prior to adulthood.

METHOD

MEDLINE, EMBASE, Psych INFO and PubMed databases were systematically searched for articles pertaining to the clinical and psychosocial outcomes (i.e. predictive validity) of BPD first diagnosed in childhood or adolescence (i.e. prior to 19 years of age). All primary empirical studies were included in the review. A narrative synthesis of the data was completed.

RESULTS

A total of 8200 abstracts were screened. Out of 214 full-text articles, 18 satisfied the predetermined inclusion criteria. Quality assessment indicated that most studies had high risk of bias in at least one study domain. Consistent with the adult literature, the diagnostic stability of BPD prior to the age of 19 years was low to moderate, and mean-level and rank-order stability, moderate to high. Individuals with BPD symptoms in childhood or adolescence had significant social, educational, work and financial impairment in later life.

CONCLUSIONS

Studies indicate that borderline pathology prior to the age of 19 years is predictive of long-term deficits in functioning, and that a considerable proportion of individuals continue to manifest borderline symptoms up to 20 years later. These findings provide some support for the clinical utility of the BPD phenotype in younger populations, and suggest that an early intervention approach may be warranted. Further prospective studies are needed to delineate risk (and protective) factors pertinent to the chronicity of BPD across the lifespan.

Pulmonary arterial hypertension associated with the use of interferon therapy for chronic hepatitis C infection complicated by extrinsic left main coronary artery compression

Interferon-alpha treatment is a rare cause of pulmonary arterial hypertension (PAH). We report a case of a 43-year-old man treated for chronic hepatitis C infection complicated by decompensated right heart failure diagnosed with PAH and external coronary artery compression secondary to a dilated pulmonary trunk. The novel complication of extrinsic coronary artery compression should be considered in PAH patients presenting with chest pain or acute coronary syndrome. Establishing a diagnosis has clinical value as pulmonary vasodilator therapy may improve symptoms.

Childhood sleep disturbance and risk of psychotic experiences at 18: UK birth cohort

BACKGROUND

Sleep disturbances are commonly reported in the psychosis prodrome, but rarely explored in relation to psychotic experiences.

AIMS

To investigate the relationship between specific parasomnias (nightmares, night terrors and sleepwalking) in childhood and later adolescent psychotic experiences.

METHOD

The sample comprised 4720 individuals from a UK birth cohort. Mothers reported on children's experience of regular nightmares at several time points between 2 and 9 years. Experience of nightmares, night terrors and sleepwalking was assessed using a semi-structured interview at age 12. Psychotic experiences were assessed at ages 12 and 18 using a semi-structured clinical interview.

RESULTS

There was a significant association between the presence of nightmares at 12 and psychotic experiences at 18 when adjusted for possible confounders and psychotic experiences at 12 (OR = 1.62, 95% CI 1.19-2.20). The odds ratios were larger for those who reported persistent psychotic experiences.

CONCLUSIONS

The presence of nightmares might be an early risk indicator for psychosis.

Selective organ preservation with neo-adjuvant chemotherapy for the treatment of muscle invasive transitional cell carcinoma of the bladder

BACKGROUND

Radiotherapy for muscle invasive bladder cancer (MIBC) aims to offer organ preservation without oncological compromise. Neo-adjuvant chemotherapy provides survival advantage; response may guide patient selection for bladder preservation and identify those most likely to have favourable result with radiotherapy.

METHODS

Ninety-four successive patients with T2-T4aN0M0 bladder cancer treated between January 2000 and June 2011 were analysed at the Royal Marsden Hospital. Patients received platinum-based chemotherapy following transurethral resection of bladder tumour; repeat cystoscopy (± biopsy) was performed to guide subsequent management. Responders were treated with radiotherapy. Poor responders were recommended radical cystectomy. Progression-free survival (PFS), disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meier method; univariate and multivariate analyses were performed using the Cox proportional hazard regression model.

RESULTS

Response assessment was performed in 89 patients. Seventy-eight (88%) demonstrated response; 53 (60%) achieved complete response (CR); 74 responders had radiotherapy; 4 opted for cystectomy. Eleven (12%) demonstrated poor response, 10 received cystectomy. Median survival for CR was 90 months (95% CI 64.7, 115.9) compared with 16 months (95% CI 5.4, 27.4; P < 0.001) poor responders. On multivariate analysis, only response was associated with significantly improved PFS, OS and DSS. After a median follow-up of 39 months (range 4-127 months), 14 patients (16%) required salvage cystectomy (8 for non-muscle invasive disease, 5 for invasive recurrence, 1 for radiotherapy related toxicity). In all, 82% had an intact bladder at last follow-up after radiotherapy; 67% had an intact bladder at last follow-up or death. Our study is limited by its retrospective nature.

CONCLUSIONS

Response to neo-adjuvant chemotherapy is a favourable prognostic indicator and can be used to select patients for radiotherapy allowing bladder preservation in >80% of the selected patients.

The changes in prostate cancer and its management in the North West of England over a 10-year period

Objectives:

Our aim was to evaluate changes in prostate cancer diagnosis and management and to examine changes in the stage and grade of newly diagnosed prostate cancer in the North West of England over a 10-year period.

Materials and methods:

Data was collected concerning the diagnosis (including stage and grade) and management of newly diagnosed prostate cancer in the North West of England. There were three time points: 2003, 2007 and 2011 including a total of 648 patients. For assessment of median time changes Spearman’s Rank correlation test was used, for the assessment of changes in Gleason grade and clinical stage Mann–Whitney U test was used, and assessment of positive margin rates was done with Fisher’s test.

Results:

Median time from management decision to surgery has reduced from 46 (2003), 34 (2007) to 27 days (2011) ( p=0.074). The proportion of patients managed with active surveillance has remained relatively constant over time (18%, 16% and 21% respectively). More minimally invasive, nerve-sparing prostatectomies are now performed, and positive margin rates have significantly reduced from 53% (2003) to 23% (2011) ( p<0.001). Gleason grade significantly increased over time ( p<0.001); Gleason 7 disease was diagnosed in 23% of patients in 2003, 32% in 2007 and 49% in 2011 ( p<0.001). There was an increase in Gleason 8 disease; 6% (2003) to 8.6% (2011), but this was not significant ( p=0.27). Increase in clinical stage was also noted over time; identification of T3 disease rose from 2% (2003 and 2007) to 5% (2011) ( p=0.045) (excluding cases with non-recorded stage).

Conclusion:

Prostate cancer management in the North West of England has evolved over the last decade, with overall improvements in management quality. We have demonstrated an increase in the presenting stage and grade of prostate cancer over a 10-year period.

Community-acquired pneumonia: why aren't national antibiotic guidelines followed?

AIMS

Adherence to guidelines for the management of community-acquired pneumonia (CAP) has been shown to improve patients' clinical outcomes. This study aimed to assess adherence to the Australian Therapeutic Guidelines (TG14) for the empirical management of CAP, and explore the potential barriers affecting adherence to these guidelines.

METHODS

Medical records were reviewed for all patients who were diagnosed with CAP within 24 h of presentation at the Royal Hobart Hospital, the main teaching hospital in Tasmania, Australia, between July 2010 and March 2011. A survey of emergency department and medical team prescribers was also undertaken to identify potential barriers to adhere with the guidelines. χ(2) and Fisher's exact tests were used to test the significance between categorical data. To compare categorical and scale data, the Mann-Whitney U-test was used.

RESULTS

A total of 193 patient records were assessed. The overall adherence to TG14 for the empirical antibiotic management of CAP was 16.1% (3.1%, 20.7% and 25.4% for patients with mild, moderate and severe CAP, respectively). Ceftriaxone was prescribed to 34.4%, 26.8% and 57.4% of patients with mild, moderate and severe CAP, respectively. The response rate to the barrier survey was 43.1%; of those who responded, 46.4% thought the influence of senior doctors on junior doctors could be a factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the existence of other guidelines that conflict with TG14 (28.6%).

CONCLUSIONS

Adherence to CAP treatment guidelines was poor, especially in patients with mild disease. Prescribing was mainly influenced by senior doctors. Efforts to improve compliance with CAP treatment guidelines should consider the potential barriers that hinder adherence.

Diagnoses, procedures, drug utilization, comorbidities, and cost of health care for people with epilepsy in 2012

Our objective was to identify the top MD-office, inpatient and outpatient diagnoses, procedures, drug classes, comorbidities, and cost of health care for people with epilepsy. We examined health insurance claims for 8388 persons with epilepsy (females = 52%, males = 48%; average age = 35 years; privately insured = 78%, and Medicaid-insured = 22%) from eight health insurance plans for the year 2012. All of the top three diagnoses for MD-office place of service were either for other convulsions (780.39) or for epilepsy (345.90 and 345.40). Two of the top three primary diagnosis codes from the inpatient hospital and emergency department places of service were 780.39 and 345.90 for convulsions and epilepsy, respectively, while the third code was 786.50 for chest pain. The top three procedures from the MD-office setting were for immunizations (90471 and 90658) and blood counts (85025). The top three procedure codes from the outpatient hospital setting were 85025 for complete blood count, 80053 for comprehensive metabolic panel, and 80048 for basic metabolic panel. In the emergency department, the top three procedures were electrocardiogram (93010), computed tomography (70450), and chest X-ray (71020). The top five drug classes among prescription drugs billed using an NDC code were (1) anticonvulsants, (2) analgesic-opioids, (3) antidepressants, (4) penicillins, and (5) dermatologicals. The mean monthly health plan paid cost for each patient with epilepsy in 2012 was $1028 (SD = $3181). Of this total, $761 (SD = $2988; 74%) was for medical, and $267 (SD = $760; 26%) was for prescription pharmacy claims. Fifty-eight percent (58%) of the patients had one or more of 29 prespecified comorbidities, while 42% had none. Monthly health-care costs increased markedly as the number of comorbidities increased. This information should help guide cost estimates and resource allocation in order to optimally care for people with epilepsy.

The Impact of the Australian and New Zealand College of Anaesthetists’ Specialist Examinations on Trainee Learning and Wellbeing: A Qualitative Study

Assessment is an essential component of any medical specialist training program and should motivate trainees to acquire and retain the knowledge and skills essential for specialist practice, and to develop effective approaches to learning, essential for continuous professional development. Ideally, this should be achieved without creating an unreasonable burden of assessment. In this qualitative study we sought to investigate the underlying processes involved in trainees’ preparation for Australian and New Zealand College of Anaesthetists’ examinations, focusing on how the examinations helped trainees to learn the Australian and New Zealand College of Anaesthetists’ curriculum, and to identify any potential areas for improvement. We also explored the effect the examinations had on trainees’ lives, to identify if the examinations were a potential threat to their wellbeing. Using a phenomenological approach and purposive sampling, we conducted semi-structured interviews with post-fellowship trainees (n=20) selected from three different regions, with sampling continuing to achieve data saturation. We undertook a thematic analysis of the transcribed interview data utilising a general inductive approach. Our preliminary data suggest that, while the examinations are an important extrinsic motivator to learn and important for professional development, interviewees described many test-driven learning strategies, including rote learning and memorising past examination questions. A strong theme was the considerable impact on participants’ relationships and social activities for prolonged periods. Our findings support further research in this area and, in particular, into alternative testing strategies that might increase the proportion of time spent in useful study while decreasing less useful study time.

The effects of evening bright light exposure on subsequent morning exercise performance

We investigated the effects of evening bright light on the circadian timing of core temperature and morning exercise performance under conditions of high thermal stress. At 20:00 h, 8 males were exposed to a standardised light protocol and thereafter to either polychromatic bright light (2,500 lux at 50 cm, BL) or no light (0 lux, NL) for 30 min. The following morning, intermittent cycling exercise was undertaken followed by a 10 km time-trial in an environmental chamber set to 35°C and 60% relative humidity. Core body temperature was measured throughout. Data were analysed using a within-subjects model and presented as mean±SD. Time of the sleep-trough in core temperature occurred ~1.75 h later following BL (P=0.07). Prior to time-trial, core temperature was 0.27±0.42°C lower in BL (95%CI: -0.02 to 0.57, P=0.07). The time-trial was completed 1.43±0.63 min (0.98-1.87) faster in BL (P=0.001). Post time-trial, intestinal temperature was 38.21±0.56°C (37.84-38.57) in BL compared to 38.64±0.42°C (38.34-38.93) in NL (P=0.10). These data provide the first evidence that a 30-min exposure to bright light prior to sleep can influence exercise performance under hot conditions during the subsequent early morning.

Influence of nocturnal and daytime sleep on initial orthostatic hypotension

PURPOSE

The incidence of vasovagal syncope is more common in the morning. Previous researchers have reported negligible diurnal variation in the physiological responses associated with initial orthostatic hypotension (IOH). Nevertheless, physical activity and sleep prior to morning and afternoon test times have not been controlled and may influence the findings. We designed a semi-constant routine protocol to examine diurnal variation in cardiorespiratory and cerebrovascular responses to active standing.

METHODS

At 06:00 and 16:00 hours, nine males (27 ± 9 years) completed an upright-stand protocol. Altimetry-measured sleep durations were 3.3 ± 0.4 and 3.2 ± 0.6 h immediately prior to the morning and afternoon test times. Continuous beat-to-beat measurements of middle cerebral artery velocity (MCAv), mean arterial blood pressure (MAP), heart rate (HR), and end-tidal carbon dioxide were obtained. Intestinal body temperature and salivary melatonin concentrations were also measured.

RESULTS

Compared with the afternoon, resting HR and body temperature were 4 ± 2 beats min(-1) and 0.45 ± 0.2 °C lower, respectively, whereas melatonin concentration was 28.7 ± 3.2 pg ml(-1) higher in the morning (P ≤ 0.02). Although all individuals experienced IOH at both times of the day, the initial decline in MAP during standing was 13 ± 4 mmHg greater in the afternoon (P = 0.01). Nevertheless, the decline in MCAv was comparable at both times of day (mean difference: 2 ± 3 cm s(-1); P = 0.5).

CONCLUSION

These findings indicate that a bout of sleep in the afternoon in healthy young individuals results in greater IOH that is compensated for by effective cerebral blood flow regulation.

A genome-wide screen identifies Salmonella Enteritidis lipopolysaccharide biosynthesis and the HtrA heat shock protein as crucial factors involved in egg white persistence at chicken body temperature

Eggs contaminated with Salmonella Enteritidis are an important source of human foodborne Salmonella infections. Salmonella Enteritidis is able to contaminate egg white during formation of the egg within the chicken oviduct, and it has developed strategies to withstand the antimicrobial properties of egg white to survive in this hostile environment. The mechanisms involved in the persistence of Salmonella Enteritidis in egg white are likely to be complex. To address this issue, a microarray-based transposon library screen was performed to identify genes necessary for survival of Salmonella Enteritidis in egg white at chicken body temperature. The majority of identified genes belonged to the lipopolysaccharide biosynthesis pathway. Additionally, we provide evidence that the serine protease/heat shock protein (HtrA) appears essential for the survival of Salmonella Enteritidis in egg white at chicken body temperature.