Clinical Application of APOE in Alzheimer's Prevention: A Precision Medicine Approach

Population-attributable risk models estimate that up to one-third of Alzheimer's disease (AD) cases may be preventable through risk factor modification. The field of AD prevention has largely focused on addressing these factors through universal risk reduction strategies for the general population. However, targeting these strategies in a clinical precision medicine fashion, including the use of genetic risk factors, allows for potentially greater impact on AD risk reduction. Apolipoprotein E (APOE), and specifically the APOE ε4 variant, is one of the most well-established genetic influencers on late-onset AD risk. In this review, we evaluate the impact of APOE ε4 carrier status on AD prevention interventions, including lifestyle, nutrigenomic, pharmacogenomic, AD comorbidities, and other biological and behavioral considerations. Using a clinical precision medicine strategy that incorporates APOE ε4 carrier status may provide a highly targeted and distinct approach to AD prevention with greater potential for success.

Analysis on current flow style for vehicle alternator fault prediction

Vehicle alternator is only seen as fragment piece in vehicle. This project will analyse the vehicle alternator current output flow style. A study on charging rate onto battery can be made based on this analyst. From this a prediction can be made on the vehicle alternator health and may prevent it from affecting other charging system component. Features extracted from the raw sample data are root mean square (RMS), waveform length (WL) and autoregressive (AR). These features will then go through normality test to find the sample is normally distributed or not. The normality test used in this experiment is Jarque-Bera (JB) test. After go through the normality test, it shows that need to continue with non-parametric test. Because JB test shows that p-value is less than 0.05 confidence level. Kruskal-Wallis is used as non-parametric data validation. In this test, the hypothesized value is the value is the median instead of the mean as in Analysis if Variance (ANOVA). The Kruskal-Wallis test evaluates for any significance difference in the population medians on a dependent variable across all levels of a factor. For classification K-Nearest Neighbour (KNN) is used to find the number of K to differentiate between classes. After that the K value is use in Holdout method for training and testing. Final result shows that the accuracy of this machine learning tools is 94%. This number is a good percentage to be able to called as vehicle alternator fault prediction.

Trends in Diabetic Retinopathy, Visual Acuity, and Treatment Outcomes for Patients Living With Diabetes in a Fundus Photograph-Based Diabetic Retinopathy Screening Program in Bangladesh

IMPORTANCE

Diabetic retinopathy (DR) is the leading cause of low vision among working-age adults. An estimated 6.9 million people in Bangladesh were living with diabetes in 2017, which is projected to increase to more than 10 million people in 2025. Currently, no standardized and/or large-scale DR screening program exists in Bangladesh.

OBJECTIVE

To develop a novel fundus photograph-based eye screening model for early detection of DR to prevent vision loss in Bangladeshi individuals with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, 49 264 patients with diabetes underwent opportunistic eye screening at 2 eye hospitals and 1 diabetic hospital in Bangladesh between June 1, 2010, and September 30, 2017. The data set was analyzed from April 8 to December 30, 2018. Technicians were trained to obtain 2-field digital fundus photographs and to grade each according to a standardized DR severity scale. Each patient was counseled and triaged for treatment using defined DR referral criteria.

MAIN OUTCOMES AND MEASURES

Primary DR grading outcomes, visual acuity, and treatment outcomes.

RESULTS

A total of 49 264 patients (54.3% male; mean [SD] age, 50.8 [12.3] years) underwent DR screening during a 7-year period. The DR prevalence rate across all 3 sites was 33% (95% CI, 33%-33%). Prevalence rates varied by center (Chittagong, 64.6% [95% CI, 64.0%-65.0%]; Dhaka, 39.8% [95% CI, 39.0%-41.0%]; and Feni, 13.0% [95% CI, 13.0%-14.0%]). Across all age groups, male patients were at higher risk of prevalent DR than female patients (odds ratio, 1.99; 95% CI, 1.90-2.07). The prevalence was 3.9% for preproliferative DR, 7.8% for proliferative DR, and 19.2% for maculopathy. Individuals with DR had significantly worse visual acuity than those with no DR (best-corrected visual acuity, 0.35 vs 0.21 logMAR; P < .001). The rate of moderate visual impairment was 12.2%, and the rate of blindness was 2.5%. Primary treatments included laser photocoagulation (n = 1637), intravitreal injection (n = 1440), and vitrectomy (n = 309).

CONCLUSIONS AND RELEVANCE

Screening Bangladeshi individuals known to have diabetes using fundus photography identified large numbers of patients with sight-threatening proliferative DR, maculopathy, and visual impairment or blindness. Expansion of eye screening services in Bangladesh is warranted as part of a national government eye care and diabetes health policy.

Discordance in Xpert® MTB/RIF assay results among low bacterial load clinical specimens in Bangladesh

BACKGROUND

The Xpert® MTB/RIF assay detects Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance. RIF-resistant (RIF-R) MTB cases detected using Xpert on sputum specimens at three private-sector TB screening centres in Dhaka, Bangladesh, were subjected to consecutive confirmatory Xpert testing, the results of which were MTB-positive/RIF-susceptible, MTB-positive/RIF-indeterminate or MTB-negative.

OBJECTIVE

To assess the possible causes of discordant MTB and RIF-R results.

METHODS

Discordant confirmatory Xpert test results were subjected to further investigations using the GenoType® MTBDRplus assay, culture and rpoB gene sequencing.

RESULTS

The confirmatory Xpert test was performed on a remnant or a second specimen collected from individuals with an initial RIF-R result (n = 69); 22 (32%) results were discordant, 20 of which had an 'MTB detected-very low' result. Further investigations were mostly concordant with the confirmatory Xpert test. Average variability in paired cycle threshold (Ct) values were higher in 'MTB detected-very low' results vs. specimens with low, medium or high detected MTB results (P < 0.05); discordant results were mostly observed in specimens with 'MTB detected-very low' (20/22).

CONCLUSIONS

Repeating the Xpert test and comparing with other available tests should be considered in case of 'MTB detected-very low, RIF resistance detected' results on Xpert.

Genome Sequencing and Transcriptome Analysis of the Hop Downy Mildew Pathogen Pseudoperonospora humuli Reveal Species-Specific Genes for Molecular Detection

Pseudoperonospora humuli is an obligate oomycete pathogen of hop (Humulus lupulus) that causes downy mildew, an important disease in most production regions in the Northern Hemisphere. The pathogen can cause a systemic infection in hop, overwinter in the root system, and infect propagation material. Substantial yield loss may occur owing to P. humuli infection of strobiles (seed cones), shoots, and cone-bearing branches. Fungicide application and cultural practices are the primary methods to manage hop downy mildew. However, effective, sustainable, and cost-effective management of downy mildew can be improved by developing early detection systems to inform on disease risk and timely fungicide application. However, no species-specific diagnostic assays or genomic resources are available for P. humuli. The genome of the P. humuli OR502AA isolate was partially sequenced using Illumina technology and assembled with ABySS. The assembly had a minimum scaffold length of 500 bp and an N50 (median scaffold length of the assembled genome) of 19.2 kbp. A total number of 18,656 genes were identified using MAKER standard gene predictions. Additionally, transcriptome assemblies were generated using RNA-seq and Trinity for seven additional P. humuli isolates. Bioinformatics analyses of next generation sequencing reads of P. humuli and P. cubensis (a closely related sister species) identified 242 candidate species-specific P. humuli genes that could be used as diagnostic molecular markers. These candidate genes were validated using polymerase chain reaction against a diverse collection of isolates from P. humuli, P. cubensis, and other oomycetes. Overall, four diagnostic markers were found to be uniquely present in P. humuli. These candidate markers identified through comparative genomics can be used for pathogen diagnostics in propagation material, such as rhizomes and vegetative cuttings, or adapted for biosurveillance of airborne sporangia, an important source of inoculum in hop downy mildew epidemics.

Proinflammatory CX3CR1+CD59+Tumor Necrosis Factor-Like Molecule 1A+Interleukin-23+ Monocytes Are Expanded in Patients With Ankylosing Spondylitis and Modulate Innate Lymphoid Cell 3 Immune Functions

OBJECTIVE

Gut-derived innate lymphoid cell 3 (ILC3) has been shown to participate in the pathogenesis of ankylosing spondylitis (AS). CX₃ CR1+ mononuclear phagocytes (MNPs) have been demonstrated to modulate ILC3 function in the gut. This study was undertaken to investigate the role of proinflammatory CX₃ CR1+CD59+ MNPs in modulating ILC3 function in AS patients.

METHODS

MNP subsets in the blood of AS patients and controls were analyzed by flow cytometry. The presence of CX₃ CR1+CD59+ cells in tissue was confirmed by confocal microscopy. Expression of the proinflammatory chemokines CX₃ CL1 and CCL2 and decoy receptor 6 (DcR-6) was analyzed. Peripheral CX₃ CR1+CD59+ cells were cocultured with ILC3, and changes in their frequency were evaluated by flow cytometry. Transcriptome analysis of circulating CX₃ CR1+ monocytes was also performed.

RESULTS

DcR-6 deficiency and CCL2 overexpression were observed in inflamed tissues from AS patients. In the gut, the proinflammatory CX₃ CR1+CD59+ MNP population was expanded, correlated with the presence of bacteria, and produced high levels of tumor necrosis factor-like molecule 1A (TL1A) and interleukin-23 (IL-23). MNPs positive for CD11b, CD11c, and major histocompatibility complex class II, predominantly expressing CX₃ CR1, were also expanded in the small intestines of treatment-naive SKG relative to BALB/c mice. The frequency of gut-derived CX₃ CR1+CD59+CCR9+TL1A+IL-23+ MNPs was significantly higher in the peripheral blood and synovial fluid of AS patients than controls. CCR9+CX₃ CR1+CD59+ monocytes were also expanded in AS synovial and bone marrow samples. Transcriptome analysis of isolated CX₃ CR1+CD59+ monocytes demonstrated a specific proinflammatory profile in AS. Isolated proinflammatory CX₃ CR1+CD59+ MNPs from AS patients induced the expansion and activation of ILC3.

CONCLUSION

Proinflammatory CX₃ CR1+CD59+TL1A+IL-23+ MNPs are expanded in AS patients and display a specific proinflammatory transcriptome profile. Given the ability of these cells to support ILC3 expansion, they may promote a sustained proinflammatory status in AS.

Risk Factors for Fatal Middle East Respiratory Syndrome Coronavirus Infections in Saudi Arabia: Analysis of the WHO Line List, 2013-2018

Objectives. To explore complex associations among demographic factors, risk factors, health care, and fatality rates of Middle East respiratory syndrome coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia.Methods. We based this study on analysis of a publicly accessible line listing of 1256 MERS-CoV cases (2013 to October 2018) available on the World Health Organization's Web site. For analyses of demographic factors (e.g., age, gender), access to health care, promptness of laboratory services, risk factors (comorbidity, exposure to camels and persons with MERS-CoV), occupation (health care), and outcome (fatality), we used descriptive statistics, risk ratio (RR), and the Pearson χ² test.Results. Presence of comorbidity (RR = 3; 95% confidence interval [CI] = 2.2, 3.9), being male (RR = 1.6; 95% CI = 1.2, 2.1), exposure to dromedary camels (RR = 1.6; 95% CI = 1.3, 2.3), and consumption of camel milk (RR = 1.5; 95% CI = 0.9, 1.7) can significantly increase risk for fatality. Health care workers have significantly lower fatality (P < .001) than the rest of the persons with MERS-CoV.Conclusions. Policies that promote health awareness for the high-risk population and their prompt seeking of health care should be considered. Publicly accessible line lists of infectious diseases such as MERS-CoV can be valuable sources for epidemiological analysis.

Phosphorous in the environment: characteristics with distribution and effects, removal mechanisms, treatment technologies, and factors affecting recovery as minerals in natural and engineered systems

Phosphorus (P), an essential element for living cells, is present in different soluble and adsorbed chemical forms found in soil, sediment, and water. Most species are generally immobile and easily adsorbed onto soil particles. However, P is a major concern owing to its serious environmental effects (e.g., eutrophication, scale formation) when found in excess in natural or engineered environments. Commercial chemicals, fertilizers, sewage effluent, animal manure, and agricultural waste are the major sources of P pollution. But there is limited P resources worldwide. Therefore, the fate, effects, and transport of P in association with its removal, treatment, and recycling in natural and engineered systems are important. P removal and recycling technologies utilize different types of physical, biological, and chemical processes. Moreover, P minerals (struvite, vivianite, etc.) can precipitate and form scales in drinking water and wastewater systems. Hence, P minerals (e.g., struvite, vivianite etc.) are problems when left uncontrolled and unmonitored although their recovery is beneficial (e.g., slow release fertilizers, sustainable P sources, soil enhancers). Sources like wastewater, human waste, waste nutrient solution, etc. can be used for P recycling. This review paper extensively summarizes the importance and distribution of P in different environmental compartments, the effects of P in natural and engineered systems, P removal mechanisms through treatment, and recycling technologies specially focusing on various types of phosphate mineral precipitation. In particular, the factors controlling mineral (e.g., struvite and vivianite) precipitation in natural and engineered systems are also discussed.

Domain I of β2GPI is capable of blocking serum IgA antiphospholipid antibodies binding in vitro: an effect enhanced by PEGylation

Objectives

This study aims to inhibit antiphospholipid syndrome (APS) serum derived IgA anti-beta-2-glycoprotein I (aβ2GPI) binding using Domain I (DI).

Methods

Serum from 13 APS patients was tested for IgA aβ2GPI and Anti-Domain I. Whole IgA was purified by peptide M affinity chromatography from positive serum samples. Serum was tested for IgA aβ2GPI binding in the presence and absence of either DI or of two biochemically modified variants containing either 20 kDa of poly(ethylene glycol) (PEG) or 40 kDa of PEG.

Results

Significant inhibition with DI was possible with average inhibition of 23% (N = 13). Further inhibitions using 20 kDa PEG-DI and 40 kDa PEG-DI variants showed significant inhibition (p = 0.0001) with both the 40 kDa PEG-DI and 20 kDa PEG-DI variants showing increased inhibition compared with DI alone (p = 0.0001 and p = 0.001, n = 10).

Conclusions

Inhibition of IgA aβ2GPI by DI is possible and can be enhanced by biochemical modification in a subset of patients.

Is health a priority among decision-makers of Pakistan? Evidence from Parliamentary questions screening

OBJECTIVES

The objectives of the study were to assess the interest of Pakistani parliamentarians in health issues, including the comparison of interest by gender, to determine the relation of health issues raised in the parliament with national health priorities set by Pakistan's Health Ministry and to assess the nature of health questions.

STUDY DESIGN

Cross-sectional study.

METHODS

We assessed the Pakistani parliamentarians' interest and importance given to the country's health problems by retrospectively counting parliamentary health-related questions raised on the floor of the house from 2012 to 2016. Categorical variables and themes were created and identified respectively based on questions' contents and analyzed in SAS v9.4.

RESULTS

A total of 25,496 questions were asked in the parliament, out of which 408 (1.60%) were related to health issues seeking basic information and policies. An even smaller proportion (1.31%) of the questions were related to national health priorities. Despite a low ratio of female to male members (1:4), females asked five times more questions about health than their male counterparts.

CONCLUSIONS

The members of parliament asked a low percentage of questions about health compared to other affairs in the country. It could, therefore, be assumed that they have low interest in health issues of the country, and this might be one of the reasons for the challenging state of health in the country. However, female members asked the majority of questions about health issues and could, therefore, play a vital role in improving the dismal state of the country's health.

Red Cell Alloantibodies in Thalassaemia Patients Who Received Ten or More Units of Transfusion

Thalassaemia patients are the highest consumers of blood. Recurrent exposure to allogenic red cell antigen puts this population at increased risk of alloimmunization. This causes delayed hemolytic transfusion reactions. So transfusion requirement increases. But no data regarding alloimmunization was available in Bangladesh. Aim of this study was to estimate the prevalence of alloimmunization and to find out the potential factors associated with its development. This analytical cross sectional study was done by enrolling 97 patients, received at least 10 units transfusions, through convenient sampling. Indirect and direct antiglobulin tests were done to detect immunization by spin tube technique keeping an autocontrol and carried out in the Department of Haematology & Department of Transfusion Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2016 to March 2017. Polyclonal anti-AHG reagent was used. A total 21 patients developed alloimmunization (21.6%) and 4 patients (4.1%) developed autoimmunization. Age, gender, splenectomy and number of transfusion are shown significant risk factors for alloimmunization. Data from this study demonstrate that the RBC alloimmunization is significantly high in our country. So, pretransfusion antibody screening needs to be initiated in order to ensure safe transfusion and RBC phenotyping should be started before starting first transfusion to prevent alloimmunization.

Model-informed drug development approach supporting approval of the 4-week (Q4W) dosing schedule for nivolumab (Opdivo) across multiple indications: a regulatory perspective

BACKGROUND

A nivolumab dosage regimen of 480 mg intravenously (i.v.) every 4 weeks (Q4W) was approved by FDA for the majority of the approved indications for nivolumab.

METHODS

The proposed new dosage regimen was supported by pharmacokinetic modeling and simulation, dose/exposure-response relationships for efficacy and safety in the indicated patient populations, and the clinical safety data with the 480 mg Q4W dosage regimen. Pharmacokinetic exposures achieved with 480 mg Q4W were predicted for 4166 patients in 21 clinical studies with various types of solid and hematological tumors. Exposure-response analyses were conducted to predict 480 mg Q4W safety and efficacy across all FDA-approved indications for nivolumab.

RESULTS

For the overall population, the geometric mean exposure achieved with 480 mg i.v. Q4W was 5.2% higher for steady state Cavg and 15.6% lower for Ctrough than those with 3 mg/kg i.v. Q2W, the approved dosage regimen. The simulated concentration-time course achieved with 480 mg Q4W regimen was below the median concentration achieved with 10 mg/kg i.v. Q2W that was also studied in clinical trials. The predicted probability of adverse events was similar between 480 mg Q4W and that observed with the 3 mg/kg Q2W regimen. Efficacy results were found to be similar between Q2W and Q3W dosage regimens in patients with renal cell carcinoma. The predicted efficacy for each indication suggested that the efficacy with 480 mg Q4W is unlikely to be compromised compared with that observed with 3 mg/kg Q2W.

CONCLUSIONS

The model-informed analyses of predicted exposure, efficacy and safety based on data from extensive clinical experience with nivolumab suggest that the benefit-risk profile of 480 mg Q4W regimen is comparable to the approved 3 mg/kg Q2W regimen, thus providing the regulatory basis for the approval of 480 mg Q4W regimen in the absence of clinical efficacy data with this new dosage regimen.

Hepatitis B Antibody Level Falls after Initial Phage of Chemotherapy in Childhood Haematological Malignancy

Hepatitis B virus (HBV) infection is a worldwide one of the major public health problem. Vaccination against HBV is highly effective at a very low cost. During treatment and for a variable period after completion of chemotherapy and radiotherapy children became immunosuppress. The main laboratory marker used to assess hepatitis B immunity is IgG antibody to the surface antigen (HBsAg). Surgical procedures and multiple blood transfusions increase the risk of hepatitis B virus infection in these immune suppressed patients. In Bangladesh, data are unavailable regarding prevalence of HBsAg in children with cancer and their protective immune status against hepatitis B virus while on treatment or after completion of chemotherapy. The results of this study may aid physicians in the development of evidence-based guidelines for revaccination of children with cancer during and after treatment with chemotherapy. This observational study was conducted from November 2013 to February 2015 in the department of Paediatric Haematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Children were recruited from both the inpatient and outpatient units of the department of Paediatric Hematology and Oncology at BSMMU. Blood specimens were collected from the children who were receiving inpatient and outpatient care from the department of Pediatric Hematology and Oncology, 2.0ml of venous blood was drawn and serum was separated and stored at -20°C until testing then HBV antibody titer was assayed at the department of Virology laboratory of BSMMU. A structured questionnaire was used for data collection. Among 28 children, 19(67.9%) were male and 9(32.1%) female, male female ratio 2.1:1. Among the 28 children, ALL was in 24(85.7%), NHL 3(10.7%), and APML 1(3.7%). Among 28 children, anti-HBs titer was more than 10mIU/ml in all patients. But six month after initiation of chemotherapy, 8(28.57%) patients had anti-HBs titer less than 10mIU/ml. Hepatitis B antibody titre level significantly reduced after 6 months chemotherapy in children with hematological malignancies.

Exploring relevance, public perceptions, and business models for establishment of private well water quality monitoring service

Existing public policies mostly focus on public water systems, leaving aside the quality issues regarding private wells in small and rural locations. Establishment of affordable and accessible water quality monitoring services may ensure acceptable levels of all the parameters. This paper aims to explore (a) health risk because of chemical contaminants of private wells, (b) population perspective on well water quality and monitoring, and (c) to create a business model of a centralized water quality monitoring service. The results show potential problems with toxic levels of arsenic, barium, cadmium, chromium, lead, mercury, and selenium. About 5% of the province's population is at risk for potential exposure to contaminated private well water. The survey reinforces that the successful implementation of water testing laboratories for private wells is a shared responsibility between well owners and the government organizations, and almost three-fourths respondents were willing to share the cost up to certain limit. A business model including financial projections for a centralized water testing laboratory is presented. Drinking of unmonitored private well water is putting population health at risk. Either strong regulation with mandatory water testing or voluntary water testing with adequate government subsidy can ensure sustainable function of a centralized water testing laboratory.

Evaluating feasibility and acceptability of a group WHO trans-diagnostic intervention for women with common mental disorders in rural Pakistan: a cluster randomised controlled feasibility trial

AIMS

The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan.

METHODS

This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews.

RESULTS

The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention.

CONCLUSION

This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.