Physical Activity Detection for Diabetes Mellitus Patients Using Recurrent Neural Networks

Diabetes mellitus (DM) is a persistent metabolic disorder associated with the hormone insulin. The two main types of DM are type 1 (T1DM) and type 2 (T2DM). Physical activity plays a crucial role in the therapy of diabetes, benefiting both types of patients. The detection, recognition, and subsequent classification of physical activity based on type and intensity are integral components of DM treatment. The continuous glucose monitoring system (CGMS) signal provides the blood glucose (BG) level, and the combination of CGMS and heart rate (HR) signals are potential targets for detecting relevant physical activity from the BG variation point of view. The main objective of the present research is the developing of an artificial intelligence (AI) algorithm capable of detecting physical activity using these signals. Using multiple recurrent models, the best-achieved performance of the different classifiers is a 0.99 area under the receiver operating characteristic curve. The application of recurrent neural networks (RNNs) is shown to be a powerful and efficient solution for accurate detection and analysis of physical activity in patients with DM. This approach has great potential to improve our understanding of individual activity patterns, thus contributing to a more personalized and effective management of DM.

Rapid-Acting Insulin Used to Treat a Case of Early Cystic Fibrosis-Related Diabetes Complicated by Post Prandial Hypoglycemia

Background/Objective

Cystic fibrosis-related diabetes (CFRD) is one of the most common nonrespiratory complications of cystic fibrosis (CF). There is a lack of clinical research to provide guidance on optimal treatment regimens for various subtypes of CFRD.

Case Report

This case describes an 18-year-old woman, diagnosed with CF in infancy, who presented to our clinic for evaluation of possible CFRD and episodes of hypoglycemia. Subsequent testing revealed normal fasting glucose with elevated blood glucose levels on oral glucose tolerance test, consistent with the diagnosis of CFRD without fasting hyperglycemia. She was found to have large glycemic excursions after carbohydrate-containing meals, followed by delayed postprandial hypoglycemia.

Discussion

We initiated low-dose mealtime rapid-acting analog insulin and saw both a decrease in her postprandial hyperglycemia as well as resolution of her hypoglycemic episodes.

Conclusion

This case highlights the spectrum of pancreatic dysfunction and insulin dysregulation in CFRD as well as the benefit of prandial insulin alone as a treatment option.

Novel UL23 and UL30 substitutions in HSV1 and HSV2 viruses related to polymorphism or drug resistance

Data on herpes simplex virus (HSV) polymorphism as well as acyclovir (ACV) and foscarnet (FOS) resistance mutations are not exhaustive and may hinder accurate diagnosis by next-generation sequencing (NGS). Here, we report novel UL23 and UL30 substitutions for HSV1 and HSV2 identified in immunocompromised patients treated for hematological malignancies during the last 6 years of HSV resistance surveillance at the University Hospital of Lyon. For HSV1, 35 novel UL23 substitutions and 52 novel UL30 substitutions were identified. For HSV2, 2 novel UL23 substitutions and 12 novel UL30 substitutions were identified. These results allow to complete the database of HSV1 and HSV2 substitutions, related either to polymorphism or to ACV and FOS resistance.

Sustainable intensification of agriculture as a tool to promote food security: A bibliometric analysis

Sustainable intensification (SI) of agriculture is required to satisfy the growing populations' nutritional needs, and therefore food security while limiting negative environmental impacts. The study aims to investigate the global scientific output of sustainable intensification research from 2010 to 20 August 2021. The data was retrieved from the Web of Science (WoS) Core Collection and was analyzed using a bibliometric method and VOS viewer to determine the most productive countries and organizations by collaboration analysis, including the keywords to analyze the research hotspots and trends, and the most cited publications in the field. From the 1,610 studies published in the theme of sustainable agriculture by 6,346 authors belonging to 1,981 organizations and 115 countries, the study found an increased number of publications and citations in 2020, with 293 publications and 10,275 citations. The United States ranked highest in countries collaborating with the most publications in the field. The occurrence of keywords like “food security”, “climate change”, “agriculture”, “ecosystem services”, “conservation agriculture”, “Sub-Sahara Africa”, “Africa”, “biodiversity”, and “maize” in both author and all keywords (author and index) reveal the significance of sustainable intensification in Africa, as a solution to food insecurity under climate change conditions. The availability of funding agencies from big economies explains the growing interest by developing countries in the SI of agriculture research due to the growing population, food insecurity, and access to limited land for farming.

Changing Narratives and Provoking Dialogue: An Analysis of the HIV Stigma and Faith Summit

GLAAD in partnership with the Gilead COMPASS Initiative® Coordinating Centers conducted a three-day summit to address the HIV epidemic in the Southern region of the United States. The summit featured virtual panel discussions with HIV experts, faith leaders, community advocates, and entertainers to bring about conversation and change around HIV stigma.

Popular Culture and Shaping HIV Perception

The Gilead COMPASS Initiative® used celebrity partnerships to highlight HIV prevalence in the Southern U.S. and support Southern HIV and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) organizations. Using various media platforms, HIV organizations engaged with popular culture in collaboration with national media advocacy and public relations organizations to campaign against stigmatization and raise awareness about HIV.

Combined immunosuppression for acquired hemophilia A: CyDRi is a highly effective low-toxicity regimen

Acquired hemophilia A (AHA) is a rare severe autoimmune bleeding disorder with significant morbidity and mortality. Although critical for disease control, there is no consensus for the best immunosuppressive regimen. Most authors use steroids first line, followed by other agents for steroid failures. Upfront combined regimens offer the advantage of reduced steroid exposure and toxicity as well as increased efficacy. We retrospectively analyzed data from 32 patients with AHA treated on an identical such institutional protocol: cyclophosphamide 1000 mg on days 1 and 22, dexamethasone 40 mg on days 1, 8, 15, and 22, and rituximab 100 mg on days 1, 8, 15, and 22 (the regimen was termed CyDRi). All patients received at least 1 cycle of CyDRi. If necessary, CyDRi was repeated until remission, no sooner than day 43 of the previous cycle. Bleeding control was rapidly achieved. The median time for bleeding control was 15.5 days (range, 0-429 days; interquartile range, 2.5-29.5 days). Thirty-one (96.8%) of 32 patients achieved durable complete remission (CR); 29 (90.6%) of 32 patients were alive at last follow-up, all of them in CR. The median time to reach first CR was 77 days (range, 19-939 days; interquartile range, 31-115 days). Toxicity and side effects were acceptable and milder than those of commonly used, prolonged steroid therapies. In conclusion, the CyDRi regimen produced markedly higher CR rates and overall survival than currently used sequential regimens. Taken together, CyDRi proved to be an attractive option for the immunosuppression of elderly patients with AHA.

ODP171 Choosing GLP-1RA Over Insulin for Patients with Type 2 Diabetes and Severe Hyperglycemia

Introduction

Although insulin remains the recommended treatment in type 2 diabetes for hyperglycemia with catabolic symptoms, it is also the generally recommended treatment for persistent hyperglycemia or hemoglobin A1c (HbA1c) values above 10% 1 . Recent data has suggested that glucagon like peptide 1 receptor agonists (GLP-1RAs) are also powerful at glucose lowering while additionally offering extra-glycemic benefits such as weight loss with minimal risk of hypoglycemia. Unfortunately, data on initial use of GLP-1RA is limited in patients with very high hemoglobin A1cs. Our objective was to evaluate outcomes in patients with type 2 diabetes and a baseline HbA1c of 10% or greater treated with GLP-1RAs instead of insulin.

Methods

This study is a small retrospective case series of insulin-naïve patients with uncontrolled type 2 diabetes who were prescribed an injectable GLP-1RA. Patients included had a baseline hemoglobin A1c ≥ 10% without signs of catabolism (weight loss, ketosis, significant polyuria), a minimum of one follow-up visit after initiating GLP-1RA, and at least one HbA1c measurement within six months of initiating treatment. Patients were excluded if they had previously been on insulin or a GLP-1RA in the past 1 year. The primary endpoint was change in HbA1c after 3-6 months of GLP-1 RA use.

Results

Of the patients initially screened, 7 patients fulfilled criteria and were included in the final analysis. The age range was 45-73 with 4 female patients and 3 male patients. The number of years patients had been diagnosed with type 2 diabetes ranged from 0 to 13 with 1 patient having newly diagnosed diabetes not previously on medications. Of the 6 patients who were on medical treatment at baseline, 3 patients were on monotherapy with either metformin or a sulfonylurea and 3 patients were on 2-4 oral hypoglycemic agents. Patients were continued on their initial medication regimen with the exception of DPP-4 inhibitors which were stopped at the time of GLP-1RA initiation. Mean baseline HbA1c prior to initiation of GLP-1RA was 11.9%. Following 3-6 months of GLP-1RA use, mean HbA1c significantly improved to 7.5% (p value= 0. 0005). All patients showed improvement of HbA1c in response to GLP-1RA initiation (mean HbA1c reduction = 4.4, minimum = 1.9, maximum = 7.5). All patients remained on GLP-1RA without significant side effects.

Conclusion

In this limited case series of patients with HbA1c ≥ 10%, GLP-1RAs were well tolerated and resulted in significant improvement in HbA1c. Our results suggest that GLP-1RAs should be considered as an alternative treatment option to insulin in non-catabolic patients with very high hemoglobin A1cs. References: 1. Committee ADAPP. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2021;45(Supplement_1): S125-S143. doi: 10.2337/dc22-S009

Presentation: No date and time listed

Composted Municipal Green Waste Infused with Biocontrol Agents to Control Plant Parasitic Nematodes-A Review

The last few years have witnessed the emergence of alternative measures to control plant parasitic nematodes (PPNs). We briefly reviewed the potential of compost and the direct or indirect roles of soil-dwelling organisms against PPNs. We compiled and assessed the most intensively researched factors of suppressivity. Municipal green waste (MGW) was identified and profiled. We found that compost, with or without beneficial microorganisms as biocontrol agents (BCAs) against PPNs, were shown to have mechanisms for the control of plant parasitic nematodes. Compost supports a diverse microbiome, introduces and enhances populations of antagonistic microorganisms, releases nematicidal compounds, increases the tolerance and resistance of plants, and encourages the establishment of a "soil environment" that is unsuitable for PPNs. Our compilation of recent papers reveals that while the scope of research on compost and BCAs is extensive, the role of MGW-based compost (MGWC) in the control of PPNs has been given less attention. We conclude that the most environmentally friendly and long-term, sustainable form of PPN control is to encourage and enhance the soil microbiome. MGW is a valuable resource material produced in significant amounts worldwide. More studies are suggested on the use of MGWC, because it has a considerable potential to create and maintain soil suppressivity against PPNs. To expand knowledge, future research directions shall include trials investigating MGWC, inoculated with BCAs.

AB0051 THE EFFECTS OF NON-INVASIVE VAGUS NERVE STIMULATION ON IMMUNOLOGICAL RESPONSES AND PATIENT REPORTED OUTCOME MEASURES OF FATIGUE IN PATIENTS WITH CHRONIC FATIGUE SYNDROME, FIBROMYALGIA, AND RHEUMATOID ARTHRITIS

Background:

Fatigue is reported as a common symptom among autoimmune and other chronic diseases such as fibromyalgia (FM), a long-term condition with uncertain pathophysiology. Previous studies from our group suggest that non-invasive vagus nerve stimulation (nVNS) may contribute to the improvement of patient reported outcome measures (PROMs) of fatigue in patients with primary Sjögren’s Syndrome (1).

Objectives:

This follow-up study uses the gammaCore device (electroCore) to assess the effect of nVNS on PROMs of fatigue and immune responses in chronic fatigue syndrome (CFS), FM and rheumatoid arthritis (RA).

Methods:

The study included thirteen CFS, fourteen FM and fifteen RA patients who used the gammaCore nVNS device twice daily over a 26-day period. Pre- and post- nVNS bloods were drawn at baseline and final visits. Whole blood samples were stimulated with 2 ng/mL lipopolysaccharide (LPS) and the IL-6 and TNF-α cytokine concentrations were quantified at 24 hours. In addition, the epidermal growth factor (EGF), IFN-γ, IL-6, IP-10, MIP-1α, and TNF-α levels were measured in ‘pre-nVNS’ serum and flow cytometric profiles of whole blood immune cells were analysed. The patient reported outcome measures (PROMs) recorded at each visit were the Visual Analogue Scale (VAS) (0-100 cm) of abnormal fatigue, Hospital Anxiety and Depression (HAD) Scale, Orthostatic Grading Scale, Epworth Sleepiness Scale (daytime sleepiness), and Profile of fatigue (PRO-F) for Physical and Mental fatigue. Paired t-tests were performed to assess for changes in PROMs, cytokine levels, and cell subset distribution and associations of cytokine response with PROMs were investigated by correlation analyses.

Results:

Eleven CFS, twelve FM and fourteen RA patients completed the study. There was a significant reduction in daytime sleepiness in CFS (p =0.0321) and FM (p =0.0294) patients between the final and baseline visits and a significant reduction in HAD depression (p =0.0413) in FM (Fig.1). Improvement in VAS for abnormal fatigue, HAD-Anxiety, HAD-Depression, PRO-F Physical and Mental fatigue was observed in all three groups over the study period with a reduction in VAS fatigue in 64% of CFS, 67% of FM and 62% of RA patients. There were no significant changes in the immune cell subsets or in cytokine response. Finally, higher baseline pre-nVNS supernatant IL-6 levels were predictive of an improvement in VAS fatigue (p =0.0006), Daytime Sleepiness (p =0.0466) and PRO-F Physical fatigue (p =0.0196) in RA, while higher baseline TNF-α levels were predictive of an improvement in VAS fatigue (p =0.0003), Daytime Sleepiness (p =0.0380), Orthostatic (p =0.0281) and PRO-F Physical fatigue (p =0.0007) in FM.

Conclusion:

Our findings suggest that nVNS may contribute to the improvement of PROMs of fatigue in CFS, FM and RA. NVNS led to significant reductions in daytime sleepiness in CFS and FM, and depression in FM. Further studies and a larger sample size are needed to investigate the potential effects of nVNS on diseases characterised by persistent fatigue.

References:

[1]Tarn J, Legg S, Mitchell S, Simon B, Ng WF. The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue and Immune Responses in Patients With Primary Sjögren’s Syndrome. Neuromodulation Technol Neural Interface. 2018;22(5):580–5.

Figure 1.

VAS for abnormal fatigue and PROMs recorded at baseline and final visits in patients with chronic fatigue syndrome (CFS), fibromyalgia (FM) and rheumatoid arthritis (RA). Boxplots show the median, upper, and lower quartiles for PROMs at visit 1 and visit 3 in each disease group. Paired-t tests revealed a significant reduction in daytime sleepiness in CFS and FM (B), and a significant reduction in HAD depression in FM (E). Improvement trends were observed in VAS for abnormal fatigue, HAD-Anxiety, HAD-Depression, PRO-F Physical fatigue and PRO-F Mental fatigue in all three groups over the 26-day study period.

Acknowledgements:

This study received infrastructural support from the National Institute of Health Research (NIHR) Newcastle Biomedical Research Centre at Newcastle Hospitals Foundation Trust and Newcastle University.

Disclosure of Interests:

Emmanuella Traianos: None declared, Bethany Dibnah: None declared, Dennis Lendrem: None declared, Yasmin Clark: None declared, Victoria Macrae: None declared, Victoria Slater: None declared, Karl Wood: None declared, David Storey: None declared, Bruce Simon Shareholder of: Bruce Simon is an employee and shareholder of electroCore., Employee of: electroCore, Inc., Justyna Blake Shareholder of: Justyna Blake is an employee of electroCore, and receives stock ownership., Employee of: electroCore, Inc., Jessica Tarn: None declared, Wan Fai Ng: None declared

Persistence and clearance of high-risk human papillomavirus and cervical dysplasia at 1 year in women living with human immunodeficiency virus: a prospective cohort study

OBJECTIVE

Evaluate 1-year outcomes of cervical cancer screening and treatment using primary high-risk human papillomavirus (HPV) testing in women living with human immunodeficiency virus (HIV).

DESIGN

Prospective cohort study.

SETTING

HIV treatment centre in Botswana.

POPULATION

Women living with HIV.

METHODS

Participants underwent cervical cancer screening with high-risk HPV testing and triage evaluation at baseline and 1-year follow up. Excisional treatment was offered as indicated. Histopathology was the reference standard.

MAIN OUTCOME MEASURES

Persistence, clearance and incidence of high-risk HPV infection; and persistence, progression, regression, cure and incidence of cervical dysplasia.

RESULTS

Among 300 women screened at baseline, 237 attended follow up (79%). High-risk HPV positivity significantly decreased from 28% at baseline to 20% at 1 year (P = 0.02). High-risk HPV persistence was 46% and clearance was 54%; incidence was high at 9%. Prevalence of cervical intraepithelial neoplasia Grade 2 (CIN2) or higher was most common in participants with incident high-risk HPV (53%). CIN2 or higher was also common in those with persistent high-risk HPV (32%) and even in those who cleared high-risk HPV (30%). Of the high-risk HPV-positive participants at baseline with <CIN2, 40% progressed to CIN2 or higher at follow up.

CONCLUSION

The high incidence of high-risk HPV and high-grade cervical dysplasia in women living with HIV after one round of high-risk HPV-based screening and treatment raises concern about the rate of progression of high-risk HPV infection to dysplasia. Persistent disease is common. Caution in spacing cervical cancer screening intervals using high-risk HPV testing in women living with HIV is warranted.

TWEETABLE ABSTRACT

High incidence and persistence of HPV and CIN2+ in women living with HIV 1 year after screening and treatment.

Polyglandular Autoimmune Syndrome Type II in a Patient Presenting With Hypotension After Acute Illness

Introduction: Polyglandular Autoimmune Syndrome Type II (PAS-2) is a rare disorder characterized by two or more endocrine diseases (primary adrenal insufficiency, autoimmune thyroid disease, type 1 diabetes). Of these, the most common is autoimmune thyropathy, followed by Type 1 Diabetes (1). These endocrinopathies rarely have concurrent onset. This case reports a 22-year-old male, recently recovered from severe pneumonia, who presented to the Emergency Department in acute adrenal crisis and was diagnosed with PAS-2.

Case: A 22-year-old male with past medical history of celiac disease presented with abdominal discomfort, nausea, vomiting, fatigue and dizziness for 1–2 weeks. Review of systems included a 20-pound weight loss over several months. Recent history included a hospitalization at another facility three weeks prior for pneumonia and septic shock requiring admission to the ICU and vasopressor treatment. He was not discharged on any medications. He was afebrile with heart rate of 105/min, blood pressure 78/48 mm Hg and BMI of 17.2. Physical exam revealed dry mucous membranes and mild diffuse abdominal tenderness. Skin was warm and dry without hyperpigmentation. Laboratory values included sodium 123 (135 - 146 mmol/L), potassium 6.8 (3.3 - 4.8 mmol/L), glucose 47 (70 - 100 mg/dL), TSH 37.67 (0.3 - 5.00 uIU/mL), and FT4 0.7 (0.7 - 1.7 ng/dL). He was started on fluids and intravenous hydrocortisone. Cortisol and ACTH levels drawn prior to the initiation of steroids resulted at 0.6 (6–20 mcg/dl) and 977 (9 - 46 pg/mL) respectively. Additional labs included: aldosterone < 1 ng/dL, 21 hydroxylase antibody positive, TPO antibody > 1000 (0 - 100 Units) and GAD-65 antibody > 47 IU/mL (<5 IU/mL). Levothyroxine was initiated after hydrocortisone. Blood glucose was elevated during hospitalization, peaking at 227 mg/dL. He was discharged on prednisone, fludrocortisone and levothyroxine. At 2 week follow up, he reported overall improvement in health and was pleased with a weight gain of 12 lbs. Blood glucose remained mildly elevated (123 - 143 mg/dL).

Conclusion: The patient had pneumonia and septic shock septic at an outside hospital three weeks prior to presentation. There was no record of steroid administration or suspicion of adrenal insufficiency. We postulate that his severe illness contributed to significant depletion of his adrenal reserve, and therefore he presented to our facility a short time later in overt adrenal crisis. Adrenal crisis is unusual to be the first presentation of PAS-2. It is important to have a high index of suspicion for adrenal insufficiency and PAS-2 in patients presenting with severe illness or hypotension who have known autoimmune disorders.

Reference: 1. Kahaly, G.J., Frommer, L. Polyglandular autoimmune syndromes. J Endocrinol Invest. 2018; 41: 91–98.

Evaluating the efficiency of the Dental Teacher system as a digital preclinical teaching tool

AIM

To investigate the use of a preparation evaluation system for enhancing the learning and performance of undergraduate dental students when cutting preparations.

MATERIALS AND METHODS

Two groups of eighteen students each were randomly chosen from the fourth year of the dental programme. The task chosen for this study was to make a cavity in preparation for a mesio-occlusal ceramic onlay in a plastic tooth. The dimensions of the cavity were defined, and 2 burs of known size were used for preparation. For assessment, each tooth preparation was scanned with a digital scanner and analysed using the Dental Teacher software. In the control group, a second corrective preparation was made following the supervisor's instructions. In the test group, the second preparation was made based on Dental Teacher analysis. The final cavities were all scanned and assessed by Dental Teacher comparing the similarity of students' onlay cavity preparations to the ideal preparation. All data were recorded and analysed by the software, including cavity depth and width in the occlusal and proximal box, the extent of mesiobuccal cusp reduction and shoulder width around the mesiobuccal cusp. Finally, the data were statistically evaluated using a Wilcoxon matched pairs test and a Mann-Whitney U test.

RESULTS

Three of the 6 cavity dimension parameters improved significantly in the test group whilst no improvement was found in the control group. A positive correlation was found between the improvement and the deviation measured for the first preparations, and it was stronger in the test group than in the control group.

CONCLUSIONS

The use of Dental Teacher helped students to learn the preparation technique for onlay restorations more efficiently and seems to be a promising and useful method to facilitate their individual performance. Student feedback showed a great demand for digital aids in education.

In Vivo Demonstration of the Haldane Effect during Extracorporeal Gas Exchange

During the extracorporeal support (LFPPV-ECCO2R) of 11 patients suffering from severe lung failure (ARDS), we consistently noticed a higher arterial than mixed-venous PCO2 in blood samples drawn at the same time. Two explanations are possible: a) the Haldane effect (HE), b) CO2 from lung tissue metabolism. In order to distinguish changes in PCO2 due to the HE from those due to tissue CO2 production, CO2 content (CCO2) was calculated. The results were compared to animal experiments with hyperoxic apnea, after which arterial and mixed-venous samples were drawn simultaneously. All blood gas samples were analyzed for pH, PCO2, PO2, and 02-saturation, from which CCO2 was calculated. In both groups, PaCO2 was 2.15 mmHg (2.7 mmHg respectively) higher at a lower CaCO2 (-2.87 ml/l, -14.9 ml/l). Oxygen saturation increased by 8.1% in the human group and 17.8% in the animal group. A significant relationship was found between changes in PCO2 and changes in 02-saturation. This is a demonstration of the Haldane effect.

Abstract 546: Metformin Significantly Increased Survival Rate in Patients With Diabetes and Comorbid Heart Disease

Objective: We assessed the hypothesis that metformin use significantly decreases risk of all-cause and heart disease (HD) mortality in patients with diabetes mellitus (DM).

Methods: Subjects with DM aged ≥30 (n=3612) participating in 1999 -2010 National Health and Nutrition Examination Surveys, who had anti-DM drug therapy information, and were followed up by December 2011 were analyzed. Baseline DM, coronary heart disease (CHD) and heart failure (HF) were defined as a physician-diagnosis of the disease(s). Death from HD was classified using ICD10:I20-I25).

Results: Mean (SD) age of 3612 participants was 63.1 (13.02), 83.4% (3056/3612) were under anti-DM therapies, and 20.3% was in metformin monotherapy, 4.9% in metformin combination (MCO), 24.8% in insulin, 45.4% in thiazolidinedione, sulfonylurea, and combinations, and 4.7% in any other antidiabetic drugs therapies. Baseline CHD and HF rates were 11.38% and 9.13%. At the end of follow-up, 1024 died from all-cause (21.86%), and 222 died from HD. Multivariate Cox’s proportional hazard regression analysis indicated that diabetic patients with comorbid HD (CHD and/or HF) had significant higher all-cause mortality than those without. However, these excess mortalities were significantly reduced in patients with metformin therapies than their counterparts without metformin. The hazard ratios (HR, 95%CI) of metformin use versus those without for all-cause mortality was 0.53 (0.38-0.76, p=0.001). Diabetic patients with CHD and with metformin therapies had a significantly lower 10-year all-cause mortality than those without metformin (33% vs. 64%, p<0.001). Similarly, diabetic patients with HF and with metformin therapies had a significantly lower 10-year all-cause mortality than their counterparts (42.8% vs. 73.1%, p<0.001). The effects of metformin on all-cause mortality were positively modified after adjusting dyslipidemia and insulin resistance.

In conclusion , metformin significantly increased survival rates from all-cause mortality in diabetic patients with comorbid CHD and/or HF. The mortality risk reduction may be partially explained by an effect of metformin on a reduction of dyslipidemia and insulin resistance.

Impact of diabetes mellitus on risk of cardiovascular disease and all-cause mortality: Evidence on health outcomes and antidiabetic treatment in United States adults

AIM

To examine the epidemic of diabetes mellitus (DM) and its impact on mortality from all-cause and cardiovascular disease (CVD), and to test the effect of antidiabetic therapy on the mortality in United States adults.

METHODS

The analysis included a randomized population sample of 272149 subjects ages ≥ 18 years who participated in the National Health Interview Surveys (NHIS) in 2000-2009. Chronic conditions (hypertension, DM and CVD) were classified by participants’ self-reports of physician diagnosis. NHIS-Mortality Linked Files, and NHIS-Medical Expenditure Panel Survey Linkage Files on prescribed medicines for patients with DM were used to test the research questions. χ², Poisson and Cox’s regression models were applied in data analysis.

RESULTS

Of all participants, 22305 (8.2%) had DM. The prevalence of DM significantly increased from 2000 to 2009 in all age groups (P < 0.001). Within an average 7.39 (SD = 3) years of follow-up, male DM patients had 1.56 times higher risk of death from all-cause (HR = 1.56, 95%CI: 1.49-1.64), 1.72 times higher from heart disease [1.72 (1.53-1.93)], 1.48 times higher from cerebrovascular disease [1.48 (1.18-1.85)], and 1.67 times higher from CVD [1.67 (1.51-1.86)] than subjects without DM, respectively. Similar results were observed in females. In males, 10% of DM patients did not use any antidiabetic medications, 38.1% used antidiabetic monotherapy, and 51.9% used ≥ 2 antidiabetic medications. These corresponding values were 10.3%, 40.4% and 49.4% in females. A significant protective effect of metformin monotherapy or combination therapy (except for insulin) on all-cause mortality and a protective but non-significant effect on CVD mortality were observed.

CONCLUSION

This is the first study using data from multiple linkage files to confirm a significant increased prevalence of DM in the last decade in the United States. Patients with DM have significantly higher risk of death from all-cause and CVD than those without DM. Antidiabetic mediations, specifically for metformin use, show a protective effect against all-cause and CVD mortalities.

[Input of a laboratory in the management of patients with Ebola virus disease and in the training of health personnel: experience of the Forecariah Ebola treatment centre (Guinea) in 2015]

Ebola virus disease (EVD) is associated with a high lethality rate even when the afflicted are provided with good support in an Ebola treatment center (ETC). Basic laboratory tests can help to better understand the pathophysiology of the disease, to guide treatment and to establish simple protocols and procedures tailored to the practice of medicine in the context of such precarious environment for caregivers. Based on a few clinical cases of patients treated in the ETC of Forecariah, Guinea, run by the French Red Cross, this article describes the difficult conditions associated with the provision of medical practice in this challenging environment, aiming to minimize the casualties in the EVD patient and to train the health staff.

A Primer on Diabetes Mellitus: Foundations for the Incoming First-Year Resident

INTRODUCTION

Given the increasing prevalence of diabetes mellitus, trainees should have a strong foundation in the management of diabetes. Published literature on the knowledge base and comfort level of medical trainees in diabetes care describes varying levels of exposure to diabetes management in both inpatient and outpatient settings.

METHODS

This eight-module curriculum provides a foundation in the diagnosis, evaluation, and management of diabetes mellitus in the adult patient, as well as pharmacological treatment, patient education, and complications. Specifically, the modules consist of an introduction to diabetes, diagnosis and glycemic goals, patient education, basic nutrition, noninsulin therapies, insulin therapies, complications of diabetes, and financial considerations and cost. Each is a stand-alone presentation that may be viewed nonsequentially. We estimate each module taking 15 to 30 minutes to read. Students received a postsurvey.

RESULTS

We received responses from 23 (18%) of the total eligible residents over the course of 3 years. Approximately 50% of respondents completed an endocrinology elective as either a medical student or first-year resident. Overall, the majority of respondents felt that the modules had the correct amount of content, the online format was adequate, their understanding of diabetes was enhanced, and the curriculum led to altering their care.

DISCUSSION

This resource is unique to MedEdPORTAL as it includes basic information on diabetes education and medical-nutritional therapy. We have required completion of these modules by our internal medicine residents since the class that enrolled in 2013. The curriculum is directed towards incoming first-year internal medicine residents but may also be used by trainees in other primary care fields.

MRI during radiotherapy of glioblastoma : Does MRI allow for prognostic stratification?

AIM

To evaluate the role of magnetic resonance imaging (MRI) as a predictor for the clinical course in patients with glioblastoma.

PATIENTS AND METHODS

In 64 patients with glioblastoma undergoing (chemo)radiotherapy MRI studies were obtained before radiation, after 30 gray (Gy), after 60 Gy and during follow-up. MRI findings were assigned to categories: definite progression, questionable progression, no change. Patients were followed clinically.

RESULTS

At 30 Gy, 23 of 64 patients (36 %) demonstrated definite (dp; n = 15) or questionable (qp; n = 8) progression; in 41/64 (64 %) no change was found compared with preradiation MRI. After radiotherapy at 60 Gy, 26 of 64 (41 %) patients showed dp (n = 18) or qp (n = 8). In 2 cases with qp at the 30 Gy MRI, progress was unquestionable in the 60 Gy MRI study. In the 64 patients, 5 of the 60 Gy MRIs showed dp/qp after being classified as no change at the 30 Gy MRI, 2 of the 30 Gy MRIs showed qp, while the 60 Gy MRI showed tumour regression and 3 fulfilled the criteria for pseudoprogression during ongoing radiotherapy. The 30 Gy study allowed for prognostic stratification: dp/qp compared to stable patients showed median survival of 10.5 versus 20 months.

CONCLUSION

MR follow-up after 30 Gy in patients undergoing (chemo)radiotherapy for glioblastoma allows prognostic appraisal. Pseudoprogression has to be taken into account, though rare in our setting. Based on these findings, early discussion of treatment modification is possible.

Abstract P2-11-12: Novel protocol combining metronomic nant-paclitaxel with HER2-targeted natural killer cells (innate immunotherapy) for HER2-positive metastatic breast cancer

Background. Natural killer (NK) cells are an important effector cell type for adoptive cancer immunotherapy. Phase 1 clinical trials in patients with advanced cancers demonstrated the safety of unmodified, activated NK-92 cells (aNK), with no evidence of cytokine storm from 18 infusions delivered over 6 months; clinical responses were observed in a subset of patients. Like T cells, NK cells can be engineered to express chimeric antigen receptors (CARs) to enhance their antitumor activity. A stable clonal HER2-specific NK-92 cell line (HER2.taNK) mediated selective and sequential killing of HER2-expressing MDA-MB-453 cells in vitro (Schönfeld. MolTher. 2015;23:330-338). In addition, HER2.taNK cells were enriched in MDA-MB-453/EGFP xenografts and reduced the number of pulmonary metastasis in a renal cell carcinoma model, suggesting that HER2.taNK cells are a promising clinical candidate for use in adoptive cancer immunotherapy. Metronomic (low-dose, continuous) chemotherapy can be more effective than high-dose therapy in patients with advanced breast cancer (Montagna. Canc. Treat. Rev. 2014;40:922-950). Here we evaluate HER2.taNK cells in combination with metronomic nant-paclitaxel (lyophilized polymeric micellar formulation of paclitaxel) in a mouse model of HER2-positive breast cancer to determine the feasibility of a human clinical trial of HER2.taNK in combination with metronomic nant-paclitaxel.

Methods. HER2.taNK cells were generated as described previously (Schönfeld. MolTher. 2015;23:330-338). MDA-MB-453 cells were implanted into the mammary fat pads of female nude mice. When tumors reached 100 mm3, mice were divided into 6 groups of 5 mice and dosed (IV) with saline (10 mL/kg, qd x 15), nant-paclitaxel (2.5-4 mg/kg q2d x 15), γ-irradiated (5 Gy) HER2.taNK cells (1 x 107 cells, days 1, 3, 5, and 8), or nant-paclitaxel + γ-irradiated (5 Gy) HER2.taNK cells–γ-irradiation is a potential safety measure for clinical application and prevents HER2.taNK cell replication while preserving antitumor activity. Tumor size and animal weights were measured every other day post-implantation.

Results: Results obtained 20 days post-treatment are shown in the table. Nant-paclitaxel alone and HER2.taNK alone significantly inhibited tumor growth. The combination of nant-paclitaxel + HER2.taNK led to significant tumor regressions (p&lt;0.05).

Treatment Dose T/C (%) P-ValueSalinenant-paclitaxel5 mg/kg-26.7 P &lt; 0.05 (vs saline) HER2.taNK1 x 107 cells-22.2 P &lt; 0.05 (vs saline)nant-paclitaxel +5 mg/kg +-60.0P &lt; 0.05 (vs nant-paclitaxel)HER2.taNK1 x 107 cellsP &lt; 0.05 (vs HER2.taNK)

Conclusions: Single agent nant-paclitaxel and HER2.taNK were similarly effective at inhibiting tumor growth in this mouse model of HER2+ breast cancer. The combination of nant-paclitaxel + HER2.taNK appeared to be synergistic resulting in tumor regressions and significantly better efficacy vs each agent alone. This study illustrates the potential for combining metronomic low-dose chemotherapy with NK-based immunotherapy in a clinical trial of patients with metastatic breast cancer.

Citation Format: Rabizadeh S, Simon B, Klingemann H, Sims D, Weiss R, Soon-Shiong P. Novel protocol combining metronomic nant-paclitaxel with HER2-targeted natural killer cells (innate immunotherapy) for HER2-positive metastatic 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 P2-11-12.

Introduction of a metabolic joint asymmetry score derived from conventional bone scintigraphy. A new tool to differentiate psoriatic from rheumatoid arthritis

AIM

Clinical differentiation of psoriatic arthritis (PsA) and rheumatoid arthritis (rA) based on the pattern of joint involvement can be difficult; the frequent form of PsA with polyarthritis of the peripheral joints may sometime resemble rA. We investigated a metabolic joint asymmetry score (MJAS), reflecting the overall asymmetric joint involvement on conventional bone scintigraphy, for differentiating PsA from rA in patients presenting with peripheral polyarthritis.

PATIENTS, METHODS

106 patients (n = 61, PsA; n = 45, rA) with peripheral polyarthritis (≥ 5 joints) as well as 26 control subjects with no history of chronic joint disorders were analyzed. The intensity of articular 99mTc-MDP uptake in 40 peripheral joint pairs was scored regarding the bilateral difference of each joint based on a scale of 0-2 (no significant, moderate, and marked asymmetry, respectively). The patient's MJAS was defined as the sum of uptake difference scores of all joint pairs. The association of MJAS with the underlying condition (Psoriasis criteria, Revised Criteria of the ACR) was examined.

RESULTS

5280 peripheral joint pairs were investigated. There was no significant difference in the total number of involved joints in PsA 15.0 ± 8.2 versus rA 17.5 ± 8.8 patients (p = 0.132), but significantly less involvement in the control group (6.7 ± 5.0, p < 0.001). MJAS was markedly higher in PsA (17.0 ± 9.6) than in rA (4.8 ± 3.9, p < 0.001), and correlated with the total number of involved joints in PsA (r = 0.516, p < 0.001), but not in rA (r = 0.078, p = 0.380). The MJAS disparity between PsA and rA persisted after exclusion of the DIP joints (14.4 ± 7.7 vs. 4.4 ± 3.3; p<0.001).

CONCLUSIONS

The new reproducible semi-quantification method for the asymmetry of metabolic joint involvement permits differentiation of psoriatic from rheumatoid peripheral arthritis with MJAS being markedly higher in patients with PsA as compared to rA patients. The score may offer an effective complementary tool for characterizing patients with peripheral polyarthritis.

Optical polymers with tunable refractive index for nanoimprint technologies

In order to realize a versatile high throughput production of micro-optical elements, UV-curable polymer composites containing titanium dioxide nanoparticles were prepared and characterized. The composites are based on an industrial prototype epoxy polymer. Titanium dioxide nanoparticles smaller than 10 nm were synthesized by the nonaqueous sol method and in situ sterically stabilized by three different organic surfactants. The composites exhibit high transparency. Distinct alteration of optical transmission properties for visible light and near IR wavelength range could be avoided by adaption of the stabilizing organic surfactant. Most importantly, the refractive index (RI) of the composites that depends on the fraction of incorporated inorganic nanoparticles could be directly tuned. E.g. the RI at a wavelength of 635 nm of a composite containing 23 wt% titanium dioxide nanoparticles is increased to 1.626, with respect to a value of 1.542 for the pure polymer. Furthermore, it could be demonstrated that the prepared inorganic-organic nanocomposites are well suited for the direct fabrication of low-cost micro-optical elements by nanoimprint lithography. A low response of the optical composite properties to temperature treatment up to 220 °C with a shrinkage of only about 4% ensures its application for integrated micro-optical elements in industrial production.

Predictors of primary care management of depression in the Veterans Affairs healthcare system

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.

Profile of incident chronic kidney disease related-mineral bone disorders in chronic kidney disease Stage 4 and 5: A hospital based cross-sectional survey

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels <30 ng/mL was 66.3%, 59%, 89.3% and 74.7% respectively. Echocardiography was carried out in 471 patients; 96% of whom had VC (calcification score ≥1). Patients with VC were older and had lower 25(OH) D levels than those without. Lateral abdominal X-rays were obtained in 558 patients, 6.8% of whom were found to have AAC, which was associated with older age. Indian patients with incident CKD-MBD have a high prevalence of hypocalcemia, 25(OH) D deficiency and VC even prior to initiating dialysis while AAC does not appear to be common. The association between 25(OH) D deficiency and VC needs further exploration.

Tomographic diffractive microscopy and multiview profilometry with flexible aberration correction

We have developed a tomographic diffractive microscope in reflection, which permits observation of sample surfaces with an improved lateral resolution, compared to a conventional holographic microscope. From the same set of data, high-precision measurements can be performed on the shape of the reflective surface by reconstructing the phase of the diffracted field. Doing so allows for several advantages compared to classical holographic interferometric measurements: improvement in lateral resolution, easier phase unwrapping, reduction of the coherent noise, combined with the high-longitudinal precision provided by interferometric phase measurements. We demonstrate these capabilities by imaging various test samples.

Association of human cytomegalovirus DNAaemia and specific granzyme B responses in lung transplant recipients

In lung transplant recipients (LTRs), human cytomegalovirus (HCMV) DNAaemia could be associated with HCMV disease and reduced allograft survival. In the present study we analysed whether or not HCMV-specific granzyme B (Grz-B) responses indicating CD8(+) T cell cytotoxicity exert an impact on HCMV DNAaemia and relate to specific interferon (IFN)-γ secretion. HCMV-specific Grz-B responses were quantitated by enzyme-linked immunosorbent assay (ELISA) in 70 samples from 39 HCMV seropositive LTRs who were prospectively investigated for HCMV DNA plasma levels and IFN-γ kinetics using a standardized CD8(+) T cell assay (QuantiFERON®-CMV assay). In all LTRs who were protected from HCMV DNAaemia by early and persistent IFN-γ responses, Grz-B responses were also detected. In LTRs who developed episodes of HCMV DNAaemia, the Grz-B responses which were detected prior to viral DNA detection differed significantly in patients who experienced episodes with high (exceeding 1000 copies/ml) and low plasma DNA levels (P = 0·0290, Fisher's exact test). Furthermore, the extent of Grz-B release prior to viral DNAaemia correlated statistically with the detected levels of IFN-γ (P < 0·0001, Spearman's rank test). Of note, simultaneous detection of Grz-B and IFN-γ secretion was associated significantly with protection from high HCMV DNA plasma levels during the subsequent follow-up (P = 0·0057, Fisher's exact test), and this association was stronger than for IFN-γ detection alone. We conclude that, in addition to IFN-γ responses, Grz-B secretion by CD8(+) T cells is essential to control HCMV replication and a simultaneous measurement of IFN-γ and Grz-B could contribute to the immune monitoring of LTRs.

Impact of the Northridge Earthquake on the Mental Health of Veterans: Results From a Panel Study

Objective: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center.

Methods: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact.

Results: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status.

Conclusions: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non–Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.

(Disaster Med Public Health Preparedness. 2011;5:S220-S226)