Eight weeks of high-intensity interval training versus stretching do not change the psychoneuroendocrine response to a social stress test in emotionally impulsive humans

PURPOSE

Research supports physical activity as a method to heighten stress resistance and resilience through positive metabolic alterations mostly affecting the neuroendocrine system. High-intensity interval training (HIIT) has been proposed as a highly effective time-saving method to induce those changes. However, existing literature relies heavily on cross-sectional analyses, with few randomised controlled trials highlighting the necessity for more exercise interventions. Thus, this study aims to investigate the effects of HIIT versus an active control group on the stress response to an acute psychosocial stressor in emotionally impulsive humans (suggested as being strong stress responders).

METHODS

The study protocol was registered online (DRKS00016589) before data collection. Sedentary, emotionally impulsive adults (30.69 ± 8.20 y) were recruited for a supervised intervention of 8 weeks and randomly allocated to either a HIIT (n = 25) or a stretching group (n = 19, acting as active controls). Participants were submitted to a test battery, including saliva samples, questionnaires (self-efficacy- and perceived stress-related), visual analogue scales (physical exercise- and stress-related), and resting electroencephalography and electrocardiography assessing their reaction to an acute psychological stressor (Trier Social Stress Test) before and after the exercise intervention.

RESULTS

HIIT increased aerobic fitness in all participants, whereas stretching did not. Participants from the HIIT group reported perceiving exercising more intensively than those from the active control group (ƞp2 = 0.108, p = 0.038). No further group differences were detected. Both interventions largely increased levels of joy post-TSST (ƞp2 = 0.209, p = 0.003) whilst decreasing tension (ƞp2 = 0.262, p < 0.001) and worries (ƞp2 = 0.113, p = 0.037). Finally, both interventions largely increased perceived levels of general self-efficacy (ƞp2 = 0.120, p = 0.029).

CONCLUSION

This study suggests that 8 weeks of HIIT does not change the psychoneuroendocrine response to an acute psychological stress test compared to an active control group in emotionally impulsive humans. Further replications of supervised exercise studies highly powered with active and passive controls are warranted.

The impact of COVID-19 on the well-being of Victorian children born with cleft lip and/or palate

BACKGROUND

A longitudinal cohort study was established to investigate the well-being of children born with cleft lip and/or palate (CL/P) during the COVID-19 pandemic, in Victoria, Australia.

MATERIALS AND METHODS

The Royal Children's Hospital cleft service database was used to identify children aged between 4 and 17 years old born with an isolated CL/P. Families of eligible children who consented to participate were asked to complete the Strengths and Difficulties Questionnaire (SDQ) between October and December 2020 and again 6-month later. SDQ results from typically developing Australian children during the COVID-19 pandemic were utilized from a previously published study.

RESULTS

63 parents completed the baseline questionnaire, with 44 completing the 6-month follow-up. For participants at baseline, the mean age was 8.9 years, with 55% male. All outcome domains of the SDQ improved between baseline and timepoint 2, with the difference in total difficulties scores being statistically significant, indicating a reduction in total difficulties at timepoint 2, associated with the easing of COVID-19 restrictions. When compared with the Australian population during the COVID-19 pandemic, Victorian children born with CL/P had lower SDQ scores for all difficulties outcome domains, with statistically significant results for conduct problems, hyperactivity, peer problems and total difficulties, indicating fewer difficulties for children born with CL/P.

CONCLUSIONS

Children born with CL/P experienced fewer difficulties when compared with the typically developing Australian population during the COVID-19 pandemic. The level of restrictions imposed because of the pandemic also had little influence on the well-being of these children.

Interlaboratory Study on Zebrafish in Toxicology: Systematic Evaluation of the Application of Zebrafish in Toxicology's (SEAZIT's) Evaluation of Developmental Toxicity

Embryonic zebrafish represent a useful test system to screen substances for their ability to perturb development. The exposure scenarios, endpoints captured, and data analysis vary among the laboratories who conduct screening. A lack of harmonization impedes the comparison of the substance potency and toxicity outcomes across laboratories and may hinder the broader adoption of this model for regulatory use. The Systematic Evaluation of the Application of Zebrafish in Toxicology (SEAZIT) initiative was developed to investigate the sources of variability in toxicity testing. This initiative involved an interlaboratory study to determine whether experimental parameters altered the developmental toxicity of a set of 42 substances (3 tested in duplicate) in three diverse laboratories. An initial dose-range-finding study using in-house protocols was followed by a definitive study using four experimental conditions: chorion-on and chorion-off using both static and static renewal exposures. We observed reasonable agreement across the three laboratories as 33 of 42 test substances (78.6%) had the same activity call. However, the differences in potency seen using variable in-house protocols emphasizes the importance of harmonization of the exposure variables under evaluation in the second phase of this study. The outcome of the Def will facilitate future practical discussions on harmonization within the zebrafish research community.

Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol

PURPOSE/OBJECTIVE(S)

Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery.

MATERIALS/METHODS

Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method.

RESULTS

Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc).

CONCLUSION

The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.

Measurement of the Branching Fractions B(B^{0}→pp[over ¯]pp[over ¯]) and B(B_{s}^{0}→pp[over ¯]pp[over ¯])

Searches for the rare hadronic decays B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] are performed using proton-proton collision data recorded by the LHCb experiment and corresponding to an integrated luminosity of 9  fb^{-1}. Significances of 9.3σ and 4.0σ, including statistical and systematic uncertainties, are obtained for the B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] signals, respectively. The branching fractions are measured relative to the topologically similar normalization decays B^{0}→J/ψ(→pp[over ¯])K^{*0}(→K^{+}π^{-}) and B_{s}^{0}→J/ψ(→pp[over ¯])⁢ϕ(→K^{+}K^{-}). The branching fractions are measured to be B(B^{0}→pp[over ¯]pp[over ¯])=(2.2±0.4±0.1±0.1)×10^{-8} and B(B_{s}^{0}→pp[over ¯]pp[over ¯])=(2.3±1.0±0.2±0.1)×10^{-8}. In these measurements, the first uncertainty is statistical, the second is systematic, and the third one is due to the external branching fraction of the normalization channel.

PACK syndrome: A case series and review

A rare overlap syndrome between CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome and primary biliary cholangitis (PBC) is described as PACK syndrome, an acronym for primary biliary cholangitis, anticentromere antibodies, CREST syndrome, and keratoconjunctivitis sicca. In this retrospective cohort analysis and review, we present fourteen patients who meet diagnostic criteria for PACK syndrome in one of the largest case series of this group. All patients were female, 86% of whom were White with an average age of 66.7 years (range 39-78 years). The prevalence was 5.08% in our PBC cohort (n=256) similar to previous findings. CREST syndrome was diagnosed prior to PBC in 58% of our patients and limited pulmonary and renal involvement were observed. This syndrome is rare, but given its insidious development, clinicians should be aware of this potential overlap in CREST-only and PBC-only patients.

Readmission Risk after COVID-19 Hospitalization: A Moderation Analysis by Vital Signs

Hospital admissions for coronavirus disease 2019 (COVID-19) are a common occurrence during periods of widespread viral transmission as are 30-day readmissions after COVID-19 hospitalization. This article provides an analysis of risk factors for readmission after COVID-19 hospitalization, in particular, vital signs upon discharge and their predictive value. In addition, this article evaluates whether the stabilization of vital signs within 24 hours of discharge can reduce readmission risk attributable to less modifiable primary factors such as underlying pulmonary and cardiac disease. The authors aim to aid the practicing clinician by providing an approach to safely risk stratify hospitalized COVID-19 patients who may be ready for discharge from the hospital.

Objective

Readmission to the hospital after hospitalization with coronavirus disease 2019 (COVID-19) is associated with significant morbidity and mortality. Hospital clinicians may identify the presence of a patient’s comorbid conditions, overall severity of illness, and clinical status at discharge as risk factors for readmission. Objective data are lacking to support reliance on these factors for discharge decision making. The objective of our study was to examine risk factors for readmission to the hospital after COVID-19 hospitalization and the impact of vital sign abnormalities, within 24 hours of discharge, on readmission rates.

Methods

In total, 2557 COVID-19-related hospital admissions within the Lifespan Health System, a large multicenter health system (Rhode Island), of 2230 unique patients aged 18 years and older, occurring from April 1, 2020 to December 31, 2020 were analyzed. Risk factors associated with readmission within 30 days were identified and analyzed using Cox regression. A moderation analysis by vital signs at discharge on the risk of readmission was performed.

Results

Clinical factors associated with readmissions included existing cardiovascular conditions (risk ratio 2.32, 95% confidence interval [CI] 1.10–4.90) and pulmonary disease (risk ratio 3.25, 95% CI 1.62–6.52). The absence of abnormal vital signs within 24 hours of discharge was associated with decreased 30-day readmission rates (risk ratio 0.70, 95% CI 0.52–0.94). Elevated C-reactive protein and d-dimer values and in-hospital complications including stroke, myocardial infarction, acute renal failure, and gastrointestinal bleeding were not associated with an increased risk of readmission. In moderation analysis, the presence of normal vital signs within 24 hours of discharge was associated with decreased readmission risk in patients who had primary risk factors for readmission including pulmonary disease (risk ratio 0.80, 95% CI 0.65–0.99), psychiatric disorders, and substance use (risk ratio 0.70, 95% CI 0.52–0.94).

Conclusions

Comorbid conditions, including pulmonary and cardiovascular disease, are associated with readmission risk after COVID-19 hospitalization. The normalization of vital signs within 24 hours of discharge during COVID-19 hospitalization may be an indicator of readiness for discharge and may mitigate some readmission risk conferred by comorbid conditions.

Hyperglycemia and Hypoglycemia-Related Chorea in an 83-Year-Old Man

We report a case of a patient who first presented with hyperglycemic chorea, and subsequently with hypoglycemic chorea. The patient's hypoglycemia was thought to be iatrogenic, highlighting the importance of careful glucose management following glycemia- related chorea. Presumably secondary to the patient's chorea, the patient also suffered from new onset shoulder pain, which was managed with gabapentin. Unfortunately, due to the patient's renal failure, the gabapentin, combined with infection, led to encephalopathy in this patient. This report presents and offers useful tips on the management of a unique patient who suffered from hyperglycemic chorea, hypoglycemic chorea, and encephalopathy, all within a few weeks.

Plasma concentrations of tris(1-chloro-2-propyl) phosphate and a metabolite bis(2-chloroisopropyl) 1-carboxyethyl phosphate in Sprague-Dawley rats and B6C3F1/N mice from a chronic study of tris(chloropropyl) phosphate via feed

Tris(chloropropyl) phosphate (TCPP) is an organophosphorus flame retardant and plasticizer used in manufacturing and multiple consumer products. Commercial TCPP is a ubiquitous environmental contaminant and TCPP or its metabolites have been detected in human plasma and urine. In response to the demonstrated widespread human exposure and lack of toxicity data, the Division of the National Toxicology Program is investigating the chronic toxicity of TCPP following perinatal exposure in HSD:Sprague Dawley®SD® (HSD) rats (up to 20,000 ppm) and adult exposure in B6C3F1/N mice (females, up to 10,000 ppm; males up to 5000 ppm) to TCPP via feed. Systemic exposure and bioaccumulation were assessed by measuring plasma concentrations of tris(1-chloro-2-propyl)phosphate (TCIPP), the most abundant TCPP isomer. TCIPP concentrations in TCPP-exposed rats and mice ranged from 3.43 to 1180 ng/mL and increased with exposure concentration at all time points. No sex differences were observed in rats, but male mice had higher TCIPP concentrations than females. TCIPP did not bioaccumulate in rats or mice over the course of the study. Low TCIPP concentrations were seen in some control rats and mice that were attributed to background TCPP present during sample collection, preparation and/or analysis. Bis(2-chloroisopropyl) 1-carboxyethyl phosphate (BCPCP), a TCPP metabolite, was quantified in plasma from control and selected exposed animals. Results showed increases in BCPCP concentration that were proportional to exposure concentration in rats and mice at concentrations much higher than TCIPP, indicating that BCPCP might be a more suitable biomarker of TCPP exposure.

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Tris(chloropropyl)phosphate (TCPP) has widespread environmental exposure.

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We measured plasma levels of TCPP following chronic feed exposure in rodents.

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The most abundant isomer of TCPP (TCIPP) increased with exposure with no accumulation.

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Bis(2-chloroisopropyl)1-carboxyethyl phosphate (BCPCP) levels were higher than TCIPP.

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Metabolite BCPCP may be a more suitable biomarker for TCPP exposure.

Clostridioides difficile Induced Rhabdomyolysis Associated With Decompensated Cirrhosis

Rhabdomyolysis (RBD) occurs secondary to tissue injury, resulting in (muscle) cell lysis and release of intracellular electrolytes and proteins into circulation. An elevation in the muscle enzyme, creatine kinase (CK), is a diagnostic marker and indicates muscle breakdown. Symptoms include dark urine caused by release of myoglobin, myalgias, and acute kidney injury (AKI). RBD is categorized as (1) traumatic, (2) nontraumatic exertional (ie, metabolic myopathies), or (3) non-exertional and non-traumatic. Clostridioides difficile (CD) has been previously reported to cause RBD, but the risk factors, pathogenesis, and recommended treatment regimen remain unclear.

Cardiovascular Mortality After Type 1 and Type 2 Myocardial Infarction in Young Adults

BACKGROUND

Type 2 myocardial infarction (MI) and myocardial injury are associated with increased short-term mortality. However, data regarding long-term mortality are lacking.

OBJECTIVES

This study compared long-term mortality among young adults with type 1 MI, type 2 MI, or myocardial injury.

METHODS

Adults age 50 years or younger who presented with troponin >99th percentile or the International Classification of Diseases code for MI over a 17-year period were identified. All cases were adjudicated as type 1 MI, type 2 MI, or myocardial injury based on the Fourth Universal Definition of MI. Cox proportional hazards models were constructed for survival free from all-cause and cardiovascular death.

RESULTS

The cohort consisted of 3,829 patients (median age 44 years; 30% women); 55% had type 1 MI, 32% had type 2 MI, and 13% had myocardial injury. Over a median follow-up of 10.2 years, mortality was highest for myocardial injury (45.6%), followed by type 2 MI (34.2%) and type 1 MI (12%) (p < 0.001). In an adjusted model, type 2 MI was associated with higher all-cause (hazard ratio: 1.8; 95% confidence interval: 1.2 to 2.7; p = 0.004) and cardiovascular mortality (hazard ratio: 2.7; 95% confidence interval: 1.4 to 5.1; p = 0.003) compared with type 1 MI. Those with type 2 MI or myocardial injury were younger and had fewer cardiovascular risk factors but had more noncardiovascular comorbidities. They were significantly less likely to be prescribed cardiovascular medications at discharge.

CONCLUSIONS

Young patients who experience a type 2 MI have higher long-term all-cause and cardiovascular mortality than those who experience type 1 MI, with nearly one-half of patients with myocardial injury and more than one-third of patients with type 2 MI dying within 10 years. These findings emphasize the need to provide more aggressive secondary prevention for patients who experience type 2 MI and myocardial injury.

Preoperative carfilzomib and lulizumab based desensitization prolongs graft survival in a sensitized non-human primate model

Sensitized patients are difficult to transplant due to pre-formed anti-donor immunity. We have previously reported successful desensitization using carfilzomib and belatacept in a non-human primate (NHP) model. Here we evaluated selective blockade of the co-stimulatory signal (CD28-B7) with Lulizumab, which preserves the co-inhibitory signal (CTLA4-B7). Five maximally MHC-mismatched pairs of NHPs were sensitized to each other with two sequential skin transplants. Individuals from each pair were randomized to either desensitization with once-weekly Carfilzomib (27mg/m² IV) and Lulizumab (12.5mg/kg SC) over four weeks, or no desensitization (Control). NHPs then underwent life-sustaining kidney transplantation from their previous skin donor. Rhesus-specific anti-thymocyte globulin was used as induction therapy and immunosuppression maintained with tacrolimus, mycophenolate, and methylprednisolone. Desensitized subjects demonstrated a significant reduction in donor-specific antibody, follicular helper T cells (CD4⁺PD-1⁺ICOS⁺), and proliferating B cells (CD20⁺Ki67⁺) in the lymph nodes. Interestingly, regulatory T cell (CD4⁺CD25⁺CD127^lo) frequency was maintained after desensitization in addition to increased frequency of naïve CD4 T cells (CCR7⁺CD45RA⁺) and naïve B cells (IgD⁺CD27^-CD20⁺) in circulation. This was associated with significant prolongation in graft survival (MST = 5.8 ± 4.0 vs. 64.8 ± 36.3; p<0.05) and lower antibody-mediated rejection scores compared to control animals. However, all desensitized animals eventually developed AMR and graft failure. Desensitization with CFZ and Lulizumab improves allograft survival in allosensitized NHPs, by transient control of the germinal center and shifting of the immune system to a more naive phenotype. This regimen may translate into clinical practice to improve outcomes of highly sensitized transplant patients.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Impacts of post-Brexit agricultural policy on fruit and vegetable intake and cardiovascular disease

Background

The post-Brexit agricultural regime represents an opportunity to positively influence food systems and improve public health. Health-improving measures could include expanding the UK production of fruits and vegetables (F&V), thus increasing F&V availability. Currently, only 1.4% of total agricultural land in England is allocated to F&V. This study aims to estimate the potential impacts of allocating additional land to F&V production on cardiovascular disease (CVD) and inequalities in England between 2021 and 2030.

Methods

We used the previously validated IMPACT Food Policy model to translate changes in land allocated to F&V into changes in F&V intake and associated CVD mortality, expressed in number of deaths prevented or postponed (DPPs) by age, sex, and Index of Multiple Deprivation (IMD) quintile. We modelled two scenarios that assumed a linear increase in agricultural land allocated to F&V until it covers a) 10% and b) 20% of all land suitable for production of horticultural crops in England. We assumed that F&V prices would drop to a new equilibrium. We used Monte Carlo simulations to produce uncertainty intervals.

Results

Our model suggested that by 2030, F&V intake might increase by approximately 4% (95% Uncertainty Interval: 2%-7%) and 8% (4%-13%) respectively, under the first scenario. Under the second scenario, F&V intake could increase by approximately 17% (10%-29%) and 37% (26%-51%) respectively. These increases in F&V intake were associated with 3360 (1760-5920) CVD DPPs under the first scenario and 15700 (9000-24310) under the second scenario in 2021-2030. Our modelled scenarios could also reduce inequalities, with some 16% of DPPs occurring in the least deprived group compared with 22% in the most deprived.

Conclusions

Policymakers should consider the public health impacts of the post-Brexit agricultural regime in England. Increasing the land allocated to F&V production could substantially reduce the burden of CVD and associated inequalities.

Key messages

The post-Brexit agricultural policy can be an opportunity to improve diet and public health in the UK. Increasing the agricultural land allocated to fruit and vegetable production in England could reduce the burden of cardiovascular disease and associated inequalities.

Umbrella review of strategies to improve uptake of screening programmes

Introduction

High participation rates in screening programmes targeting non-communicable diseases are instrumental in achieving full screening benefits; however, screening programmes remain underused, especially among vulnerable populations. We conducted an umbrella review to assess the type of approaches screening programmes use to maximise uptake, the effectiveness of the approaches and the impact on equity.

Methods

Electronic databases were searched (1999-2019) for systematic reviews on approaches aimed at improving uptake of screening programmes for adults in middle- and high-income countries, with participation rate as the primary outcome. A narrative synthesis was undertaken to present the results by strategy, screening programme and strength of evidence. This study was registered in PROSPERO [CRD42019132087].

Results

In total, 3,059 records were identified, and 82 systematic reviews were included. Preliminary findings suggest contradictory evidence, and effectiveness appears to depend on the disease screened for and specific program implementation. Invitation methods including letters and direct reminders seem to work universally. However, combined approaches using access-enhancing, individual- and system-directed strategies seem to be more effective than single approaches such as invitation methods alone. Few studies evaluated the impact on equity.

Conclusions

Strategies to improve uptake of screening programmes have the potential to be effective. However, there are many components within the system, either at individual, health care professional or health care system level that can influence uptake of screening programmes. Within each screening programme, it is likely that a range of interventions is needed to improve the uptake as opposed to a single intervention.

Key messages

Improving uptake of screening programmes is a complex issue with many factors influencing the process. A range of interventions is favoured over single interventions.

Pretransplant Desensitization with Costimulation Blockade and Proteasome Inhibitor Reduces DSA and Delays Antibody-Mediated Rejection in Highly Sensitized Nonhuman Primate Kidney Transplant Recipients

BACKGROUND

Patients with broad HLA sensitization have poor access to donor organs, high mortality while waiting for kidney transplant, and inferior graft survival. Although desensitization strategies permit transplantation via lowering of donor-specific antibodies, the B cell-response axis from germinal center activation to plasma cell differentiation remains intact.

METHODS

To investigate targeting the germinal center response and plasma cells as a desensitization strategy, we sensitized maximally MHC-mismatched rhesus pairs with two sequential skin transplants. We administered a proteasome inhibitor (carfilzomib) and costimulation blockade agent (belatacept) to six animals weekly for 1 month; four controls received no treatment. We analyzed blood, lymph node, bone marrow cells, and serum before desensitization, after desensitization, and after kidney transplantation.

RESULTS

The group receiving carfilzomib and belatacept exhibited significantly reduced levels of donor-specific antibodies (P=0.05) and bone marrow plasma cells (P=0.02) compared with controls, with a trend toward reduced lymph node T follicular helper cells (P=0.06). Compared with controls, carfilzomib- and belatacept-treated animals had significantly prolonged graft survival (P=0.02), and renal biopsy at 1 month showed significantly reduced antibody-mediated rejection scores (P=0.02). However, four of five animals with long-term graft survival showed gradual rebound of donor-specific antibodies and antibody-mediated rejection.

CONCLUSIONS

Desensitization using proteasome inhibition and costimulation blockade reduces bone marrow plasma cells, disorganizes germinal center responses, reduces donor-specific antibody levels, and prolongs allograft survival in highly sensitized nonhuman primates. Most animals experienced antibody-mediated rejection with humoral-response rebound, suggesting desensitization must be maintained after transplantation using ongoing suppression of the B cell response.

B-09 Cerebral Grey Matter After Out-Of-Hospital Cardiac Arrest In Good Outcome Survivors

Objective

The purpose of this study was to evaluate the impact of out-of-hospital cardiac arrest (OHCA) on cognitive functioning and brain volumes, in good outcome survivors.

Method

Participants were medically stable OHCA survivors. Two control groups were also recruited: patients who experienced myocardial infarction (MI), and healthy controls (HC) with no history of cardiovascular disease. Neuropsychological assessment was conducted using the Neuropsychological Assessment Battery (NAB). Imaging was performed on a 3T Siemens Trio MRI scanner. Cerebral grey matter volume (GM; measured by voxel-based morphometry in SPM12) results are presented.

Results

Participants (nOHCA = 9, nMI = 19, nHC = 13) ranged in age from 30 to 85 years. When controlling for age, whole-brain analyses revealed decreased GM in anterior cingulate cortex, bilateral hippocampus in the OHCA and in the MI group compared to the HC group. In addition, the MI group had decreased GM compared to the HC in the thalamus and the right dorsolateral prefrontal cortex (p < .001). No significant differences in GM were observed between the MI and OHCA groups. The hippocampus was selected as a region-of-interest for further analyses. The Total NAB Index was correlated with hippocampal GM in the OHCA group but not in the MI group (rOHCA = .78, p = .014).

Conclusions

Results revealed select areas of GM reduction in OHCA and MI groups, suggesting a contribution of cardiovascular disease to observed atrophy. Reductions are related to cognitive performance only in the cardiac arrest group which may suggest that these volume losses represent clinically meaningful changes.

Secondary lymphoid tissue and costimulation-blockade resistant rejection: A nonhuman primate renal transplant study

Naïve T cell activation requires antigen presentation combined with costimulation through CD28, both of which optimally occur in secondary lymphoid tissues such as lymph nodes and the spleen. Belatacept impairs CD28 costimulation by binding its ligands, CD80 and CD86, and in doing so, impairs de novo alloimmune responses. However, in most patients belatacept is ineffective in preventing allograft rejection when used as a monotherapy, and adjuvant therapy is required for control of costimulation-blockade resistant rejection (CoBRR). In rodent models, impaired access to secondary lymphoid tissues has been demonstrated to reduce alloimmune responses to vascularized allografts. Here we show that surgical maneuvers, lymphatic ligation, and splenectomy, designed to anatomically limit access to secondary lymphoid tissues, control CoBRR and facilitate belatacept monotherapy in a nonhuman primate model of kidney transplantation without adjuvant immunotherapy. We further demonstrate that animals sustained on belatacept monotherapy progressively develop an increasingly naïve T and B cell repertoire, an effect that is accelerated by splenectomy and lost at the time of belatacept withdrawal and rejection. These pilot data inform the role of secondary lymphoid tissues on the development of CoBRR and the use of costimulation molecule-focused therapies.

Daratumumab in Sensitized Kidney Transplantation: Potentials and Limitations of Experimental and Clinical Use

BACKGROUND

Donor-specific antibodies are associated with increased risk of antibody-mediated rejection and decreased allograft survival. Therefore, reducing the risk of these antibodies remains a clinical need in transplantation. Plasma cells are a logical target of therapy given their critical role in antibody production.

METHODS

To target plasma cells, we treated sensitized rhesus macaques with daratumumab (anti-CD38 mAb). Before transplant, we sensitized eight macaques with two sequential skin grafts from MHC-mismatched donors; four of them were also desensitized with daratumumab and plerixafor (anti-CXCR4). We also treated two patients with daratumumab in the context of transplant.

RESULTS

The animals treated with daratumumab had significantly reduced donor-specific antibody levels compared with untreated controls (57.9% versus 13% reduction; P<0.05) and prolonged renal graft survival (28.0 days versus 5.2 days; P<0.01). However, the reduction in donor-specific antibodies was not maintained because all recipients demonstrated rapid rebound of antibodies, with profound T cell-mediated rejection. In the two clinical patients, a combined heart and kidney transplant recipient with refractory antibody-mediated rejection and a highly sensitized heart transplant candidate, we also observed a significant decrease in class 1 and 2 donor-specific antibodies that led to clinical improvement of antibody-mediated rejection and to heart graft access.

CONCLUSIONS

Targeting CD38 with daratumumab significantly reduced anti-HLA antibodies and anti-HLA donor-specific antibodies in a nonhuman primate model and in two transplant clinical cases before and after transplant. This supports investigation of daratumumab as a potential therapeutic strategy; however, further research is needed regarding its use for both antibody-mediated rejection and desensitization.

Systematic review of the methods used in economic evaluations of targeted physical activity and sedentary behaviour interventions

The burden of noncommunicable diseases (NCD) on health systems worldwide is substantial. Physical inactivity and sedentary behaviour are major risk factors for NCD. Previous attempts to understand the value for money of preventative interventions targeting physically inactive individuals have proved to be challenging due to key methodological challenges associated with the conduct of economic evaluations in public health. A systematic review was carried out across six databases (Medline, SPORTSDiscus, EconLit, PsychINFO, NHS EED, HTA) along with supplementary searches. The review examines how economic evaluations published between 2009-March 2017 have addressed methodological challenges with the aim of bringing to light examples of good practice for future studies. Fifteen economic evaluations from four high-income countries were retrieved; there is a dearth of studies targeting sedentary behaviour as an independent risk factor from physical activity. Comparability of studies from the healthcare and societal perspectives were limited due to analysts' choice in cost categories, valuation technique and time horizon differing substantially. The scarcity of and inconsistencies across economic evaluations for these two behaviours have exposed a mismatch between calls for more preventative action to tackle NCD and the lack of information available on how resources may be optimally allocated in practice. Consequently, this paper offers a table of recommendations on how future studies can be improved.

Abstract 281: Antihypertensive Pharmacotherapy Eligibility Based Upon the 2017 ACC/AHA High Blood Pressure Clinical Practice Guidelines Among Young Adults Prior to Myocardial Infarction

Introduction: A recent study showed that in a cohort of young adults with MI (age ≤ 50 years) most young adults would not have been eligible for primary prevention statin therapy prior to their myocardial infarction (MI). Recent guidelines for hypertension re-define stage 1 hypertension to a systolic blood pressure (SBP) 130-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg and reclassify individuals with stage I hypertension and an elevated risk of atherosclerotic cardiovascular disease (ASCVD) to be eligible for pharmacotherapy. Our aim was to estimate the proportion of individuals with stage 1 hypertension who would be eligible for pharmacotherapy based on the 2017 hypertension guidelines among a cohort of adults ≤ 50 years of age prior to their MI.

Methods: The YOUNG-MI registry is a retrospective cohort which includes patients who presented with a first MI at age ≤ 50 to two large academic centers. We simulated the eligibility for anti-hypertensive pharmacotherapy for each patient by assigning a SBP value ranging from 128mmHg to 140 mmHg in 2 mmHg increments, while assuming a normal DBP. All individuals diagnosed with diabetes or chronic kidney disease were considered to be eligible for anti-hypertensive pharmacotherapy if their SBP was greater than or equal to 130mmHg, per the guidelines. The pooled cohort equations were used to calculate the cardiovascular risk in the remaining patients. Those with an ASCVD of ≥ 10% and Stage 1 hypertension (SBP 130-139 mmHg) were considered to be eligible for pharmacotherapy.

Results: Among 1838 adults, 284 (15.5%) had diabetes and 142 (9.2%) had chronic kidney disease and were thus classified as eligible for pharmacotherapy. The remaining 1412 individuals (median age 45 years, interquartile range 41-48 years; 17.1% women) had their eligibility determined based on the ASCVD risk score. In this group, the proportion eligible for anti-hypertensive therapy ranged from 7.7% (95% confidence interval 6.5%-9%) for a SBP of 130 to 11.4% (95% CI 9.8%-12.9%) for a SBP of 138 (Figure) .

Conclusions: While the new guidelines increase the number of individuals eligible for anti-hypertensive therapy, most young adults with Stage 1 hypertension would still not be eligible for pharmacotherapy prior to their MI, highlighting potential under-treatment of this at-risk young population.

Contact X-ray Brachytherapy as an Adjunct to a Watch and Wait Approach is an Affordable Alternative to Standard Surgical Management of Rectal Cancer for Patients with a Partial Clinical Response to Chemoradiotherapy

AIMS

Emerging evidence suggests that contact X-ray brachytherapy (CXB) may increase the clinical complete response rate and durability when administered after standard chemoradiotherapy in patients with rectal cancer. The addition of CXB in partial responders is therefore probably cost-effective. The affordability of widening access to CXB in the UK, however, has not been evaluated.

MATERIALS AND METHODS

Decision analytical modelling with Monte Carlo simulation was used to evaluate long-term costs for the management of patients with rectal cancers who were given a CXB boost when a clinical complete response was not initially achieved following chemoradiotherapy in order to facilitate a watch and wait approach. A third-party payer (National Health Service) perspective was adopted, probabilistic sensitivity analysis was carried out and a scenario analysis was performed to investigate the effect of the number of referral centres and number of patients treated with CXB.

RESULTS

We estimate that 818 (95% confidence interval 628-1021) patients per year are eligible for CXB as an adjunct to a watch and wait approach in England and Wales. As this management is less costly than surgical management for each individual patient, the more patients treated, the more affordable the technology. Even if as few as 125 patients are treated nationally in 15 centres, the cost of implementing this technology would be less than £4 million. If the average number of patients treated in each centre is 30, this technology would be cost saving within 5 years.

CONCLUSIONS

The cost of CXB is not prohibitive according to the National Institute for Health and Care Excellence threshold for implementation of new technology and may even be cost saving within 5 years compared with standard surgical management, depending on the uptake of the technology and the number of referral centres.

Causes of Troponin Elevation and Associated Mortality in Young Patients

BACKGROUND

While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals.

METHODS

We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file.

RESULTS

Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001).

CONCLUSION

There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction.

Whole body physiologically based modelling of β-blockers in the rat: events in tissues and plasma following an i.v. bolus dose

BACKGROUND AND PURPOSE

Whole body physiologically based pharmacokinetic (PBPK) models have been increasingly applied in drug development to describe kinetic events of therapeutic agents in animals and humans. The advantage of such modelling is the ability to incorporate vast amounts of physiological information, such as organ blood flow and volume, to ensure that the model is as close to reality as possible.

EXPERIMENTAL APPROACH

Previous PBPK model development of enantiomers of a series of seven racemic β-blockers, namely, acebutolol, betaxolol, bisoprolol, metoprolol, oxprenolol, pindolol and propranolol, together with S-timolol in rat was based on tissue and blood concentration data at steady state. Compounds were administered in several cassettes with the composition mix and blood and tissue sampling times determined using a D-optimal design.

KEY RESULTS

Closed-loop PBPK models were developed initially based on the application of open loop forcing function models to individual tissues and compounds. For the majority of compounds and tissues, distribution kinetics was adequately characterized by perfusion rate-limited models. For some compounds in the testes and gut, a permeability rate-limited distribution model was required to best fit the data. Parameter estimates of the tissue-to-blood partition coefficient through fitting of individual enantiomers and of racemic pair were generally in agreement and also concur with those from previous steady-state experiments.

CONCLUSIONS AND IMPLICATIONS

PBPK modelling is a very powerful tool to aid drug discovery and development of therapeutic agents in animals and humans. However, careful consideration of the assumptions made during the modelling exercise is essential.

Current practice of continence advisors in managing faecal incontinence in the United Kingdom: results of an online survey

AIM

To investigate the current practice of continence advisors in the United Kingdom.

METHOD

Continence advisors were contacted by email or letter to participate in a survey. The survey contained 27 questions which addressed the practice of each continence advisor, their knowledge of continence management and the adequacy of their training.

RESULTS

Two hundred and twenty-six out of a total of 448 continence advisors (50.4%), responded. One hundred and seventy (76.9%) advisors treated both faecal and urinary incontinence, 51 (23.1%) treated urinary incontinence. Thirty-six advisors (16.1%) were lone workers and 130 (58.6%) had more than 10 years' experience. The majority of the advisors (75.6%) performed a digital rectal examination as part of their assessment. Regarding the management of faecal incontinence, 148 prescribed suppositories, 127 offered enemas and 147 advised on rectal irrigation. Most of the advisors taught pelvic floor exercises (n = 207) and urge resistance techniques (n = 188). One hundred and fifty-nine (87.4%) prescribed the Peristeen Coloplast^® anal plug and 78 (47.6%) prescribed the Renew^® anal insert. Eighty-nine advisors (42.6%) felt they had not been adequately trained to provide a bowel continence service.

CONCLUSION

The majority of continence advisors in the UK manage faecal incontinence. They are able to initiate a broad range of conservative treatment options; however, almost half of the advisors who answered the survey felt inadequately trained and may be better supported by further training.

Study of young patients with myocardial infarction: Design and rationale of the YOUNG-MI Registry

The YOUNG-MI registry is a retrospective study examining a cohort of young adults age ≤ 50 years with a first-time myocardial infarction. The study will use the robust electronic health records of 2 large academic medical centers, as well as detailed chart review of all patients, to generate high-quality longitudinal data regarding the clinical characteristics, management, and outcomes of patients who experience a myocardial infarction at a young age. Our findings will provide important insights regarding prevention, risk stratification, treatment, and outcomes of cardiovascular disease in this understudied population, as well as identify disparities which, if addressed, can lead to further improvement in patient outcomes.

Abstract 036: LDL-Cholesterol Lowering Among Young Adults Who Experience a First Myocardial Infarction

Background: Current data suggest patients who have a myocardial infarction (MI) benefit from aggressive LDL cholesterol (LDL-C) lowering. Consequently, initiation of lipid lowering therapy is a class I recommendation post-MI to reduce the risk of future adverse events. We sought to evaluate LDL-C lowering among patients who experience a first MI at a young age.

Methods: Clinical & billing data were used to identify women < 50 years and men < 45 years who had a first MI from two large medical centers. Type of MI was adjudicated by review of medical records, and only patients with a Type 1 MI were included. The magnitude of LDL-C reduction was calculated by comparing the LDL-C pre-MI to the LDL-C one year later.

Results: 280 patients (age 42 years ± 5; 35% women) with a complete lipid panel prior to MI and 1 year post-MI were included in this analysis. The mean LDL-C was 123 mg/dL pre-MI, and 82 mg/dL post-MI (p<0.0001). In the entire population, the mean reduction in LDL-C post MI was 27% (95% CI, -32% to -23%), although men had a greater reduction than women (32% vs. 16%, p<0.001). When examining the post-MI LDL-C levels, 214 (76%) reached an LDL-C of <100 mg/dL and 115 (41%) reached an LDL-C of <70 mg/dL. Out of patients who had LDL-C>130mg/dL pre-MI (n=114), 82 (71%) reached an LDL-C of <100 mg/dL, and 35 (30%) reached an LDL-C of <70 mg/dL. Notably, 54 (19%) patients had an LDL-C increase at one year.

Conclusions: Among patients experiencing MI at a young age, LDL-C reduction was only modest (27% reduction). Women had a significantly smaller reduction in LDL-C compared with men. Further research is needed to determine the underlying reasons for the sub-optimal reduction in LDL-C, as well as sex specific differences that may account for these disparities.

Abstract 194: Diagnostic Accuracy of ICD Coding Among Young Patients With Suspected Myocardial Infarction

Background: Quality-of-care and outcomes research rely on proper coding of acute myocardial infarction (MI). Given the under-appreciation of MI in younger patients, as well as other conditions which may mimic MI, our purpose was to determine the extent to which diagnostic coding can discriminate young patients with MI from those who may present with alternate diagnoses that can account for elevated cardiac biomarkers.

Methods: Using clinical and coding data, we identified all patients presenting with a potential first MI (elevated cardiac biomarkers, ICD9 and ICD10 codes) at a young age (women < 50; men < 45 years of age) to two large medical centers over a 16-year period. Diagnosis and type of MI were adjudicated by review of medical records, as defined by the Third Universal Definition of MI.

Results: A total of 4531 patients (1951 women and 2580 men) with suspected MI were included in the analysis. Of those who ruled-in for MI (N=1579), only 1065 (67%) were accurately identified by diagnosis codes. Of 2952 patients who ruled-out for MI, 814 (27.5%) were falsely coded for MI. These patients had alternative explanations for their presentation, including: severe renal dysfunction (20.3%), myocarditis (13.7%), pulmonary embolism (5.4%), rhabdomyolysis/myositis (2.1%), and chest wall trauma (2.1%). The overall sensitivity of diagnosis codes was 67% and specificity was 72%.

Conclusions: Misclassifications in acute MI coding are highly prevalent in young patients with suspected acute coronary syndrome. Diagnostic codes had a modest sensitivity and specificity for diagnosing acute MI in young patients. False positive coding for MI among young individuals was largely due to confounding presentations, such as myocarditis, that increase cardiac biomarkers.

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m², hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS).

When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection.

The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.

Smoking Cessation, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology

Cigarette smoking has been implicated in causing many cancers and cancer deaths. There is mounting evidence indicating that smoking negatively impacts cancer treatment efficacy and overall survival. The NCCN Guidelines for Smoking Cessation have been created to emphasize the importance of smoking cessation and establish an evidence-based standard of care in all patients with cancer. These guidelines provide recommendations to address smoking in patients and outlines behavioral and pharmacologic interventions for smoking cessation throughout the continuum of oncology care.