Overall survival from tebentafusp versus nivolumab plus ipilimumab in first-line metastatic uveal melanoma: a propensity score-weighted analysis

BACKGROUND

Tebentafusp demonstrated a superior overall survival (OS) benefit [hazard ratio (HR) 0.51] compared to investigator's choice (82% pembrolizumab) in a randomized, phase III trial (IMCgp100-202; N = 378) in untreated metastatic uveal melanoma (mUM). The 1-year OS rates for tebentafusp and pembrolizumab were 73% and 59%, respectively. In the single-arm GEM1402 (N = 52), the 1-year OS rate for nivolumab plus ipilimumab (N+I) in mUM was 52%. Due to limitations in conducting randomized trials in mUM, we compared OS on tebentafusp or pembrolizumab (IMCgp100-202) to N+I (GEM1402) in untreated mUM using propensity scoring methods.

PATIENTS AND METHODS

Analyses were adjusted using propensity score-based inverse probability of treatment weighting (IPTW), balancing age, sex, baseline lactate dehydrogenase (LDH), baseline alkaline phosphatase, disease location, Eastern Cooperative Oncology Group status, and time from primary diagnosis to metastasis. OS was assessed using IPT-weighted Kaplan-Meier and Cox proportional hazard models. Sensitivity analyses using alternative missing data and weights methods were conducted.

RESULTS

The primary IPTW analysis included 240 of 252 patients randomized to tebentafusp from IMCgp100-202 and 45 of 52 N+I-treated patients from GEM-1402. Key baseline covariates, including LDH, were generally well balanced before weighting. The IPTW-adjusted OS favored tebentafusp, HR 0.52 [95% confidence interval (CI) 0.35-0.78]; 1-year OS was 73% for tebentafusp versus 50% for N+I. Sensitivity analyses showed consistent superior OS for tebentafusp with all IPTW HRs ≤0.61. IPTW analysis of pembrolizumab versus N+I showed no significant difference in OS (HR 0.72; 95% CI 0.50-1.06).

CONCLUSIONS

Tebentafusp was previously shown to provide an OS benefit compared to checkpoint inhibitors or chemotherapy in untreated mUM. Propensity score analysis demonstrated a similar OS benefit for tebentafusp compared with N+I. These data further support tebentafusp as the standard of care in previously untreated human leukocyte antigen (HLA)-A∗02:01+ adult patients with mUM.

Evolution with recombination as Gibbs sampling

This work presents a population genetic model of evolution, which includes haploid selection, mutation, recombination, and drift. The mutation-selection equilibrium can be expressed exactly in closed form for arbitrary fitness functions without resorting to diffusion approximations. Tractability is achieved by generating new offspring using n-parent rather than 2-parent recombination. While this enforces linkage equilibrium among offspring, it allows analysis of the whole population under linkage disequilibrium. We derive a general and exact relationship between fitness fluctuations and response to selection. Our assumptions allow analytical calculation of the stationary distribution of the model for a variety of non-trivial fitness functions. These results allow us to speak to genetic architecture, i.e., what stationary distributions result from different fitness functions. This paper presents methods for exactly deriving stationary states for finite and infinite populations. This method can be applied to many fitness functions, and we give exact calculations for four of these. These results allow us to investigate metastability, tradeoffs between fitness functions, and even consider error-correcting codes.

Chromosome-level genome sequence of the Genetically Improved Farmed Tilapia (GIFT, Oreochromis niloticus) highlights regions of introgression with O. mossambicus

BACKGROUND

The Nile tilapia (Oreochromis niloticus) is the third most important freshwater fish for aquaculture. Its success is directly linked to continuous breeding efforts focusing on production traits such as growth rate and weight. Among those elite strains, the Genetically Improved Farmed Tilapia (GIFT) programme initiated by WorldFish is now distributed worldwide. To accelerate the development of the GIFT strain through genomic selection, a high-quality reference genome is necessary.

RESULTS

Using a combination of short (10X Genomics) and long read (PacBio HiFi, PacBio CLR) sequencing and a genetic map for the GIFT strain, we generated a chromosome level genome assembly for the GIFT. Using genomes of two closely related species (O. mossambicus, O. aureus), we characterised the extent of introgression between these species and O. niloticus that has occurred during the breeding process. Over 11 Mb of O. mossambicus genomic material could be identified within the GIFT genome, including genes associated with immunity but also with traits of interest such as growth rate.

CONCLUSION

Because of the breeding history of elite strains, current reference genomes might not be the most suitable to support further studies into the GIFT strain. We generated a chromosome level assembly of the GIFT strain, characterising its mixed origins, and the potential contributions of introgressed regions to selected traits.

Prediction as a basis for skilled reading: insights from modern language models

Reading is not an inborn human capability, and yet, English-speaking adults read with impressive speed. This study considered how predictions of upcoming words impact on this skilled behaviour. We used a powerful language model (GPT-2) to derive predictions of upcoming words in text passages. These predictions were highly accurate and showed a tight relationship to fine-grained aspects of eye-movement behaviour when adults read those same passages, including whether to skip the next word and how long to spend on it. Strong predictions that were incorrect resulted in a prediction error cost on fixation durations. Our findings suggest that predictions for upcoming words can be made based on the analysis of text statistics and that these predictions guide how our eyes interrogate text at very short timescales. These findings open new perspectives on reading and language comprehension and illustrate the capability of modern language models to inform understanding of human language processing.

How to sequence 10,000 bacterial genomes and retain your sanity: an accessible, efficient and global approach

Non-typhoidal Salmonella(NTS)are typically associated with enterocolitis and linked to the industrialisation of food production. In recent years, NTS has been associated with invasive disease (iNTS disease) causing an estimated 77,000 deaths each year worldwide; 80% of mortality occurs in sub-Saharan Africa. New clades of S. Typhimurium and S. Enteritidis have been identified, which are characterised by genomic degradation, altered prophage repertoires and novel multidrug resistant plasmids. To understand how these clades are contributing to the burden and severity of iNTS disease, it is crucial to expand genome-based surveillance to cover more countries, and incorporate historical isolates to generate an evolutionary timeline of the development of iNTS.

We developedand validateda robust and inexpensive method for large-scale collection and sequencing of bacterial genomes. The “10,000 Salmonella genomes” project established a worldwide research collaboration to generate information relevant to the epidemiology, drug resistance and virulence factors of Salmonellae using a whole-genome sequencing approach. By streamlining collection of isolates and developing an efficient logistics pipeline, we gathered 10,419 clinical and environmental isolates from collections in low and middle-income countries within six months. Genome sequences are now available for isolates from 51 countries/territories dating from 1949 to 2017, with ~80 % representing African and Latin-American datasets. Our method can be applied to other large sample collections that require maximisation of resources within a limited timeframe. Detailed genome analyses are in progress and it is hoped that the resulting data will contribute to public health control strategies in low and middle-income countries.

An accessible, efficient and global approach for the large-scale sequencing of bacterial genomes

We have developed an efficient and inexpensive pipeline for streamlining large-scale collection and genome sequencing of bacterial isolates. Evaluation of this method involved a worldwide research collaboration focused on the model organism Salmonella enterica, the 10KSG consortium. Following the optimization of a logistics pipeline that involved shipping isolates as thermolysates in ambient conditions, the project assembled a diverse collection of 10,419 isolates from low- and middle-income countries. The genomes were sequenced using the LITE pipeline for library construction, with a total reagent cost of less than USD$10 per genome. Our method can be applied to other large bacterial collections to underpin global collaborations.

Metabolic syndrome contributes to the pulmonary arterial dysfunction in pulmonary hypertension in heart failure with preserved ejection fraction

Background

Many Heart Failure with preserved Ejection Fraction (HFpEF) patients have metabolic syndrome and develop Exercise Induced Pulmonary Hypertension (EIPH). The pathogenesis of EIPH in HFpEF remains unclear as there is no rodent model. As the SGLT2 inhibitor Empagliflozin improves clinical outcome in patients with type 2 diabetes and cardiovascular risk, we tested its effect on EIPH in a novel rat model of HFpEF.

Methods

Obese ZSF1 (HFpEF model) with leptin receptor mutation have metabolic syndrome and received the VEGF-inhibitor SU5416 to stimulate PH (Obese + Sugen). Half also received Empagliflozin (0.2 mg/kg/day) in drinking water from 8 to 22 weeks old. Lean ZSF1 lacking the mutation served as controls. During treadmill exercise, right/left ventricle (RV/LV) hemodynamics were evaluated via catheters. Pulmonary artery vascular smooth muscle cells (PAVSMC) prepared from normal or diabetic patients were cultured in standard media, or with Palmitate acid, Glucose and Insulin (PGI) to induce metabolic stress. Flow cytometry was used to evaluate reactive oxygen species (ROS) in mitochondria (Mitosox) or cytoplasm (CellROX).

Results

Relative to Lean, Obese + Sugen had increased body weight and HgA1C (Fig. 1A). Relative to Lean and at rest, Obese + Sugen showed mildly elevated RVSP and LVEDP. After exercise, LVSP and LVEDP rose similarly in Lean and Obese + Sugen. However, after exercise, Obese + Sugen showed a markedly greater increase in RVSP and exercise intolerance consistent with EIPH (Fig. 1B). In MR imaging of PA, Lean showed dobutamine (5 μg/kg/min)-induced PA dilation, which was not seen in Obese + Sugen (Fig. 1C). Protein levels of sGCβ1 (key regulator of PA relaxation) and its transcription factor (NFYA) both were decreased in PA from Obese + Sugen relative to Lean (Fig. 1D). Obese + Sugen + SGLT2 inhibitor treated rats showed marked improvements metabolic syndrome (body weight, HgA1c), exercise induced increase in RVSP, PA response to dobutamine, and increased NFYA and sGCβ1 expression (Fig. 1A–D). We observed greater ROS-induced DNA damage (8-OHdG staining) (Fig. 1E) and mitochondrial complex I, III, and IV activity in Obese + Sugen PA that was normalized in Obese + Sugen + SGLT2 inhibitor (Fig. 1F), suggesting a role of ROS in EIPH. Control human PAVSMC treated with PGI media showed elevated cytoplasmic and mitochondrial ROS, associated with increased mitochondrial complex I, III, IV and V activity (Fig. 1F, G). PGI media also accelerated the degradation of NFYA RNA and protein level in a manner mimicked by H2O2, and prevented by catalase/SOD (Fig. 1H, I), suggesting PGI-induced ROS enhanced NFYA degradation. Diabetic human PAVSMCs cultured in normal media resembled PGI-treated normal cells with respect to sGCb1 and NFYA expression, and in response to catalase/SOD (Fig. 1H, I).

Conclusions

In this PH-HFpEF model, metabolic syndrome contributes to PA dysfunction and EIPH through mitochondrial dysfunction and enhanced ROS, which were improved by Empagliflozin treatment.

Figure 1

Funding Acknowledgement

Type of funding source: None

Rapid Creation of an Online Discussion Space (r/nipah) During a Serious Disease Outbreak: Observational Study

BACKGROUND

During health emergencies, the people within affected communities ask many questions at a time when professional medics and health agencies are overstretched and struggling to cope. Our previous research has shown that, during the 2014-2015 West Africa Ebola crisis, volunteer-moderated online discussion forums were able to provide peer-to-peer reliable, trustworthy, and well-managed information. We speculated that with the right mix of epistemic and experiential knowledge, such a discussion forum could be set up rapidly during a future serious disease outbreak.

OBJECTIVE

The aim of this study was to set up a peer-to-peer health information exchange forum within the shortest time possible after the emergence of a real outbreak of a serious infectious disease. An outbreak of Nipah virus in Kerala, India, in May 2018 provided the opportunity to test our theories.

METHODS

We initiated a Nipah virus discussion forum on the platform Reddit, recruiting volunteer moderators from within the existing Reddit community. This facilitated posts and comments to the forum from genuine Reddit users. We gathered and analyzed data on the number of posts, comments, page views, and subscribers during the period of May 24 to June 23, 2018, by using the data analysis tools embedded in the Reddit platform.

RESULTS

We were able to set up a functioning health information exchange platform by May 24, 2018, within two weeks of the index case and one week of the official World Health Organization verification of a Nipah virus outbreak. Over the following five weeks, the forum received a steady flow of traffic including posts (36) and comments (21) submitted, page views (840), and subscribers (33). On the busiest day, 368 page views were recorded. The forum provided information in the languages spoken in the outbreak region as well as in English on how the virus spreads, symptoms of the disease, and how to take measures to avoid contracting it. Information on government helpline numbers and frequently asked questions was also provided to the community at risk.

CONCLUSIONS

The delivery of a fully functional discussion forum within a short space of time during an actual health emergency demonstrates that our suggestion is fully practical. Our theory that Reddit could provide a suitable platform to host such a forum was upheld. This offers great potential for public health communication during future serious disease outbreaks.

Realtime Tracking of Passengers on the London Underground Transport by Matching Smartphone Accelerometer Footprints

Passengers travelling on the London underground tubes currently have no means of knowing their whereabouts between stations. The challenge for providing such service is that the London underground tunnels have no GPS, Wi-Fi, Bluetooth, or any kind of terrestrial signals to leverage. This paper presents a novel yet practical idea to track passengers in realtime using the smartphone accelerometer and a training database of the entire London underground network. Our rationales are that London tubes are self-driving transports with predictable accelerations, decelerations, and travelling time and that they always travel on the same fixed rail lines between stations with distinctive bumps and vibrations, which permit us to generate an accelerometer map of the tubes’ movements on each line. Given the passenger’s accelerometer data, we identify in realtime what line they are travelling on and what station they depart from, using a pattern-matching algorithm, with an accuracy of up to about 90% when the sampling length is equivalent to at least 3 station stops. We incorporate Principal Component Analysis to perform inertial tracking of passengers’ positions along the line when trains break away from scheduled movements during rush hours. Our proposal was painstakingly assessed on the entire London underground, covering approximately 940 km of travelling distance, spanning across 381 stations on 11 different lines.

The availability and reliability of information on the premorbid functional status of stroke patients in hospital

In order to predict outcome after a stroke and set realistic targets for rehabilitation, it is essential to have reliable information on the patient's premorbid functional status. We assessed the availability of information on premorbid continence, mobility and mental status by examining the medical and nursing notes, one week after admission to a teaching hospital, of 164 stroke patients. Simple rating scales were used and results compared to information obtained from patients' relatives. Useful information on previous mobility was obtained from the notes in 58% of cases, on continence in 47%, and mental state in 44%. Although agreement between medical and nursing notes was reasonable (possibly due to sharing of information), agreement with the same information obtained from relatives was very poor. Information on the premorbid functional status of stroke patients is often not available in hospital notes, and when recorded is often inaccurate. Such data should be routinely obtained using standardized measures.

Increasing patient engagement in rehabilitation activities

Despite evidence that intensive rehabilitation speeds recovery from acute illness, several studies on British rehabilitation units have shown that the time spent by patients in therapeutic activities is low and that levels of 'engagement' are poor. We carried out an observational study of patient activity on four rehabilitation wards for the elderly (51 patients observed at half-hourly intervals between 8 a.m. and 5 p.m. on five successive days).

Patients were found to be engaged in therapeutically useful activities at only 17% of the observation points. When time spent in the therapy departments (where activities were not monitored) was excluded the proportion of useful activities fell to 11%. Similar patterns of activity were seen in all patient subgroups.

An intervention scheme was therefore devised, whereby an hourly activities programme tailored to the needs of each patient was worked out by therapists and ward staff, to be supervised by nurses. One nurse also organized regular group activities. The intervention programme, which required no extra resources, was instituted on two of the four wards.

A repeat survey conducted two months later showed a 55% increase in the proportion of time spent in useful activities on the two intervention wards but no change on the other two wards.

The 'S' test - a preliminary study of an instrument for selecting the most appropriate mobility aid

Objective: To develop and evaluate a qualitative and quantitative instrument for selecting the ideal mobility aid for those with mobility disorders.

Setting: A district general hospital-based geriatric unit.

Subjects: Elderly inpatients and outpatients with mobility disorders.

Interventions: Structured assessments with different mobility aids to select the most suitable.

Outcome measures: Safety, stance, stability, step/stride pattern and speed were considered.

Results: The 'S' test successfully selected an aid for all 49 subjects. For most this aid offered marked improvement in qualitative and quantitative aspects of gait when compared with the subject's usual aid.

Conclusions: The 'S' test is an effective tool for selecting mobility aids within an institutional setting.

International employees' concerns during serious disease outbreaks and the potential impact on business continuity: Lessons identified from the 2014-15 West African Ebola outbreak

This paper presents the findings of research carried out into the information-seeking behaviour, and information requirements of a small sample of international workers stationed in West Africa during the Zaire Ebola virus outbreak of 2014-15. The research study under which these results were obtained was part of exploratory research for a PhD focused on the use, and potential uses, of social media platforms during serious disease outbreaks that might be used to inform policy planning for public health and emergency response interventions. Thus, the findings from this study may provide valuable insights to business continuity managers and emergency planners in making future decisions about information exchange and crisis decision-making during future serious disease outbreaks.

Health Advice from Internet Discussion Forums: How Bad Is Dangerous?

BACKGROUND

Concerns over online health information-seeking behavior point to the potential harm incorrect, incomplete, or biased information may cause. However, systematic reviews of health information have found few examples of documented harm that can be directly attributed to poor quality information found online.

OBJECTIVE

The aim of this study was to improve our understanding of the quality and quality characteristics of information found in online discussion forum websites so that their likely value as a peer-to-peer health information-sharing platform could be assessed.

METHODS

A total of 25 health discussion threads were selected across 3 websites (Reddit, Mumsnet, and Patient) covering 3 health conditions (human immunodeficiency virus [HIV], diabetes, and chickenpox). Assessors were asked to rate information found in the discussion threads according to 5 criteria: accuracy, completeness, how sensible the replies were, how they thought the questioner would act, and how useful they thought the questioner would find the replies.

RESULTS

In all, 78 fully completed assessments were returned by 17 individuals (8 were qualified medical doctors, 9 were not). When the ratings awarded in the assessments were analyzed, 25 of the assessments placed the discussion threads in the highest possible score band rating them between 5 and 10 overall, 38 rated them between 11 and 15, 12 rated them between 16 and 20, and 3 placed the discussion thread they assessed in the lowest rating band (21-25). This suggests that health threads on Internet discussion forum websites are more likely than not (by a factor of 4:1) to contain information of high or reasonably high quality. Extremely poor information is rare; the lowest available assessment rating was awarded only 11 times out of a possible 353, whereas the highest was awarded 54 times. Only 3 of 78 fully completed assessments rated a discussion thread in the lowest possible overall band of 21 to 25, whereas 25 of 78 rated it in the highest of 5 to 10. Quality assessments differed depending on the health condition (chickenpox appeared 17 times in the 20 lowest-rated threads, HIV twice, and diabetes once). Although assessors tended to agree on which discussion threads contained good quality information, what constituted poor quality information appeared to be more subjective.

CONCLUSIONS

Most of the information assessed in this study was considered by qualified medical doctors and nonmedically qualified respondents to be of reasonably good quality. Although a small amount of information was assessed as poor, not all respondents agreed that the original questioner would have been led to act inappropriately based on the information presented. This suggests that discussion forum websites may be a useful platform through which people can ask health-related questions and receive answers of acceptable quality.

The neonatal gut harbours distinct bifidobacterial strains

BACKGROUND

Recent studies have described the bifidobacterial composition of neonates at a species level; however, with advancing technologies we can gain insight into the diversity of the bifidobacterial microbiota residing within the infant gut.

OBJECTIVE

To compare species and strain diversity of culturable bifidobacterial populations in faecal samples obtained from healthy term infants on three different feeding regimes.

STUDY DESIGN

In total, 51 healthy term infants were recruited for this study and divided equally into three different groups (n=17) based on their feeding regime during the first 4 weeks of life. Culturable bifidobacterial populations were analysed at week 1, week 4 and 6 months of age. Isolates were characterised to species level by 16s rRNA-internally transcribed spacer (ITS) gene sequence analysis and to strain level by pulsed field gel electrophoresis (PFGE).

RESULTS

In total,173 bifidobacterial strains were detected across all three groups from 2295 isolates, 42% (72 of 173) of which were detected in the prebiotic-fed group, followed by 30% (52 of 173) and 28% (49 of 173) in the breastfed and non-prebiotic-fed groups, respectively. Surprisingly, only two of the 51 infants harboured an identical bifidobacterial strain which was not present in the other 49 infants. Prebiotic supplementation in the early neonatal period increased the prevalence of Bifidobacterium longum in infants, in addition to promoting strain diversity. B. longum was the dominant species recovered from all three groups during the first 6 months of life, followed by Bifidobacterium breve and Bifidobacterium bifidum.

CONCLUSIONS

This study reveals a hitherto unknown level of diversity at the strain level among bifidobacteria isolated from different infants and the influence prebiotic formula feeding has on the bifidobacterial population.

Immune Tolerance Maintained by Cooperative Interactions between T Cells and Antigen Presenting Cells Shapes a Diverse TCR Repertoire

The T cell population in an individual needs to avoid harmful activation by self peptides while maintaining the ability to respond to an unknown set of foreign peptides. This property is acquired by a combination of thymic and extra-thymic mechanisms. We extend current models for the development of self/non-self discrimination to consider the acquisition of self-tolerance as an emergent system level property of the overall T cell receptor repertoire. We propose that tolerance is established at the level of the antigen presenting cell/T cell cluster, which facilitates and integrates cooperative interactions between T cells of different specificities. The threshold for self-reactivity is therefore imposed at a population level, and not at the level of the individual T cell/antigen encounter. Mathematically, the model can be formulated as a linear programing optimization problem that can be implemented as a multiplicative update algorithm, which shows a rapid convergence to a stable state. The model constrains self-reactivity within a predefined threshold, but maintains repertoire diversity and cross reactivity which are key characteristics of human T cell immunity. We show further that the size of individual clones in the model repertoire becomes heterogeneous, and that new clones can establish themselves even when the repertoire has stabilized. Our study combines the salient features of the “danger” model of self/non-self discrimination with the concepts of quorum sensing, and extends repertoire generation models to encompass the establishment of tolerance. Furthermore, the dynamic and continuous repertoire reshaping, which underlies tolerance in this model, suggests opportunities for therapeutic intervention to achieve long-term tolerance following transplantation.

To Use or Not to Use: The Prenatal Genetic Technology/Worry Conundrum

We conducted an exploratory, qualitative study investigating the factors influencing the use of genetic counseling and prenatal genetic testing for two groups: pregnant women 35 years of age and over (AMA) at the time of delivery and pregnant women with an abnormal maternal serum triple screen (MSAFP3). The convenience sample consisted of 25 semistructured interviews of women/couples and 50 observations of genetic counseling sessions. Worry turned out to be the most important variable influencing decision making about prenatal genetic testing and was greater in the MSAFP3 group than in the AMA group. The women in the AMA group appeared to assign the risk of having a child with Down syndrome to their age category rather than to themselves individually, whereas, the risk perception for women with an abnormal MSAFP3 appeared to have shifted from a general population risk for pregnant women to an individual, personal risk. There was a general lack of understanding and also more misinformation about the MSAFP3 screen compared to amniocentesis. Women in both groups were torn between fear of an invasive test and worry about the health of their fetus for the rest of their pregnancy if they did not undergo amniocentesis.

To Use or Not to Use: Male Partners' Perspectives on Decision Making About Prenatal Diagnosis

We conducted an exploratory, qualitative pilot study investigating the use of genetic counseling and prenatal genetic technologies between women and their male partners for two referral groups: pregnant women 35 years of age and over (AMA) at the time of delivery and pregnant women with an abnormal maternal serum triple screen (MSAFP3). The convenience sample consisted of 25 semistructured interviews and 50 observations of genetic counseling sessions. Male partners' styles of decision making and the way they viewed prenatal diagnosis decision making were examined. We defined three decision-making styles based on our interpretation of the data: (1) domain, (2) joint-delegated, and (3) saliency. The male partners also seemed to view prenatal diagnosis as either an information decision or an action decision and appeared to take a more active role in decision making when the decision was viewed as an action decision.

Acquire: an open-source comprehensive cancer biobanking system

MOTIVATION

The probability of effective treatment of cancer with a targeted therapeutic can be improved for patients with defined genotypes containing actionable mutations. To this end, many human cancer biobanks are integrating more tightly with genomic sequencing facilities and with those creating and maintaining patient-derived xenografts (PDX) and cell lines to provide renewable resources for translational research.

RESULTS

To support the complex data management needs and workflows of several such biobanks, we developed Acquire. It is a robust, secure, web-based, database-backed open-source system that supports all major needs of a modern cancer biobank. Its modules allow for i) up-to-the-minute 'scoreboard' and graphical reporting of collections; ii) end user roles and permissions; iii) specimen inventory through caTissue Suite; iv) shipping forms for distribution of specimens to pathology, genomic analysis and PDX/cell line creation facilities; v) robust ad hoc querying; vi) molecular and cellular quality control metrics to track specimens' progress and quality; vii) public researcher request; viii) resource allocation committee distribution request review and oversight and ix) linkage to available derivatives of specimen.

The effect of sensory-focused therapeutic interventions on functional outcomes in the hemiplegic upper limb following stroke

Background:

Despite the high prevalence of upper limb sensorimotor impairments among stroke victims, very few evidence-based reviews exist about the functional benefit of sensory-focussed therapeutic interventions upon the hemiplegic upper limb following stroke. This systematic-review aims to address this concern to determine the efficacy of sensory-focussed therapeutic interventions upon functional outcomes in the hemiplegic upper limb following stroke.

Methods:

Studies included within the systematic review were sourced from the following databases: Medline; SPORTDiscus; AMED; CINAHL; and PEDro, via EBSCO Host. The keywords used to obtain the pertinent literature were: ‘stroke’, ‘therapy’, ‘rehabilitation’, ‘function’, ‘upper limb’ and ‘sensory’. The reference list of each retrieved paper was hand searched to identify any additional relevant literature. Two independent researchers applied the specific inclusion/exclusion criteria to each paper to eliminate any irrelevant studies. The methodological quality of each of the selected papers was assessed using a modified version of the Downs and Black checklist. This gave a final total of 11 studies to be included within the systematic review. A data extraction form was devised and all relevant data was extrapolated from each study by two independent researchers. For each study, primary outcome measures were compared between the experimental group and the control group, pre- and post-treatment using the mean and standard deviation values. Statistical significance of these values was also assessed and compared using the respective P values.

Results:

Statistically significant results from all the included studies suggest that functional motor abilities of the hemiplegic upper limb following stroke can be improved by the application of the following sensory-focussed interventions: mirror therapy; thermal therapy; transcutaneous electrical stimulation; intermittent pneumatic compression; and proprioceptive and exteroceptive stimulation therapy. Due to significant differences in methodology and outcome measures, it was difficult to draw a comparison between the efficacies of specific sensory interventional subtypes evaluated within this review.

Conclusions:

This systematic review provides evidence to support the use of several sensory-focused therapeutic interventions for improving motor recovery in the hemiplegic upper-limb following stroke.

Implications:

This review indicates that sensory-focused therapeutic interventions should be employed in clinical practice as an evidence-based means to improve the functional abilities of patients with hemiplegic upper limbs post stroke.

Donor-directed MHC class I antibody is preferentially cleared from sensitized recipients of combined liver/kidney transplants

For patients with chronic renal and liver diseases, simultaneous liver and kidney transplantation (SLKT) is the best therapeutic option. The role of a pretransplant donor-specific antibody (DSA) in SLKT is unclear. We report the results of a retrospective review from 7/08 to 10/09 of SLKT at our institution. Monitoring of DSA was performed using single antigen bead assay. Between 7/08 and 10/09, there were six SLKT who had preformed DSA and positive XM (four class I and II DSA, one class I DSA only, one class II only). One-year patient and renal graft survival was 83%. Death-censored liver allograft survival was 100%. Acute humoral rejection (AHR) of the kidney occurred in 66% (three with both class I and II DSA and one with only class II DSA) of patients. In those with AHR, class I antibodies were rapidly cleared (p < 0.01) while class II antibodies persisted (p = 0.25). All patients who had humoral rejection of their kidney had preformed anticlass II antibodies. Liver allografts may not be fully protective of the renal allograft, especially with pre-existing MHC class II DSA. Long-term and careful follow-up will be critical to determine the impact of DSA on both allografts.

Recurrence and survival following preoperative sorafenib for advanced renal cell carcinoma

384

Background: The impact of neoadjuvant or preoperative therapy in the setting of advanced renal cell carcinoma on recurrence-free or survival outcomes is not known.

Methods: 28 patients with renal cell carcinoma were treated with preoperative sorafenib in a prospective pilot study (LCCC 0603). Patient files were reviewed a median of 885 days (2.42 years) following nephrectomy. Records were evaluated for 13 patients with nonmetastatic disease for development of recurrence, and for 15 patients with stage IV disease for survival.

Results: For the nonmetastatic patients, only 2 patients had developed recurrent disease, one underwent metastectomy and remains in surveillance and the other is on second line systemic targeted therapy. A median recurrence-free survival has not been met after a median 2.5 years. For stage IV disease patients at a median follow up of 2.3 years, a median survival has also not been reached. Four patients are deceased, one patient is lost to follow up, and 10 remain alive. Treatments for metastatic disease included continued sorafenib, high dose interleukin-2, sunitinib, pazopanib, temsirolimus, and everolimus. Some stage IV patients have also enjoyed prolonged treatment-free intervals ranging from six months to over two years, with biopsy confirmed, but indolent disease.

Conclusions: Although these data are descriptive, these observations are suggestive that preoperative therapy with sorafenib is unlikely to accelerate the growth of grossly metastatic or micrometastatic disease. Further studies are needed to determine whether preoperative therapy is valuable in improving recurrence-free or overall survival endpoints.

[Table: see text]

Biomarker analyses from a phase III, randomized, open-label, first-line study of gefitinib (G) versus carboplatin/paclitaxel (C/P) in clinically selected patients (pts) with advanced non-small cell lung cancer (NSCLC) in Asia (IPASS)

8006^

Background: IPASS demonstrated overall superiority of first-line G vs C/P for progression-free survival (PFS) in never/light ex-smokers with stage IIIB/IV adenocarcinoma NSCLC in Asia. PFS favored CP initially and then G. Outcome was correlated with biomarkers (preplanned exploratory objective). Methods: 683 patients provided tissue samples. Analyses included primary endpoint PFS (Cox proportional hazards) and secondary endpoint objective response rate (ORR; logistic regression) by biomarker status. Results: EGFR mutation (M) status was evaluable in 437 pts by Amplification Refractory Mutation System (ARMS; 60% M+). M+ pts had significantly longer PFS and higher ORR and M- pts significantly shorter PFS and lower ORR with G than C/P. In M unknown pts PFS and ORR were similar to overall population. Post hoc analysis of overall survival favored G in M+ pts (31% maturity; HR 0.78; 95% CI 0.50–1.20) and C/P in M- pts (53% maturity; HR 1.38; 95% CI 0.92–2.90); differences were not statistically significant and follow-up is ongoing. EGFR gene-copy number was evaluable in 406 pts by fluorescence in situ hybridization (FISH; 61% FISH +). Similar PFS and ORR results to analyses by M status were observed, driven by the overlap in EGFR FISH and M status. EGFR protein expression (PE) was evaluable in 365 pts by immunohistochemistry (73% PE+). PFS outcomes did not differ statistically between PE+ and PE-. ORR favored G in both PE+ and - pts. Conclusions: EGFR M status was a strong predictive biomarker for the efficacy of G vs C/P in this clinically selected first-line setting.

[Table: see text]

No significant financial relationships to disclose.

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.

Epidermal growth factor receptor (EGFR) immunohistochemistry: Comparison of antibodies (Abs) and cut points to predict benefit from gefitinib in a phase III placebo-controlled study in advanced non-small cell lung cancer (NSCLC)

7576

Background: Tumor tissues obtained from the ISEL phase III trial assessing the efficacy of gefitinib vs placebo in chemotherapy-pretreated NSCLC were used to evaluate two Abs (DAKO and Zymed) and assess whether different cut points of EGFR protein expression improved prediction of response and survival benefit from gefitinib. Methods: EGFR protein expression in tumor samples was assessed by immunohistochemistry using DAKO EGFR pharmDx kit (scoring percent of tumor cells with positive staining, predefined cut point of =10%) and Zymed monoclonal Ab clone 31G7 (scoring proportion of positive cells times staining intensity [scale 0–400], predefined cut point of =200). Results: Clinical characteristics of the patients (pts) assessed with DAKO (n=379) and Zymed (n=357) Abs reflected the overall study population (N=1692) with the exception of fewer never-smokers and Asians. Of the pts evaluated with DAKO/Zymed Abs, females represented 32%/31%; never-smokers, 13%/14%; Asians, 6%/4%; adenocarcinomas, 44%/42%; and 88%/88% of pts were refractory to most recent chemotherapy. With the above criteria, 70% of tumor samples were scored as positive using DAKO Ab and 68% using the Zymed Ab (agreement between assessments 76%). The objective response rates in gefitinib treated EGFR-positive pts defined with various cut points with DAKO Ab (=1% to =90%) varied between 8% and 12%, and with Zymed Ab (score =50 to =350), between 10% and 13%. Lower cut points with the DAKO Ab provided the best discrimination between EGFR positive and EGFR negative patients in terms of survival hazard ratios (HRs) comparing gefitinib to placebo, with a significant treatment/cut point interaction for the 10% cut point (p=0.049). A similar trend was noted for Zymed Ab, although the discrimination between HRs was less apparent and not significant for any cut point analyzed. Conclusion: Assessment with DAKO PharmDx kit, according to percentage of positive staining, may provide more accurate prediction of survival benefit for gefitinib-treated pts than assessment with Zymed Ab and staining index. Use of higher cut points to define positivity does not improve discrimination of the test.

No significant financial relationships to disclose.

Illness action rediscovered: a case study of upper limb pain

Theoretical frameworks provide generalised accounts of illness action although empirical studies of the process are still in short supply. This study of upper limb pain provided a case study of illness action; as it is a common condition, there is uncertainty about its treatment and management, orthodox and non-orthodox care are seen as legitimate sources of help and it is linked with a range of causes. Face-to-face informal interviews were carried out with 47 informants with upper limb pain and their practitioners (n= 19). The data were analysed in two different ways. The general stages of the illness action process were identified through a descriptive analysis of the upper limb pain sufferers' accounts and the policies and practices reported by their practitioners. Then, case studies were constructed to depict individual pathways through healthcare and consequences for sufferers. The illness action process was characterised by the normalisation and accommodation of pain informed by a discourse that predominantly invoked ageing and the wear and tear of the body. Practitioners also preferred to adopt a biomechanical approach and were reluctant to attribute psychosocial labels. The case studies illustrated the divergent, negotiated and opportunistic nature of the process and showed that the use of both orthodox and non-orthodox care formed only part of strategies used to manage upper limb pain. Sufferers evaluated the care they received in terms of pain alleviation, and were resigned to searching for the best way of living with their pain.

Gene Gun-delivered pGM-CSF Adjuvant Induces Enhanced Emigration of two Dendritic Cell Subsets from the Skin

Two subsets of sheep afferent lymph dendritic cells (DC) are defined by the differential expression of CD172a and CD45RA. The majority (~70%) of CD172a(+) subset is CD45RA/CD11c(+)/CD207(+)/TLR4(+). The CD172a(-) DC are CD45RA(+)/CD207(-) and express low levels of CD11c and CD86. Real-time RT-PCR showed that CD172(+) DC produce IL-1beta and IL-10 and high levels of IL-18 but almost no IL-12p40; CD172a(-) DC express IL-12p40 but no IL-10 and low levels of IL-1beta and IL-18. Gene gun-delivered granulocyte-macrophage colony-stimulating factor (pGM-CSF) caused an early rise in the output of CD172a(+) DC, changes to DC phenotype and significant increases in the levels of expression cytokine transcripts. However, pGM-CSF did not affect any qualitative changes to cytokine expression, CD172a(+) DC remained IL-10(+)/IL-12p40(-) and the CD172(-) DC remained IL-10(-)/IL-12p40(+).

Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient satisfaction

BACKGROUND

Beliefs and mental well-being could influence decisions to consult about upper limb pain and satisfaction with care.

OBJECTIVES

To describe beliefs about upper limb pain in the community and explore associations of beliefs and mental health with consulting and dissatisfaction.

METHODS

Questionnaires were mailed to 4998 randomly chosen working-aged patients from general practices in Avon. We asked about upper limb pain, consulting, beliefs about symptoms, dissatisfaction with care, somatizing tendency (using elements of the Brief Symptom Inventory) and mental well-being (using the Short-Form 36). Associations were explored by logistic regression.

RESULTS

Among 2632 responders, 1271 reported arm pain during the past 12 months, including 389 consulters. A third or more of responders felt that arm pain sufferers should avoid physical activity, that problems would persist beyond 3 months, that a doctor should be seen straightaway and that neglect could lead to permanent harm. Consulters were significantly more likely to agree with these statements than other upper limb pain sufferers. The proportion of consultations attributable to such beliefs was substantial. Dissatisfaction with care was commoner in those with poor mental health: the OR for being dissatisfied (worst versus best third of the distribution) was 3.2 (95% CI 1.2-8.5) for somatizing tendency and 2.4 (95% CI 1.3-4.7) for SF-36 score. Both factors were associated with dissatisfaction about doctors' sympathy, communication and care in examining.

CONCLUSIONS

Negative beliefs about upper limb pain are common and associated with consulting. Somatizers and those in poorer mental health tend, subsequently, to feel dissatisfied with care.