Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

PURPOSE

Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications.

METHODS AND MATERIALS

Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis.

RESULTS

Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption.

CONCLUSIONS

This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Inflammatory pathways confer resistance to chemoradiotherapy in anal squamous cell carcinoma

Anal squamous cell carcinoma (ASCC) is associated with immunosuppression and infection with human papillomavirus (HPV). Response to standard chemoradiotherapy (CRT) varies considerably. A comprehensive molecular characterization of CRT resistance is lacking, and little is known about the interplay between tumor immune contexture, host immunity, and immunosuppressive and/or immune activating effects of CRT. Patients with localized ASCC, treated with CRT at three different sites of the German Cancer Consortium (DKTK) were included. Patient cohorts for molecular analysis included baseline formalin fixed paraffin embedded biopsies for immunohistochemistry (n = 130), baseline RNA sequencing (n = 98), peripheral blood immune profiling (n = 47), and serum cytokine measurement (n = 35). Gene set enrichment analysis showed that pathways for IFNγ, IFNα, inflammatory response, TNFα signaling via NF-κB, and EMT were significantly enriched in poor responders (all p < 0.001). Expression of interferon-induced transmembrane protein 1 (IFITM1), both on mRNA and protein levels, was associated with reduced Freedom from locoregional failure (FFLF, p = 0.037) and freedom from distant metastasis (FFDM, p = 0.014). An increase of PD-L1 expression on CD4+ T-cells (p < 0.001) and an increase in HLA-DR expression on T-cells (p < 0.001) was observed in the peripheral blood after CRT. Elevated levels of regulatory T-cells and CXCL2 were associated with reduced FFLF (p = 0.0044 and p = 0.004, respectively). Inflammatory pathways in tissue in line with elevated levels of regulatory T-cells and CXCL2 in peripheral blood are associated with resistance to CRT. To counteract this resistance mechanism, the RADIANCE randomized phase-2 trial currently tests the addition of the immune checkpoint inhibitor durvalumab to standard CRT in locally advanced ASCC.

Exploring the potential of virtual reality for the self-management of chronic pain: A scoping review of its use to address health literacy

BACKGROUND

Individuals with low health literacy struggle to manage long-term conditions. Addressing pain-related health competencies is important in the management of chronic pain. Virtual reality may be a useful tool for empowering sustainable health-related stratgies due to its unique ability to engage users in artificial environments.

OBJECTIVES

The aim of this scoping review was to explore existing research on the use of virtual reality as a tool to promote health literacy in people with chronic pain.

DESIGN

Scoping Review guided by framework proposed by Arksey & O'Malley.

METHOD

Articles related to "pain", "virtual reality" and "health literacy" were searched in four electronic databases: CINAHL, PubMed, Embase and PsycINFO using a formal search strategy. Studies were categorised based on intervention content using the Health Literacy Pathway Model which encompasses health knowledge, self-management skills, health communication and information seeking.

RESULTS

Thirteen studies met the inclusion criteria. Several elements of pain related health literacy were not addressed in the research. Interventions addressed health knowledge, self-management skills, decision making and featured content aiming to address emotional barriers to pain-related health literacy. Other components including active information seeking and use, actively communicating with health professionals and seeking and negotiating treatment options, were not explicitly addressed.

CONCLUSION

There is heterogeneity in existing research exploring the use of VR to support people with chronic pain. Existing VR tools to address pain-related health literacy do not cover several key components of health literacy. More research is required before a robust assessment of efficacy can be undertaken.

Combination of Fenugreek and Quinoa Husk as Sources of Steroidal and Triterpenoid Saponins: Bioactivity of Their Co-Extracts and Hydrolysates

Saponins, both steroidal and triterpenoid, exhibit distinct bioactivities. However, they are not commonly found together in natural sources; instead, sources tend to be rich in one type or another and mainly in the form of saponins rather than the sapogenin aglycones. Developing co-extracts containing both saponin or sapogenin types would be a strategy to harness their respective bioactivities, yielding multibioactive extracts. Therefore, this study evaluates the bioactivity (hypolipidemic, antioxidant, and anti-inflammatory activities) of co-extracts from fenugreek seeds (steroidal-rich saponins) and quinoa husk (triterpenoid-rich saponins), co-extracted at varying proportions, alongside their respective sapogenin-rich hydrolysates. Pancreatic lipase inhibition increased with fenugreek content in co-extracts, especially in sapogenin-rich variants. The latter substantially interfered with cholesterol bioaccessibility (90% vs. 15% in sapogenin-rich extracts). Saponin-rich co-extracts exhibited reduced cytokine release with increased fenugreek content, while sapogenin-rich counterparts showed greater reductions with higher quinoa husk content. Limited cellular antioxidant activities were observed in all extracts, with improved post-hydrolysis bioactivity. Therefore, simultaneous co-extraction of steroidal and triterpenoid sources, such as fenugreek and quinoa husk, as well as their subsequent hydrolysis, are innovative strategies for obtaining multibioactive natural extracts.

Evaluation of the interrelated effects of slaughtering, drying, and defatting methods on the composition and properties of black soldier fly (Hermetia illucens) larvae fat

The interrelated effect of different slaughtering, drying and defatting methods of black soldier fly larvae (BSFL) on the lipid composition and properties of the fat was studied. Blanching and freezing were compared as slaughtering methods, oven or freeze-drying as drying methods, and mechanical pressing or supercritical fluid extraction (SFE) as defatting methods. The different modes of slaughtering, drying, and defatting, along with both binary and ternary interactions caused significant effects on processes yields, lipid composition, moisture content and thermal properties. Thus, considering the defatting degree and the yield in total valued products (defatted meal plus fat), the combination of blanching, freeze-drying plus mechanical pressing was the worst option (51.2% and 87.5%, respectively). In contrast, the other combinations demonstrated better and comparable efficiency, although SFE is preferable for defatting (83.2% and 96.9%, respectively). The content of major fatty acids (lauric, palmitic and myristic acids) was significantly affected by the BSFL treatments, although with unsignificant impact on the total saturated fatty acids content. To preserve the integrity of the fat, the combination of blanching and oven-drying was preferred, as non-thermal methods of slaughtering and drying caused intense lipolysis, releasing free fatty acids (FFA) in the range of 18.6-23.5%. To achieve the lowest moisture content in the fats (≤0.1%), oven-drying with mechanical pressing were desired, regardless of the slaughtering method; while values > 1% were reached for freezing, freeze-drying and SFE. Both differences in FFA and moisture contents caused different thermal behaviors in the samples. Specially, the melting temperature was lower for samples with higher FFA and moisture contents, with a notable difference when freezing, freeze-drying and SFE were combined (14.5 °C vs 30.6 °C, as the mean value for the rest of samples). The different modes of processing did not affect the minor lipid compounds. Therefore, the modes employed for slaughtering, drying, and defatting of BSFL determine, either individually or in combination, the process yields, composition, and properties of the fat.

Bioetics Issues of Artificial Placenta and Artificial Womb Technology

Abstract

The worldwide infertility crisis and the increase in mortality and morbidity among infants, due to preterm births and associated complications, have stimulated research into artificial placenta (AP) and artificial womb (AW) technology as novel solutions. These technologies mimic the natural environment provided in the mother's womb, using chambers that ensure the supply of nutrients to the fetus and disposal of waste substances through an appropriate mechanism. This review aims to highlight the background of AP and AW technologies, revisit their historical development and proposed applications, and discuss challenges and bioethical and moral issues. Further research is required to investigate any negative effects of these new technologies, and ethical concerns pertaining to the structure and operation of this newly developed technology must be addressed and resolved prior to its introduction to the public sphere.

Human Cloning: Biology, Ethics, and Social Implications

Abstract

This scholarly article delves into the multifaceted domains of human cloning, encompassing its biological underpinnings, ethical dimensions, and broader societal implications. The exposition commences with a succinct historical and contextual overview of human cloning, segueing into an in-depth exploration of its biological intri-cacies. Central to this biological scrutiny is a comprehensive analysis of somatic cell nuclear transfer (SCNT) and its assorted iterations. The accomplishments and discoveries in cloning technology, such as successful animal cloning operations and advances in the efficiency and viability of cloned embryos, are reviewed. Future improvements, such as reprogramming procedures and gene editing technology, are also discussed. The discourse extends to ethical quandaries intrinsic to human cloning, entailing an extensive contemplation of values such as human dignity, autonomy, and safety. Furthermore, the ramifications of human cloning on a societal plane are subjected to scrutiny, with a dedicated emphasis on ramifications encompassing personal identity, kinship connections, and the fundamental notion of maternity. Culminating the analysis is a reiteration of the imperative to develop and govern human cloning technology judiciously and conscientiously. Finally, it discusses several ethical and practical issues, such as safety concerns, the possibility of exploitation, and the erosion of human dignity, and emphasizes the significance of carefully considering these issues.

In Memory of Professor Derek Pheby

Abstract

Professor Derek Pheby's passing in November 2022 marked a profound loss for the scientific community. Professor Derek Pheby, a stalwart figure in the fields of autoimmune diseases and bioethics, was known for his dedication to scientific research and patients' support, particularly for those affected by paraneoplastic autoimmune syndromes. Professor Pheby made significant contributions to research, especially about Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). His leadership of the ME Biobank and scientific coordination of EUROMENE demonstrated his commitment to pushing boundaries and fostering international collaborations. Professor Pheby's scientific work addressed various aspects of ME/CFS, from physician education to patient needs, the development of a post-mortem tissue bank, and effective treatments. Beyond his medical career, Professor Pheby was a crucial member of the Independent Ethics Committee of MAGI, he was a poet, humanitarian, and advocate for child protection. His generosity and boundless spirit left an enduring legacy, fostering innovative research in the pursuit of combating autoimmune diseases.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

An evaluation of a one-day pain science education event in a high school setting targeting pain related beliefs, knowledge, and behavioural intentions

BACKGROUND

Persistent pain is a common condition affecting one in four UK adults. Public understanding of pain is limited. Delivering pain education within schools may improve public understanding in the longer term.

OBJECTIVE

To evaluate the impact of a one-day Pain Science Education (PSE) event on sixth form/high school students' pain beliefs, knowledge and behavioural intention.

METHODS

Exploratory, single-site, mixed-methods, single-arm study involving secondary school students ≥16 years old attending a one-day PSE event. Outcome measures included the Pain Beliefs Questionnaire (PBQ), Concepts of Pain Inventory (COPI-ADULT), a vignette to assess pain behaviours; and thematic analysis of semi-structured interviews.

RESULTS

Ninety (mean age 16.5 years, 74% female) of the 114 attendees, agreed to participate in the evaluation. PBQ scores improved on the Organic beliefs subscale [mean difference -5.9 (95% CI -6.8, -5.0), P < 0.01] and Psychosocial Beliefs subscale [1.6 (1.0, 2.2) P < 0.01]. The COPI-Adult revealed an improvement [7.1 (6.0-8.1) points, P < 0.01] between baseline and post intervention. Pain behavioural intentions improved post education for work, exercise, and bed rest related activities (p < 0.05). Thematic analysis of interviews (n = 3) identified increased awareness of chronic pain and its underpinning biology, beliefs that pain education should be widely available, and that pain management should be holistic.

CONCLUSIONS

A one-day PSE public health event can improve pain beliefs, knowledge and behavioural intentions in high school students and increase openness to holistic management. Future controlled studies are needed to confirm these results and investigate potential long-term impacts.

A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE

Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial.

MATERIALS AND METHODS

Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding.

RESULTS

Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery.

CONCLUSIONS

Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.

Iodotyrosines Are Biomarkers for Preclinical Stages of Iodine-Deficient Hypothyroidism in Dehal1-Knockout Mice

Background: Iodine is required for the synthesis of thyroid hormone (TH), but its natural availability is limited. Dehalogenase1 (Dehal1) recycles iodine from mono- and diiodotyrosines (MIT, DIT) to sustain TH synthesis when iodine supplies are scarce, but its role in the dynamics of storage and conservation of iodine is unknown. Methods: Dehal1-knockout (Dehal1KO) mice were generated by gene trapping. The timing of expression and distribution was investigated by X-Gal staining and immunofluorescence using recombinant Dehal1-beta-galactosidase protein produced in fetuses and adult mice. Adult Dehal1KO and wild-type (Wt) animals were fed normal and iodine-deficient diets for 1 month, and plasma, urine, and tissues were isolated for analyses. TH status was monitored, including thyroxine, triiodothyronine, MIT, DIT, and urinary iodine concentration (UIC) using a novel liquid chromatography with tandem mass spectrometry method and the Sandell-Kolthoff (S-K) technique throughout the experimental period. Results: Dehal1 is highly expressed in the thyroid and is also present in the kidneys, liver, and, unexpectedly, the choroid plexus. In vivo transcription of Dehal1 was induced by iodine deficiency only in the thyroid tissue. Under normal iodine intake, Dehal1KO mice were euthyroid, but they showed negative iodine balance due to a continuous loss of iodotyrosines in the urine. Counterintuitively, the UIC of Dehal1KO mice is twofold higher than that of Wt mice, indicating that S-K measures both inorganic and organic iodine. Under iodine restriction, Dehal1KO mice rapidly develop profound hypothyroidism, while Wt mice remain euthyroid, suggesting reduced retention of iodine in the thyroids of Dehal1KO mice. Urinary and plasma iodotyrosines were continually elevated throughout the life cycles of Dehal1KO mice, including the neonatal period, when pups were still euthyroid. Conclusions: Plasma and urine iodotyrosine elevation occurs in Dehal1-deficient mice throughout life. Therefore, measurement of iodotyrosines predicts an eventual iodine shortage and development of hypothyroidism in the preclinical phase. The prompt establishment of hypothyroidism upon the start of iodine restriction suggests that Dehal1KO mice have low iodine reserves in their thyroid glands, pointing to defective capacity for iodine storage.

Validation of immunoassays for the Chlamydia trachomatis antigen Pgp3 using a chimeric monoclonal antibody

Seroepidemiology, or measuring antibodies to pathogens to estimate population-level exposure, can provide useful public health data. The tests used, however, often lack sufficient validation data due to absence of a gold standard. For many pathogens, serum antibodies can be detected long after resolution of infection, but infection status is often used as a gold standard for antibody positivity. To ensure that recently developed antibody tests for seroepidemiology of Chlamydia trachomatis (Ct), the causative agent of urogenital chlamydia and the blinding eye disease trachoma, have high performance, we generated a chimeric antibody to the immunodominant Ct antigen Pgp3. Two clones were selected to evaluate the test performance of three assays to measure antibodies to Pgp3: multiplex bead assay (MBA), enzyme-linked immunosorbent assay (ELISA), and lateral flow assay (LFA). Overall, each assay demonstrated high accuracy and precision when tested using either clone, and the clones were stable when stored at - 20 °C and 4 °C for almost 2 years. The limit of detection was similar for MBA and LFA, but almost a log-fold higher (i.e. less sensitive) using ELISA. Overall, the chimeric antibodies represent stable control reagents for tests with robust performance and will facilitate deployment of these tests to other laboratories.

Treponemal Antibody Seroprevalence Using a Multiplex Bead Assay from Samples Collected during the 2018 Nigeria HIV/AIDS Indicator and Impact Survey: Searching for Yaws in Nigeria

Yaws is a chronic, relapsing disease of skin, bone, and cartilage caused by Treponema pallidum subsp. pertenue. Yaws was last reported in Nigeria in 1996, although neighboring countries have recently reported cases. We investigated serological evidence for yaws among children aged 0-14 years in Nigeria by measuring antibodies to the treponemal antigens rp17 and TmpA in blood specimens from a 2018 nationally representative HIV survey using a multiplex bead assay. The presence of antibodies to both antigens ("double positive") likely reflects current or recent treponemal infection. Overall, 1.9% (610/31,549) of children had anti-TmpA antibodies, 1.5% (476/31,549) had anti-rp17 antibodies, and 0.1% (39/31,549) were double positive. Among households, 0.5% (84/18,021) had a double-positive child, with a clustering of double-positive children. Although numbers are low, identification of antibodies to both TmpA and rp17 may warrant investigation, including more granular epidemiologic and clinical data, to assess the potential for continuing yaws transmission in Nigerian children.

The Interaction of Slaughtering, Drying, and Defatting Methods Differently Affects Oxidative Quality of the Fat from Black Soldier Fly (Hermetia illucens) Larvae

The interrelation effect of slaughtering, drying, and defatting methods of BSFL on the oxidative quality of the derived fat was studied. Blanching and freezing were compared as slaughtering methods, followed by oven or freeze-drying for drying and mechanical pressing or SFE for defatting. The oxidative state and stability of the extracted fat and defatted meals were monitored immediately after their production, using peroxide value (PV) and Rancimat test, and over 24 weeks of storage. Slaughtering and drying methods had an independent effect on PV, with freezing and freeze-drying being the best methods. Mechanical pressing and SFE were comparable and superior to conventional hexane defatting. Interactions were observed between slaughtering and defatting, drying and defatting, and between all three factors. Generally, freeze-drying combined with any of the slaughtering and defatting methods resulted in the lowest PVs, with mechanical pressing being preferred. Freeze-drying plus mechanical pressing also produced the most stable fats during storage according to the evolution of PV, while the combination of blanching and SFE produced the least stable. A significant correlation was found between the PV at 24 weeks and the antioxidant activity of the fats. Contrary to storage assays, in accelerated Rancimat assays, freeze-dried samples were the least stable, which was partially attributed to the significant correlation with the acid values of the samples. Defatted meals followed a similar pattern to the extracted fat, except for worse oxidation for SFE defatting. Therefore, the different processing methods of slaughtering, drying, and defatting of BSFL differently affect lipid oxidation, with interactions between such successive steps.

Deciphering the interactions between lipids and red wine polyphenols through the gastrointestinal tract

This paper investigates the mutual interactions between lipids and red wine polyphenols at different stages of the gastrointestinal tract by using the simgi® dynamic simulator. Three food models were tested: a Wine model, a Lipid model (olive oil + cholesterol) and a Wine + Lipid model (red wine + olive oil + cholesterol). With regard to wine polyphenols, results showed that co-digestion with lipids slightly affected the phenolic profile after gastrointestinal digestion. In relation to lipid bioaccessibility, the co-digestion with red wine tended to increase the percentage of bioaccessible monoglycerides, although significant differences were not found (p > 0.05). Furthermore, co-digestion with red wine tended to reduce cholesterol bioaccessibility (from 80 to 49 %), which could be related to the decrease in bile salt content observed in the micellar phase. For free fatty acids, almost no changes were observed. At the colonic level, the co-digestion of red wine and lipids conditioned the composition and metabolism of colonic microbiota. For instance, the growth [log (ufc/mL)] of lactic acid bacteria (6.9 ± 0.2) and bifidobacteria (6.8 ± 0.1) populations were significantly higher for the Wine + Lipid food model respect to the control colonic fermentation (5.2 ± 0.1 and 5.3 ± 0.2, respectively). Besides, the production of total SCFAs was greater for the Wine + Lipid food model. Also, the cytotoxicity of the colonic-digested samples towards human colon adenocarcinoma cells (HCT-116 and HT-29) was found to be significantly lower for the Wine and Wine + Lipid models than for the Lipid model and the control (no food addition). Overall, the results obtained using the simgi® model were consistent with those reported in vivo in the literature. In particular, they suggest that red wine may favourably modulate lipid bioaccessibility - a fact that could explain the hypocholesterolemic effects of red wine and red wine polyphenols observed in humans.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

[Deep brain stimulation as a treatment for severe multidrug-resistant obsessive compulsive disorder]

Obsessive compulsive disorder (OCD) is a common and disabling psychiatric condition. About 10 % of patients are considered to be severely affected and refractory to the usual treatments, combining antidepressants and psychotherapy. Deep brain stimulation (DBS) is a promising treatment, reserved for specialized university centers. It is based on the implantation of electrodes aimed at modulating dysfunctional cortico-striato-thalamo-cortical circuits. After studying the different targets to be used, it is now proposed to rethink DBS in terms of networks. The improvement of pathophysiological knowledge of OCD and the development of functional neuroimaging techniques should allow the design of individualized treatment protocols.

Reactive surveillance of suicides during the COVID-19 epidemic in France, 2020- March 2022

Background

Mitigation actions during the COVID-19 pandemic, in particular lockdowns and curfews, may impact mental health and suicide in general populations. We aimed to analyse the evolution in suicide deaths from January 2020 to March 2022 in France.

Methods

Using free-text medical causes in death certificates, we built an algorithm, which aimed to identify suicide deaths. We measured its retrospective performances by comparing suicide deaths identified using the algorithm with deaths which had either an ICD10 code for ‘intentional self-harm’ or for ‘external cause of undetermined intent’ as underlying cause. The number of suicide deaths from January 2020 to November 2021 was then compared with the expected number estimated using a generalized additive model. The analysis was stratified by age group and gender. Analysis from December 2021 to March 2022 was conducted using electronic death certificates only.

Results

The free-text algorithm demonstrated high performances. From January 2020 to November 2021, suicide mortality declined during France's three lockdowns, particularly in men, and remained quite comparable with expected values between and after both of the country's lockdowns. Provisional results based on electronic death certificates suggest that suicide mortality remained stable until March 2022.

Conclusions

Monitoring suicide mortality is possible in France with a 4-month delay; this will be reduced to two days when electronic death certification is fully deployed. This study highlighted the absence of an increase in suicide mortality during France's COVID-19 pandemic, and a substantial decline during lockdowns periods, something already observed in other countries. Further studies are required to explain the factors for this decline.

Key messages

• In the absence of reactive coding of medical causes of deaths, the study proposed an approach to reactively identify suicide based on free-text medical causes from death certificates.

• Our findings provide reassurance that the COVID-19 pandemic has not had a negative impact on the general population in terms of suicide in France from March 2020 to September 2021.

Deletion of the extracellular matrix glycoprotein ADAMTSL3 increases pro-fibrotic signalling and exacerbates heart failure in mice

Background/Introduction

Cardiac fibrosis is a central pathophysiological process accompanying most cardiac diseases including heart failure, and is a predictor of poor outcomes. The fibrotic process is mediated by activated cardiac fibroblasts (CFBs), so-called myofibroblasts, which produce excessive amounts of type I collagen and other ECM molecules. The ADAMTSL family of glycoproteins is upregulated in the cardiac extracellular matrix (ECM) during heart failure, but their function in the heart is unknown. Some ADAMTSL proteins are suggested to regulate the TGFβ, a major driver of myofibroblast activation and cardiac fibrosis.

Purpose

The purpose of this study was to examine the role of ADAMTSL3 in TGFβ-regulation and heart failure.

Methods

ADAMTSL3 expression was analysed in failing hearts of patients and mice. To study the functional role of ADAMTSL3 in the failing heart, an Adamtsl3 knock-out (L3-KO) mouse was generated, and WT and L3-KO littermates were subjected to experimental heart failure by aortic banding (AB), or sham surgery, for a total of six weeks. The mice were followed with echocardiography and MRI, and the left ventricles (LVs) were harvested one and six weeks after AB or sham surgery, with molecular analyses performed. To elucidate molecular functions of ADAMTSL3 in vitro, we overexpressed ADAMTSL3 in CFBs producing an extensive ECM.

Results

We determined that ADAMTSL3 was produced by CFBs and upregulated in failing hearts of patients and mice. The L3-KO mice had a normal cardiac phenotype at baseline, but upon increased LV afterload developed a dilated cardiomyopathy phenotype with increased LV dilation and reduced systolic function from one week post-AB. Furthermore, high mortality was observed in the L3-KO mice post-AB, with 60% vs. 96% survival of WTs over six weeks. At one week post-AB RNA sequencing of LVs revealed 233 differentially expressed genes in L3-KO vs. WT, with Col1a1 and Postn among the most upregulated, suggesting increased fibrosis and TGFβ signalling. Increased canonical TGFβ signalling was confirmed by increased SMAD2/3 phosphorylation and increased Lox expression in L3-KOs six weeks post-AB. In vitro, ADAMTSL3 overexpression in cultured CFBs resulted in reduced collagen synthesis and reduced expression of COL1A1, LOX, CTGF and POSTN, indicating anti-fibrotic properties. Furthermore, ADAMTSL3 inhibited the expression of ACTA2 and SPP1, reduced α-SMA protein by 25%, and reduced proliferation and CFB contraction, suggesting attenuated TGFβ signalling and inhibited myofibroblast differentiation.

Conclusions

ADAMTSL3 was upregulated in human and mouse heart failure, and served an anti-fibrotic and cardio-protective role in failing mouse hearts. Mechanistically, ADAMTSL3 was produced by CFBs and inhibited myofibroblast differentiation and collagen synthesis through TGFβ in cultured CFBs.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Research Council of Norway

Effects of a Mealworm (Tenebrio molitor) Extract on Metabolic Syndrome-Related Pathologies: In Vitro Insulin Sensitivity, Inflammatory Response, Hypolipidemic Activity and Oxidative Stress

The mealworm (Tenebrio molitor Linnaeus 1758) is gaining importance as one of the most popular edible insects. Studies focusing on its bioactivities are increasing, although alternative forms of consumption other than the whole insect or flour, such as bioactive non-protein extracts, remain underexplored. Furthermore, the incidence of metabolic syndrome-related pathologies keeps increasing, hence the importance of seeking novel natural sources for reducing the impact of certain risk factors. The aim was to study the potential of a non-protein mealworm extract on metabolic syndrome-related pathologies, obtained with ethanol:water (1:1, v/v) by ultrasound-assisted extraction. We characterized the extract by gas-chromatography mass-spectrometry and assessed its hypolipidemic potential, its ability to scavenger free radicals, to attenuate the inflammatory response in microglial cells, to affect mitochondrial respiration and to enhance insulin sensitivity in mouse hepatocytes. The extract contained fatty acids, monoglycerides, amino acids, certain acids and sugars. The mealworm extract caused a 30% pancreatic lipase inhibition, 80% DPPH· scavenging activity and 55.9% reduction in the bioaccessibility of cholesterol (p = 0.009). The extract was effective in decreasing iNOS levels, increasing basal, maximal and ATP coupled respiration as well as enhancing insulin-mediated AKT phosphorylation at low insulin concentrations (p < 0.05). The potential of a non-protein bioactive mealworm extract against metabolic syndrome-related pathologies is shown, although further studies are needed to elucidate the mechanisms and relationship with compounds.

Ocular syphilis resurgence in an urban underserved community in the United States

AIM

To evaluate the clinical characteristics, demographics, and visual outcomes of patients with ocular syphilis at an urban hospital to increase awareness and assist in earlier diagnosis and treatment of the resurgent disease.

METHODS

A retrospective chart review was performed on patients with ICD-9 and ICD-10 diagnosis codes correlating with syphilis or syphilis-related ocular diseases between 2010 and 2019. Variables evaluated included age, gender, race, vision, ocular findings, human immunodeficiency virus (HIV) status and men who have sex with men status, recreational drug and alcohol use.

RESULTS

Ocular syphilis was diagnosed in 40 patients (53 eyes) of a total of 229 patients who tested positive for syphilis via serum and/or cerebrospinal fluid treponemal testing from 2010-2019. Among patients with ocular syphilis, most patients were males, aged 45 or above and Black, and had no diagnosed HIV infection. Approximately 50% patients had 20/40 vision or better. Nearly 50% had non-granulomatous anterior uveitis as their initial presentation, and 49% of patients had involvement of the posterior segment. Neovascular glaucoma (5.7%), papillitis (7.5%), vasculitis (5.7%), and retinal detachment (5.7%) were rarer presentations of the disease and were associated with a poorer visual prognosis.

CONCLUSION

Given the increased prevalence and protean manifestations of syphilis, early diagnosis and treatment are paramount. More studies on ocular syphilis are warranted to understand this resurging disease.

Small molecule MMRi62 targets MDM4 for degradation and induces leukemic cell apoptosis regardless of p53 status

MDM2 and MDM4 proteins are key negative regulators of tumor suppressor p53. MDM2 and MDM4 interact via their RING domains and form a heterodimer polyubiquitin E3 ligase essential for p53 degradation. MDM4 also forms heterodimer E3 ligases with MDM2 isoforms that lack p53-binding domains, which regulate p53 and MDM4 stability. We are working to identify small-molecule inhibitors targeting the RING domain of MDM2-MDM4 (MMRi) that can inactivate the total oncogenic activity of MDM2-MDM4 heterodimers. Here, we describe the identification and characterization of MMRi62 as an MDM4-degrader and apoptosis inducer in leukemia cells. Biochemically, in our experiments, MMRi62 bound to preformed RING domain heterodimers altered the substrate preference toward MDM4 ubiquitination and promoted MDM2-dependent MDM4 degradation in cells. This MDM4-degrader activity of MMRi62 was found to be associated with potent apoptosis induction in leukemia cells. Interestingly, MMRi62 effectively induced apoptosis in p53 mutant, multidrug-resistant leukemia cells and patient samples in addition to p53 wild-type cells. In contrast, MMRi67 as a RING heterodimer disruptor and an enzymatic inhibitor of the MDM2-MDM4 E3 complex lacked MDM4-degrader activity and failed to induce apoptosis in these cells. In summary, this study identifies MMRi62 as a novel MDM2-MDM4-targeting agent and suggests that small molecules capable of promoting MDM4 degradation may be a viable new approach to killing leukemia cells bearing non-functional p53 by apoptosis.

Multiplex Serology for Measurement of IgG Antibodies Against Eleven Infectious Diseases in a National Serosurvey: Haiti 2014-2015

Background

Integrated surveillance for multiple diseases can be an efficient use of resources and advantageous for national public health programs. Detection of IgG antibodies typically indicates previous exposure to a pathogen but can potentially also serve to assess active infection status. Serological multiplex bead assays have recently been developed to simultaneously evaluate exposure to multiple antigenic targets. Haiti is an island nation in the Caribbean region with multiple endemic infectious diseases, many of which have a paucity of data for population-level prevalence or exposure.

Methods

A nationwide serosurvey occurred in Haiti from December 2014 to February 2015. Filter paper blood samples (n = 4,438) were collected from participants in 117 locations and assayed for IgG antibodies on a multiplex bead assay containing 15 different antigens from 11 pathogens: Plasmodium falciparum, Toxoplasma gondii, lymphatic filariasis roundworms, Strongyloides stercoralis, chikungunya virus, dengue virus, Chlamydia trachomatis, Treponema pallidum, enterotoxigenic Escherichia coli, Entamoeba histolytica, and Cryptosporidium parvum.

Results

Different proportions of the Haiti study population were IgG seropositive to the different targets, with antigens from T. gondii, C. parvum, dengue virus, chikungunya virus, and C. trachomatis showing the highest rates of seroprevalence. Antibody responses to T. pallidum and lymphatic filariasis were the lowest, with <5% of all samples IgG seropositive to antigens from these pathogens. Clear trends of increasing seropositivity and IgG levels with age were seen for all antigens except those from chikungunya virus and E. histolytica. Parametric models were able to estimate the rate of seroconversion and IgG acquisition per year for residents of Haiti.

Conclusions

Multiplex serological assays can provide a wealth of information about population exposure to different infectious diseases. This current Haitian study included IgG targets for arboviral, parasitic, and bacterial infectious diseases representing multiple different modes of host transmission. Some of these infectious diseases had a paucity or complete absence of published serological studies in Haiti. Clear trends of disease burden with respect to age and location in Haiti can be used by national programs and partners for follow-up studies, resource allocation, and intervention planning.

Microwave-Assisted Acid Hydrolysis vs. Conventional Hydrolysis to Produce Sapogenin-Rich Products from Fenugreek Extracts

The acid hydrolysis of saponins is commonly performed by conventional heating to produce sapogenin-rich products of bioactive interest, but alternative hydrolysis methods and their impact on bioactivity have been unexplored. We compared the conventional method with microwave-assisted acid hydrolysis (MAAH) of a commercial saponin-rich extract from a typical saponin source, fenugreek, focusing on the study of temperature (100, 120, 130, 140, 150 °C) and time (10, 20, 30, 40 min) of hydrolysis. The impact of these factors was assayed on both the sapogenin yield and the bioactivity of the hydrolyzed products, specifically their antioxidant and lipase inhibitory activities. The highest sapogenin content (34 g/100 g extract) was achieved by MAAH at 140 °C and 30 min, which was higher than conventional hydrolysis at both reference conditions (100 °C, 60 min, 24.6 g/100 g extract) and comparative conditions (140 °C, 30 min, 17 g/100 g extract) (p < 0.001). Typical steroid artifacts from sapogenins were observed in very small amounts, regardless of the method of hydrolysis. Antioxidant activity of MAAH hydrolyzed extracts (around 80% DPPH inhibition) was barely affected by time and temperature, but pancreatic lipase inhibitory activity was higher (>65%) at lower MAAH temperature (<130 °C) and time (<30 min) of hydrolysis. MAAH is shown as a valid alternative to produce selective sapogenin-rich extracts from fenugreek with minor impact on their bioactivities, and whose magnitude can be modulated by the hydrolysis conditions.

Influence of In Vitro Gastric Digestion of Olive Leaf Extracts on Their Bioactive Properties against H. pylori

The aim of this work was to evaluate the influence of in vitro gastric digestion of two olive leaf extracts (E1 and E2) on their chemical composition and bioactive properties against Helicobacter pylori (H. pylori), one of the most successful and prevalent human pathogens. HPLC-PAD/MS analysis and anti-inflammatory, antioxidant, and antibacterial activities of both olive leaf extracts were carried out before and after their in vitro gastric digestion. The results showed that gastric digestion produced modifications of the chemical composition and bioactive properties of both olive leaf extracts. The main compounds in the extract E1 were hydroxytyrosol and its glucoside derivatives (14,556 mg/100 g), presenting all the identified compounds a more polar character than those found in the E2 extract. E2 showed a higher concentration of less polar compounds than E1 extract, with oleuropein (21,419 mg/100 g) being the major component. Gastric digestion during the fasted state (pH 2) induced an overall decrease of the most identified compounds. In the extract E1, while the anti-inflammatory capacity showed only a slight decrease (9% of IL-8 production), the antioxidant properties suffered a drastic drop (23% of ROS inhibition), as well as the antibacterial capacity. However, in the extract E2, these changes caused an increase in the anti-inflammatory (19% of IL-8 production) and antioxidant activity (9% of ROS inhibition), which could be due to the hydrolysis of oleuropein and ligustroside into their main degradation products, hydroxytyrosol and tyrosol, but the antibacterial activity was reduced. Gastric digestion during fed state (pH 5) had less influence on the composition of the extracts, affecting in a lesser degree their anti-inflammatory and antioxidant activity, although there was a decrease in the antibacterial activity in both extracts similar to that observed at pH 2.

Prevention and management of anastomotic leakage after colorectal surgery: A Swiss national consensus

Objective

Anastomotic leakage (AL) is one of the most feared complications of colorectal surgery. Despite surgical improvements, AL incidence remains significant and guidance on its prevention and management is lacking. The aim of the study was to achieve a Swiss nationwide consensus on clinical prevention and management of AL.

Methods

A three-step Delphi consensus meeting was performed in 2020 involving 78 Swiss surgeons from 40 centers. A steering-group drafted the questions, gathered best available evidence which was discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

The three consensus meetings were attended by 66, 57 and 37 surgeons, respectively. Surgeons’ median experience was 14 years, with 47% performing &gt;50 colorectal resections yearly. Consensus was reached on routine use of preoperative nutritional screening (100%) using nutritional scores (88%) and &gt;10% weight loss (95%). but not low BMI (63%) or low albumin (64%). Consensus was reached for no bowel preparation (BP) prior to right colectomy (RC) (76%) and for mechanical BP with oral antibiotics prior anterior resections (AR) (70%). No consensus was found on BP prior left colectomy (LC). Respondents favored a side-to-side anastomosis (76%) after RC, with extra-corporeal confection (70%), without consensus on the anastomosis being stapled or hand-sewn; an end-to-end (73%), stapled (80%) anastomosis after LC and a stapled anastomosis (86%) after AR, irrespective of the anastomosis configuration type. Anastomotic control with transanal leak-test was supported by 92%, while ICG control did not reached consensus (67%). After TME, routine diversion was favored (73%), irrespective of neoadjuvant therapy (94%) or not (70%). Consensus was reached on routine postoperative CRP monitoring (94%). CT-scan with rectal contrast enema was the preferred investigation for suspected AL after RC or LC (82%) and AR (76%). Conservative management of AL, provided appropriate clinical state, was an acceptable option after LC (72%), AR with stoma (95%), but not after RC (59%) or AR without stoma (53%).

Conclusion

Consensus was reached on several clinical aspects for prevention and management of AL among Swiss colorectal surgeons, providing national guidance. Further data is required on intraoperative aspects of anastomosis confection and control to ensure broader consensus.

OP0269 BIOMARKERS TO PREDICT RISK OF VENOUS THROMBOEMBOLISM IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING TOFACITINIB OR TUMOUR NECROSIS FACTOR INHIBITORS

Background

In the ORAL Surveillance study of patients (pts) aged ≥50 yrs with moderate to severe rheumatoid arthritis (RA) and ≥1 additional cardiovascular risk factor (NCT02092467), the incidence of pulmonary embolism was higher with tofacitinib than with tumour necrosis factor inhibitors (TNFi).1

Objectives

To explore whether biomarkers explained the associations of tofacitinib vs TNFi with venous thromboembolism (VTE) in ORAL Surveillance.

Methods

ORAL Surveillance was a prospective, open-label, event-driven, noninferiority, post-authorisation safety study. Pts were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily or a TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). For this exploratory post hoc analysis, 294 soluble, proteomic, genetic and antibody biomarkers were assessed (of which 79 have a known role in inflammation, coagulation, vascular biology and/or Janus kinase signalling). Biomarkers were quantified in serum collected at baseline (BL) and Month (M)12 in VTE cases and 4:1 matched controls. D-dimer was analysed with a larger control group (all eligible pts without VTE) and final adjudicated data from BL, M12 and study end.

Results

Of the 4362 randomised and treated pts, D-dimer was quantified in 3732 pts (54 with VTE; 3678 without) and the remaining biomarkers were analysed in 285 pts (57 VTE cases; 228 matched controls). BL characteristics were generally similar in those with or without VTE and between treatment groups. At BL, D-dimer levels were ≥2×upper limit of normal for ~50% of controls and 67% of VTE cases. Mean D-dimer levels decreased from BL to M12 in controls across treatment groups (Figure 1). Key findings from the biomarker analyses are shown in the Table 1. No biomarker showed a clear mechanistic association with the increased risk of VTE for tofacitinib vs TNFi, or demonstrated adequate performance for prognostic use in pts with RA.

Table 1.

Summary of results from biomarker analyses

BiomarkerKey resultsTier 1C-reactive protein•No association with VTE in any treatment arm at BL or M12D-dimer Thrombopoietin•Higher M12 levels were prospectively associated with greater risk of subsequent VTE with tofacitinib 10 mg BID ◦ For D-dimer, the same effect was observed with tofacitinib 5 mg BID •Treatment specificity of effects could not be establishedTier 2Factor VIII Thrombin–antithrombin complex Tissue factor pathway inhibitor Plasminogen activator inhibitor-1 Protein C Antithrombin Apolipoprotein C-III Leptin•No clinically meaningful differences across treatment armsTiers 3 & 4Exploratory proteomic assays (276 markers from multiplex panels)•Two biomarkers with no known relationship to VTE (angiogenin and TNFSF13B) showed significant associations with pulmonary embolism in the tofacitinib 10 mg BID arm ◦ Treatment specificity of effects could not be established for either analyteGenetic biomarkersFactor V Leiden R506Q, prothrombin G20210A and JAK2 V617F mutations•Factor V Leiden and prothrombin risk alleles, individually or combined, were associated with increased incidence of VTE but did not explain excess events with tofacitinib •No VTE cases or matched controls had the JAK2 mutationAntibody biomarkersACA IgG and IgM, anti-β2GP1 IgG and IgM•No statistical differences were observed between treatment arms or between VTE cases and matched controls

ACA, anticardiolipin antibody; β2GP1, beta-2-glycoprotein 1; IgG, immunoglobulin G; IgM, immunoglobulin M; JAK2, Janus kinase 2; TNFSF13B, tumour necrosis factor ligand superfamily member 13B

Conclusion

This post hoc exploratory analysis did not identify biomarkers at BL or M12 that explain the increased VTE risk for tofacitinib vs TNFi. Notably, ORAL Surveillance was neither designed nor powered to compare the risk of VTE across treatments or to identify biomarkers with a mechanistic relationship to VTE. Individual VTE risk should be considered when making decisions about initiation or maintenance of tofacitinib treatment.

References

[1]Ytterberg et al. N Engl J Med 2022; 386: 316-326.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Julia King, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Grant/research support from: Pfizer Inc, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Burak Sahin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sara A Paciga Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Zhenyu Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Craig Hyde Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, David Martin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jeffrey I Weitz Speakers bureau: Anthos, Bayer AG, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Ionis, Janssen, Novartis, Pfizer Inc, PhaseBio, Portola and Servier Pharmaceuticals, Grant/research support from: Bayer AG and Boehringer Ingelheim

Swiss consensus on the management of acute diverticulitis

Objective

Acute diverticulitis is a frequent clinical conditions encountered in emergency settings. Despite recent international guidelines, management of acute diverticulitis (AD) varies and is not standardized. The aim of the study was to achieve a Swiss nationwide consensus on clinical management of acute diverticulitis.

Methods

A three-staged consensus meeting according to the Delphi method was performed in 2020 involving 78 Swiss surgeons from 40 hospitals. A steering-group drafted the questionnaires, gathered best available evidence which was presented and discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

57 surgeons answered all the 3 rounds and 28 (53%) performed &gt; 50 colorectal resections per year. On initial workup in the emergency setting, performing leucocytes count (87%), CRP (98%) and CT imaging (98%) reached consensus for the diagnosis, but no uniform classification system of AD was retained. Signs of generalized peritonitis (100%), requiring intravenous pain medication (98%), inability to tolerate oral intake (95%), lack of adequate social support (86%), immunosuppression (96%), and complicated AD on CT (84%) were criteria for hospitalization. Persisting symptoms (95%) and immunosuppression (89%) were criteria for elective colonic resection, while the number of AD episodes were not (27%). In case of abscess, a size ≥ 4 cm reached consensus for percutaneous drainage (88%). No consensus were reached for surgical approach and techniques in the emergency settings, apart from damage control surgery for instable patients (70%). In the follow-up, recommendation for dietary restrictions or lifestyle habits did not reach reach consensus.

Conclusion

Swiss colorectal surgeons reached consensus for several diagnostics, hospitalization, and elective surgery criterias. However, emergency surgical management and follow-up are less standardized. These variations should be further assessed, and particularly in the context the latest published recommendations.

A national survey integrating clinical, laboratory, and WASH data to determine the typology of trachoma in Nauru

Background

The epidemiology of trachoma in several Pacific Islands differs from other endemic settings, in that there is a high prevalence of clinical signs of trachoma, particularly trachomatous inflammation—follicular (TF), but few cases of trichiasis and limited evidence of ocular chlamydial infection. This so-called “Pacific enigma” has led to uncertainty regarding the appropriate public health response. In 2019 alongside Nauru’s national trachoma population survey, we performed bacteriological and serological assessments of children to better understand the typology of trachoma and to determine whether there is a need for trachoma interventions.

Methods

We used two-stage cluster sampling, examining residents aged ≥1 year and collecting household-level water, sanitation, and hygiene (WASH) variables. Children aged 1–9 years provided conjunctival swabs and finger-prick dried blood spots to investigate the presence of Chlamydia trachomatis nucleic acid and anti-Pgp3 antibodies, respectively.

Principal Findings

In 818 participants aged 1–9 years, the age-adjusted TF prevalence was 21.8% (95% CI 15.2–26.2%); ocular C. trachomatis prevalence was 34.5% (95% CI 30.6–38.9), and anti-Pgp3 antibody prevalence was 32.1% (95% CI 28.4%–36.3%). The age- and gender-adjusted prevalence of trichiasis in ≥15-year-olds was 0.3% (95% CI 0.00–0.85), but no individual with trichiasis had trachomatous scarring (TS). Multivariable analysis showed an association between age and both TF (OR per year of age 1.3 [95% CI 1.2–1.4]) and anti-Pgp3 positivity (OR 1.2 [95% CI 1.2–1.3]). There were high rates of access to water and sanitation and no WASH variable was associated with the presence of TF.

Conclusions

TF, nucleic acid, and age-specific antibody prevalence collectively indicate that high levels of C. trachomatis transmission among children present a high risk of ocular damage due to trachoma. The absence of trichiasis with trachomatous scarring suggest a relatively recent increase in transmission intensity.

In contrast to several neighbouring Pacific Island nations, Nauruan children are heavily affected by active trachoma and the cause is ocular infection with C. trachomatis. Comprehensive public health intervention to control trachoma in Nauru is required. The use of laboratory markers for current and previous C. trachomatis infection should be considered in baseline trachoma prevalence surveys as we approach global elimination of trachoma, and in settings with inconsistent findings during previous screening exercises.

Integration of Single-Cell RNA- and CAGE-seq Reveals Tooth-Enriched Genes

Organ development is dictated by the regulation of genes preferentially expressed in tissues or cell types. Gene expression profiling and identification of specific genes in organs can provide insights into organogenesis. Therefore, genome-wide analysis is a powerful tool for clarifying the mechanisms of development during organogenesis as well as tooth development. Single-cell RNA sequencing (scRNA-seq) is a suitable tool for unraveling the gene expression profile of dental cells. Using scRNA-seq, we can obtain a large pool of information on gene expression; however, identification of functional genes, which are key molecules for tooth development, via this approach remains challenging. In the present study, we performed cap analysis of gene expression sequence (CAGE-seq) using mouse tooth germ to identify the genes preferentially expressed in teeth. The CAGE-seq counts short reads at the 5'-end of transcripts; therefore, this method can quantify the amount of transcripts without bias related to the transcript length. We hypothesized that this CAGE data set would be of great help for further understanding a gene expression profile through scRNA-seq. We aimed to identify the important genes involved in tooth development via bioinformatics analyses, using a combination of scRNA-seq and CAGE-seq. We obtained the scRNA-seq data set of 12,212 cells from postnatal day 1 mouse molars and the CAGE-seq data set from postnatal day 1 molars. scRNA-seq analysis revealed the spatiotemporal expression of cell type-specific genes, and CAGE-seq helped determine whether these genes are preferentially expressed in tooth or ubiquitously. Furthermore, we identified candidate genes as novel tooth-enriched and dental cell type-specific markers. Our results show that the integration of scRNA-seq and CAGE-seq highlights the genes important for tooth development among numerous gene expression profiles. These findings should contribute to resolving the mechanism of tooth development and establishing the basis for tooth regeneration in the future.

Integration of radiation oncology teaching in medical studies by German medical faculties due to the new licensing regulations : An overview and recommendations of the consortium academic radiation oncology of the German Society for Radiation Oncology (DEGRO)

The new Medical Licensing Regulations 2025 (Ärztliche Approbationsordnung, ÄApprO) will soon be passed by the Federal Council (Bundesrat) and will be implemented step by step by the individual faculties in the coming months. The further development of medical studies essentially involves an orientation from fact-based to competence-based learning and focuses on practical, longitudinal and interdisciplinary training. Radiation oncology and radiation therapy are important components of therapeutic oncology and are of great importance for public health, both clinically and epidemiologically, and therefore should be given appropriate attention in medical education. This report is based on a recent survey on the current state of radiation therapy teaching at university hospitals in Germany as well as the contents of the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog Medizin 2.0, NKLM) and the closely related Subject Catalogue (Gegenstandskatalog, GK) of the Institute for Medical and Pharmaceutical Examination Questions (Institut für Medizinische und Pharmazeutische Prüfungsfragen, IMPP). The current recommendations of the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) regarding topics, scope and rationale for the establishment of radiation oncology teaching at the respective faculties are also included.

Analytical and Clinical Performance Evaluation of ARK Fentanyl II Assay on Beckman Coulter AU System

Introduction/Objective

Drugs of abuse, specifically opioids, have been in recent years an important focus in both medicine and media due to the ‘opioid epidemic’ and large numbers of overdose deaths. Synthetic opioids such as fentanyl have contributed to this epidemic. The CDC reports that of roughly 50,000 opioid overdose deaths in 2019, nearly 73% were due to synthetic opioids. The objective of this study is to assess the analytical and clinical performance of the Fentanyl II Assay by ARK Diagnostics, Inc.

Methods/Case Report

Fentanyl was qualitatively determined by the ARK Fentanyl II Assay, a homogenous enzyme immunoassay based on competition between drug in the specimen and drug labeled with recombinant glucose-6- phosphate dehydrogenase (rG6PDH) for antibody binding sites. The presence of drug in urine increases enzyme activity, which converts nicotinamide adenine dinucleotide (NAD) to NADH in the presence of glucose-6-phosphate, resulting in an absorbance change measured by spectrophotometry. The evaluation was performed following CLSI guidelines. The analytical performance was evaluated for accuracy and precision.

Results (if a Case Study enter NA)

To evaluate the accuracy, twelve positive and eight negative specimens were tested by the ARK immunoassay performed on two Beckman Coulter instruments (AU480 and AU680) and by LC- MS/MS. The results from both instruments showed 100% agreement with the results from LC-MS/MS. On instrument AU480, the within-run CVs were 18.0% at the level of 22.510 ng/mL and 0.8% at the level of 552.628 ng/mL. The between-run CVs were 8.8% at the level of 68.928 ng/mL and 3.7% at the level of 158.947 ng/mL. On instrument AU680, the within-run CVs were 273.4% at the level of 1.052 ng/mL and 0.8% at the level of 523.788 ng/mL. The between-run CVs were 7.8% at the level of 53.779 ng/mL and 3.1% at the level of 145.263 ng/mL. In May 2021, 2,075 fentanyl assays were run at UAB. Of those, 476 returned a positive result with a positive rate of 22.9%, and 1,599 were negative with a negative rate of 77.1%. One positive result was confirmed by LC-MS/MS as negative for fentanyl but positive for norfentanyl, a metabolite of fentanyl. The clinical specificity was 99.9% and sensitivity was 100%.

Conclusion

In Conclusion, the ARK fentanyl Assay II on Beckman Coulter AU system has good accuracy, sensitivity and specificity. The precision at medium and high levels are good. However, the precision at low level needs to be improved.

Humanitarian Accountability in Displacement Contexts: Five Years on from the Grand Bargain

Humanitarian accountability has been the subject of increased attention in recent years. However, examination of how its principles and practices play out in displacement contexts is an under-explored area. In this Editorial, we outline the development of humanitarian accountability standards and practice, with particular focus on their applicability to displacement contexts. As we refer to and introduce the papers of this special issue, we reflect on positive developments and the challenges remaining. It is a particularly prescient time to reflect on the ‘state of play’ of accountability in this sector, given it is five years since the adoption of the Grand Bargain and the “Participation Revolution”, through which stakeholders undertook to increase the relevance and efficiency of humanitarian response by giving prominence to affected populations’ participation in decisions which affect their lives. Despite these commitments, however, true progress is hampered by entrenched power imbalances. In the pyramid of power relations which denote the power to influence programming, displaced populations remain at the bottom, often unheard and silenced. Yet, only when displaced communities are able to influence the kind of aid they receive, can humanitarian responses truly address their needs and pave the way for more secure, protected and resilient communities.

“Littered with Logos!”: An Investigation into the Relationship between Water Provision, Humanitarian Branding, Donor Accountability, and Self-Reliance in Ugandan Refugee Settlements

The branding of humanitarian assets and programme signage (often in English) is common practice in displacement contexts. Such visibility is a reminder of the special status of refugee spaces and a requirement imposed by donors. However, such branding, which forms part of the humanitarian organisations’ accountability to donors, raises profound issues in relation to the Comprehensive Refugee Response Framework (CRRF) and the agenda of refugee self-reliance. Drawing on our work on water access in Ugandan refugee settlements for humanitarian NGOs, we present a case study that explores the humanitarian response and its implications on the sustainability of water provision through the lens of branding and accountability. As donors and taxpayers become the (distant) audiences of visibility strategies, we argue that the branding of water structures, coupled with the lack of accountability to affected populations (AAPs) potentially undermines refugees’ sense of ownership necessary for the future upkeep and maintenance of water sources. The sector may thus compromise the sustainability of programming as advanced by the CRRF. As accountability to donors is prioritised over AAP, we argue that the impact of branding on sustainability of water provision can be better understood by investigating its psychological effects on programme beneficiaries.

RESONANCE Registry: rationale and design of the retrospective and prospective longitudinal, observational registry in pediatric and adult patients with recurrent pericarditis

Background

Annually in the United States (US), an estimated 80–90,000 patients are diagnosed with acute pericarditis and 15–30% experience recurrent pericarditis (RP), resulting in increased morbidity and reduced health-related quality of life (HRQoL). Treatment options include non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. Corticosteroids (CS) are often added to the treatment plan in RP despite CS-associated adverse events and inherent potentiation of recurrence with long-term treatment. A recent Phase 3 clinical trial RHAPSODY (NCT03737110) demonstrated efficacy and safety of rilonacept, an interleukin-1 α and β cytokine trap, in patients with RP. RHAPSODY data helped support FDA approval of the first therapy for RP. With the emergence of this targeted therapy, there is increased interest to learn more about this disease with the goal to better inform treatment and management decisions and improve long-term outcomes.

Purpose

RESONANCE Registry aims to evaluate the natural history of RP by collecting retrospective and prospective, longitudinal physician- and patient-reported outcomes data in real-world clinical practice across the US.

Methods

RP patients with active disease (recurrence within 3 years) will have both retrospective and prospective data collected (Figure 1) for as long as their RP is managed up to 5 years. For patients with inactive disease (no recurrence within 3 years), data collection will be retrospective (Figure 2). Up to 500 patients in the US are planned for enrollment at pediatric and adult medical centers, with the potential for expansion to European sites. Additionally, patients will be recruited through a novel, internet-based technology platform and screened for eligibility at a “decentralized” trial site. The registry will include variables obtained from health records, including baseline characteristics and medical history, as well as patient reported outcome (PRO) measures collected every 3 months. The RESONANCE protocol is designed to include a broad population of pediatric and adult patients, regardless of etiology or treatment course, including patients treated with rilonacept. Data will be analyzed to understand disease heterogeneity, variability in treatment and management, and impact on HRQoL. The protocol and Case Report Forms (CRFs) were developed in collaboration with physicians, patients, and patient advocates.

Conclusions

Registries utilize real-world data to fill knowledge gaps in the management of less common diseases such as RP. The RESONANCE Registry is the first RP registry designed to collect data across a broad range of patients regardless of treatment. The registry will also serve as a connection point for physicians to further educate and empower patients with information about their disease. In addition, PRO data may enable greater insights into the understanding of the burden of RP from the patient's perspective.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Kiniksa Pharmaceuticals

Characteristics of patients with atrial high rate episodes detected by implanted defibrillator and resynchronisation devices

Aims

Atrial high rate episodes (AHRE) are associated with increased risks of thromboembolism and cardiovascular mortality. However, the clinical characteristics of patients developing AHRE of various durations are not well studied.

Methods

This was an ancillary analysis of the multicenter, randomized IMPACT trial. In the present analysis, we classified patients according to duration of AHRE ≤6 minutes, &gt;6 minutes to ≤6 hours, &gt;6 hours to ≤24 hours and &gt;24 hours, and investigated the association between clinical factors and the development of each duration of AHRE.

Results

Of 2,718 patients included in the trial, 945 (34.8%) developed AHRE. The incidence rates of each AHRE duration category were 10.7, 24.0, 0.14, and 0.07%, respectively. Using Cox regression analysis, heart failure was inversely associated with AHRE &lt;6 minutes (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.40–0.85, p=0.005), while age ≥65 years and history of atrial fibrillation (AF) and/or atrial flutter (AFL) were risk factors for AHRE &gt;6 minutes. Female gender was inversely associated with AHRE &gt;6 minutes to ≤6 hours (HR 0.72, 95% CI 0.54–0.96, p=0.027) and &gt;6 hours to ≤24 hours (HR 0.70, 95% CI 0.49–1.02, p=0.061). Hypertension was associated with AHRE &gt;24 hours (HR 2.13, 95% CI 1.24–3.65, p=0.006).

Conclusion

AHRE &gt;6 minutes to ≤6 hours were most prevalent among all AHRE duration categories. Age and history of AF/AFL were risk factors for AHRE &gt;6 minutes. Women were at lower risk for AHRE &gt;6 minutes to ≤24 hours, while hypertension was associated with AHRE &gt;24 hours.

Funding Acknowledgement

Type of funding sources: None. Cumulative incidence of each AHRE burden

The Performance of Immunoassays to Measure Antibodies to the Chlamydia trachomatis Antigen Pgp3 in Different Epidemiological Settings for Trachoma

Programs to eliminate trachoma as a public health problem use prevalence of the clinical sign trachomatous inflammation-follicular (TF) in 1- to 9-year-olds in endemic districts to make decisions to begin or end mass drug administration with azithromycin. Trachomatous inflammation-follicular is used as a proxy for transmission of ocular Chlamydia trachomatis infection. Long-term monitoring of previously endemic districts for recrudescence of ocular C. trachomatis infection would benefit from a simple blood test that could be integrated with other public health programs. In this study, we evaluated multiple tests to measure antibodies against the C. trachomatis antigen Pgp3-a multiplex bead assay (MBA), an ELISA, and two versions of a lateral flow assay (LFA)-in four districts of the Amhara region of Ethiopia with varying levels of TF. Seroprevalence and seroconversion rate (SCR) results were proportional to TF prevalence by district for most tests, with the notable exception of the LFA using colloidal gold as the developing reagent. Changing the test developing reagent to black latex improved agreement between serological measures and TF prevalence and in inter-rater agreement. Seroconversion rate estimates using data derived from the LFA-gold assay were inconsistent with the shape of the age-seroprevalence curve, which did not increase in older ages. These data revealed potential complications with using SCR that will need further evaluation. Data from MBA, ELISA, and LFA with the black test line showed good agreement with each other and proportionality to TF estimates, providing further data that serology has potential utility for trachoma surveillance.

Assessment and utility of 2 Chlamydia trachomatis Pgp3 serological assays for seroprevalence studies among women in the United States

Two plasmid gene protein (Pgp3)-based serological assays, the Pgp3-ELISA and multiplex bead assay (Pgp3-MBA), were compared and used to estimate seropositivity of Chlamydia trachomatis (CT) among females 14 to 39 years old participating in the National Health and Nutrition Examination Survey between 2013-2016. Of the 2,201 specimens tested, 502 (29.5%, 95% CI 27.6-31.5) were positive using Pgp3-ELISA and 624 (28.4%, 95% CI 26.5-30.3) were positive using Pgp3-MBA. The overall agreement between the assays was 87.7%. Corresponding nucleic acid amplification test (NAAT) results were available for 1,725 specimens (from women 18-39 years old); of these, 42 (2.4%, 95% CI 1.8-3.3) were CT NAAT-positive. Most of the CT NAAT-positive specimens had corresponding positive serological assay results; 33 (78.6%, 95% CI 62.8-89.2) were Pgp3-ELISA-positive and 36 (85.7%, 95% CI 70.8-94.1) were Pgp3-MBA-positive. Although Pgp3-ELISA and Pgp3-MBA demonstrated equivalent performance in this study, an advantage of the Pgp3-MBA over Pgp3-ELISA is that it is well suited for high sample throughput applications.

Sarcopenia and surgical outcomes in patients undergoing oncologic colonic surgery

Objective

Sarcopenia is a marker for malnutrition and frailty which could lead to higher complication rate and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between sarcopenia and clinical outcomes in oncologic colonic surgery.

Methods

This retrospective study included consecutive patients operated between 2014 and 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: Skeletal Muscle Area (SMA), Skeletal Muscle Radiation Attenuation (SMRA), and Skeletal Muscle Index (SMI). Patients with major complications (&gt; grade 3a) according to Clavien classification were compared to those without. Statistical correlation between sarcopenia indices, LOS and Comprehensive Complication Index (CCI) was tested by use of the Pearson correlation.

Results

A total of 325 patients were included, 50 (15.4%) with and 275 (84.6%) without major complications. SMA and SMI were comparable between both groups (respectively 126.0 vs 125.2 cm2, p = 0.974, and 43.4 vs 44.3 cm2/m2, p = 0.636), while SMRA was significantly lower in patients with major complications (33.6 vs 37.3 HU, p = 0.018). A lower SMRA was correlated with prolonged LOS (r=-0.207, p &lt; 0.01) and higher CCI (r=-0.144, p &lt; 0.01), while the other sarcopenia indices had no influence on surgical outcomes.

Conclusion

Preoperative SMRA or muscle quality appears to be a weak predictor for adverse outcomes after oncologic colectomy.