Comparison of clinical outcomes and prognostic utility of risk stratification tools in patients with therapy-related vs de novo myelodysplastic syndromes: a report on behalf of the MDS Clinical Research Consortium

While therapy-related (t)-myelodysplastic syndromes (MDS) have worse outcomes than de novo MDS (d-MDS), some t-MDS patients have an indolent course. Most MDS prognostic models excluded t-MDS patients during development. The performances of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Global Prognostic System (MPSS), WHO Prognostic Scoring System (WPSS) and t-MDS Prognostic System (TPSS) were compared among patients with t-MDS. Akaike information criteria (AIC) assessed the relative goodness of fit of the models. We identified 370 t-MDS patients (19%) among 1950 MDS patients. Prior therapy included chemotherapy alone (48%), chemoradiation (31%), and radiation alone in 21%. Median survival for t-MDS patients was significantly shorter than for d-MDS (19 vs 46 months, P<0.005). All models discriminated survival in t-MDS (P<0.005 for each model). Patients with t-MDS had a significantly higher hazard of death relative to d-MDS in every risk model, and had inferior survival compared to patients with d-MDS within all risk group categories. AIC Scores (lower is better) were 2316 (MPSS), 2343 (TPSS), 2343 (IPSS-R), 2361 (WPSS) and 2364 (IPSS). In conclusion, subsets of t-MDS patients with varying clinical outcomes can be identified using conventional risk stratification models. The MPSS, TPSS and IPSS-R provide the best predictive power.

Longitudinal analysis of reporting and quality of systematic reviews in high-impact surgical journals

BACKGROUND

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement aims to optimize the reporting of systematic reviews. The performance of the PRISMA Statement in improving the reporting and quality of surgical systematic reviews remains unclear.

METHODS

Systematic reviews published in five high-impact surgical journals between 2007 and 2015 were identified from online archives. Manuscripts blinded to journal, publication year and authorship were assessed according to 27 reporting criteria described by the PRISMA Statement and scored using a validated quality appraisal tool (AMSTAR, Assessing the Methodological Quality of Systematic Reviews). Comparisons were made between studies published before (2007-2009) and after (2011-2015) its introduction. The relationship between reporting and study quality was measured using Spearman's rank test.

RESULTS

Of 281 eligible manuscripts, 80 were published before the PRISMA Statement and 201 afterwards. Most manuscripts (208) included a meta-analysis, with the remainder comprising a systematic review only. There was no meaningful change in median compliance with the PRISMA Statement (19 (i.q.r. 16-21) of 27 items before versus 19 (17-22) of 27 after introduction of PRISMA) despite achieving statistical significance (P = 0·042). Better reporting compliance was associated with higher methodological quality (r_s  = 0·70, P < 0·001).

CONCLUSION

The PRISMA Statement has had minimal impact on the reporting of surgical systematic reviews. Better compliance was associated with higher-quality methodology.

Functional Properties of Extrudates Prepared with Blends of Wheat Flour/Pinto Bean Meal with Added Wheat Bran

Blends made of wheat flour and bean meal at various levels of moisture and bran content, were subjected to extrusion cooking by varying temperature and screw speed. Extrudates were analysed for expansion index, bulk density, apparent viscosity, water absorption index and water solubility index using a second-order rotatable central composite design. Excepting water absorption index, functional properties were significantly affected ( p<0.05) by levels of moisture, bran or extrusion conditions. Expansion index decreased with increasing levels of moisture in the blends; for bran the effect was the inverse. Response surface solution for apparent viscosity was maximum at 24% levels of moisture, 209r.p.m., 180°C and 10% bran. For water absorption index the response surface solution was a saddle point, with a minimum at 29% levels of moisture, 232r.p.m., 177°C and 25% bran. The higher apparent viscosity and lower absorption index reflected minor damage to starch and proteins, which was attributed to a protective role of the added fibre.

Comparison of risk stratification tools in predicting outcomes of patients with higher-risk myelodysplastic syndromes treated with azanucleosides

Established prognostic tools in patients with myelodysplastic syndromes (MDS) were largely derived from untreated patient cohorts. Although azanucleosides are standard therapies for higher-risk (HR)-MDS, the relative prognostic performance of existing prognostic tools among patients with HR-MDS receiving azanucleoside therapy is unknown. In the MDS Clinical Research Consortium database, we compared the prognostic utility of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Prognostic Scoring System (MDAPSS), World Health Organization-based Prognostic Scoring System (WPSS) and the French Prognostic Scoring System (FPSS) among 632 patients who presented with HR-MDS and were treated with azanucleosides as the first-line therapy. Median follow-up from diagnosis was 15.7 months. No prognostic tool predicted the probability of achieving an objective response. Nonetheless, all five tools were associated with overall survival (OS, P=0.025 for the IPSS, P=0.011 for WPSS and P<0.001 for the other three tools). The corrected Akaike Information Criteria, which were used to compare OS with the different prognostic scoring systems as covariates (lower is better) were 4138 (MDAPSS), 4156 (FPSS), 4196 (IPSS-R), 4186 (WPSS) and 4196 (IPSS). Patients in the highest-risk groups of the prognostic tools had a median OS from diagnosis of 11-16 months and should be considered for up-front transplantation or experimental approaches.

A novel pathway of cellular activation mediated by antiphospholipid antibody-induced extracellular vesicles

BACKGROUND

Elevated levels of endothelial cell (EC)-derived extracellular vesicles (EVs) circulate in patients with antiphospholipid antibodies (APLAs), and APLAs, particularly those against β2 -glycoprotein I (β2 GPI), stimulate EV release from ECs. However, the effects of EC-derived EVs have not been characterized.

OBJECTIVE

To determine the mechanism by which EVs released from ECs by anti-β2 GPI antibodies activate unstimulated ECs.

PATIENTS/METHODS

We used interleukin (IL)-1 receptor inhibitors, small interfering RNA (siRNA) against Toll-like receptors (TLRs) and microRNA (miRNA) profiling to assess the mechanism(s) by which EVs released from ECs exposed to anti-β2 GPI antibodies activated unstimulated ECs.

RESULTS AND CONCLUSIONS

Anti-β2 GPI antibodies caused formation of an EC inflammasome and the release of EVs that were enriched in mature IL-1β, had a distinct miRNA profile, and caused endothelial activation. However, activation was not inhibited by an IL-1β antibody, an IL-1 receptor antagonist, or IL-1 receptor siRNA. EC activation by EVs required IL-1 receptor-associated kinase 4 phosphorylation, and was inhibited by pretreatment of cells with TLR7 siRNA or RNase A, which degrades ssRNA. Profiling of miRNA in EVs released from ECs incubated with β2 GPI and either control IgG or anti-β2 GPI antibodies revealed numerous differences in the content of specific miRNAs, including a significant decrease in mIR126. These observations demonstrate that, although anti-β2 GPI-derived endothelial EVs contain IL-1β, they activate unstimulated ECs through a TLR7-dependent and ssRNA-dependent pathway. Alterations in miRNA content may contribute to the ability of EVs derived from ECs exposed to anti-β2 GPI antibodies to activate unstimulated ECs in an autocrine or paracrine manner.

Maritime in transit care

Operation GRITROCK saw the first operational deployment of the Maritime In Transit Care team from the Role 2 (Enhanced) (R2(E)) Medical Treatment Facility, which is able to provide Damage Control Surgery and the limited holding of patients, situated on board RFA ARGUS. Whilst the Medical Emergency Response Team demonstrated the capability of advanced military Pre-Hospital Emergency Care (PHEC) on Op HERRICK, the need to provide a similar high level of care on contingency operations was recognised. Op GRITROCK allowed for the continued exploration of a maritime capability from an established R2(E) platform whilst providing medical evacuation capability for a significant population at risk distributed over a large Joint Operation Area. Although the patient load during the operation was low, key lessons were learnt and opportunities identified to further develop the newly recognised sub-speciality of PHEC, both medically and logistically, and these will be discussed in this article.

Distinct iron architecture in SF3B1-mutant myelodysplastic syndrome patients is linked to an SLC25A37 splice variant with a retained intron

Perturbation in iron homeostasis is a hallmark of some hematologic diseases. Abnormal sideroblasts with accumulation of iron in the mitochondria are named ring sideroblasts (RS). RS is a cardinal feature of refractory anemia with RS (RARS) and RARS with marked thrombocytosis (RARS/-T). Mutations in SF3B1, a member of the RNA splicing machinery are frequent in RARS/-T and defects of this gene were linked to RS formation. Here we showcase the differences in iron architecture of SF3B1-mutant and wild-type (WT) RARS/-T and provide new mechanistic insights by which SF3B1 mutations lead to differences in iron. We found higher iron levels in SF3B1 mutant vs WT RARS/-T by transmission electron microscopy/spectroscopy/flow cytometry. SF3B1 mutations led to increased iron without changing the valence as shown by the presence of Fe(2+) in mutant and WT. Reactive oxygen species and DNA damage were not increased in SF3B1-mutant patients. RNA-sequencing and Reverse transcriptase PCR showed higher expression of a specific isoform of SLC25A37 in SF3B1-mutant patients, a crucial importer of Fe(2+) into the mitochondria. Our studies suggest that SF3B1 mutations contribute to cellular iron overload in RARS/-T by deregulating SLC25A37.

KIR and HLA interactions are associated with control of primary CMV infection in solid organ transplant recipients

Cytomegalovirus (CMV) infection remains a major source of morbidity and mortality in solid organ transplant recipients. Killer immunoglobulin-like receptors(KIR) are genetically polymorphic natural killer(NK) cell receptors important in antiviral responses. A retrospective, single-center cohort study was performed to study the interaction of KIR genotype and primary control of CMV infection after transplantation.Time to first CMV viremia was determined for a cohort of 531 CMV serology donor positive/recipient negative solid organ transplant recipients. Of the KIR genes,KIR2DL3 and KIR2DS2 were most strongly associated with time to CMV viremia in random survival forest analysis. As KIR2DL3 and KIR2DS2 both interact with HLA-C1, these interactions were evaluated. Seventy six recipients were found to be positive for both KIR2DL3 and KIR2DS2 and expressed only HLA-C1 antigens in both recipient and donor. These patients had a substantially reduced hazard of CMV viremia in the first year after solid organ transplantation (hazard ratio 0.44, 95% CI 0.27–0.72, p=0.0012). In KIR2DL3+/KIR2DS2+/HLA-C1/1 recipients who received an organ from a non-C1/1 donor, this protective effect was not observed. These results improve our understanding of human NK cell function in primary CMV infection after transplant.

P2RY1 and P2RY12 polymorphisms and on-aspirin platelet reactivity in patients with coronary artery disease

INTRODUCTION

Association of P2RY1 and P2RY12 polymorphisms with on-aspirin platelet reactivity was investigated.

MATERIALS AND METHODS

Platelet reactivity was assessed by the light transmission aggregometry and TxB(2) assay in 423 patients with coronary artery disease (CAD) on aspirin. High residual platelet reactivity (RPR) was defined by ≥20% and ≥70% maximal aggregation stimulated with 0.5 mg/mL arachidonic acid (AA) and 10 μm ADP, respectively. Moderate RPR was considered aggregation ≥20% with AA, ≥70% with ADP, or ≥1 ng/mL stimulated TxB(2) . Fourteen P2RY1 and 35 P2RY12 single nucleotide polymorphisms (SNPs) were genotyped.

RESULTS

High RPR was detected in 24% of the patients. Moderate RPR was observed in 31% with AA, 57% with 5 μm ADP, and 82% with 10 μm ADP. Stimulated TxB(2) was ≥1 ng/mL in 23% of patients. P2RY12 SNP rs9859538 was associated with high RPR (OR = 2.16, 95% CI = 1.24-3.75, P-value = 0.004). Four P2RY12 SNPs, rs1491974, rs10513398, rs3732765, and rs10935841, showed association with moderate RPR (OR = 1.79-2.94, P-value = 0.04-0.028), while five, rs7615865, rs1388623, rs1388622, rs7634096, and rs7637803, were associated with low RPR (OR = 0.50-0.55, P-value = 0.008-0.026), following ADP stimulation. TxB(2) level <1 ng/mL was linked to five P2RY1 SNPs, rs1439010, rs1371097, rs701265, rs12497578, and rs2312265 (OR = 0.36-0.54, P-value = 0.003-0.039).

CONCLUSIONS

Polymorphisms in P2RY1 and P2RY12 are associated with on-aspirin platelet reactivity in patients with CAD.

Saving phosphorus removal at the Henderson NV plant

While the mechanism of biological phosphorus removal (BPR) and the need for volatile fatty acids (VFA) have been well researched and documented to the point where it is now possible to design a plant with a very reliable phosphorus removal process using formal flow sheets, BPR is still observed in a number of plants that have no designated anaerobic zone, which was considered essential for phosphorus removal. Some examples are given in this paper. A theory is proposed and then applied to solve problems with a shortage of VFA in the influent of the Henderson NV plant. Mixed liquor was fermented in the anaerobic zone, which resulted in phosphorus removal to very low levels. This paper will discuss some of the background, and some case histories and applications, and present a simple postulation as to the mechanism and efforts at modelling the results.

Dislocation Luminescence in Wurtzite GaN

The 364 nm PL-system in GaN is attributed to the formation of dislocation excitons and charged dislocation excitons on c-axis screw dislocations. The binding energy for the dislocation exciton, charged dislocation exciton and a hole on the screw dislocation were determined as 35 meV, 7 meV and 65 meV respectively, in accord with experiment.

Donor Heart Selection: Wythenshawe Experience

BACKGROUND

The decline in the number of suitable donor hearts has led to an increasing interest in the use of previously unacceptable donors. This study aimed to evaluate the outcome of recipients of donor hearts considered medically unsuitable for transplantation at this center that were used in other centers in the United Kingdom.

METHODS

Forty donor hearts (group 1) were declined by Wythenshawe Hospital and used in other units in the United Kingdom in the period extending from April 1998 to March 2003. One hundred four hearts (group 2) were transplanted at Wythenshawe Hospital during the same period. Donors and recipient data were obtained from the United Kingdom Cardiothoracic Transplant Audit database. Mortality in both groups was analyzed using SPSS software.

RESULTS

Mortality in patients receiving grafts from group 1 donors was significantly higher than in group 2 (P < .0009). Of the early deaths in this group 50% (6 of 12) were the result of graft failure. These donors were receiving high doses of inotropes, had ischemic time exceeding 3.5 hours, and the grafts were transplanted into high-risk patients.

CONCLUSION

Hearts declined on medical grounds by one center should be evaluated with caution before being considered suitable for transplantation, especially when more than one adverse factor is present.

Modeling of Escherichia coli inactivation by UV irradiation at different pH values in apple cider

This study examined the effects and interactions of UV light dose (1,800 to 20,331 microJ/cm2) and apple cider pH (2.99 to 4.41) on the inactivation of Escherichia coli ATCC 25922, a surrogate for E. coli O157:H7. A predictive model was developed to relate the log reduction factor of E. coli ATCC 25922 to the UV dose. Bacterial populations for treated and untreated samples were enumerated with the use of nonselective media. The results revealed that UV dose was highly significant in the inactivation of E. coli, whereas pH showed no significant effect at higher UV doses. Doses of 6,500 microJ/cm2 or more were sufficient to achieve a greater than 5-log reduction of E. coli. Experimental inactivation data were fitted adequately by a logistic regression model. UV irradiation is an attractive alternative to conventional methods for reducing bacteria in unpasteurized apple cider.

Does bispectral analysis of the electroencephalogram add anything but complexity?

BACKGROUND

Analysis of the bispectrum of EEG waveforms is a component of the proprietary BIS index-a commonly used commercial monitor of depth of anaesthesia. Does the use of the bispectrum give more information about depth of anaesthesia than the power spectrum?

METHODS

We collected and analysed EEG waveforms during induction of general anaesthesia in 39 patients, comparing the changes in bispectral parameter (SynchFastSlow), with an analogous power spectrum-based parameter (PowerFastSlow). Both compare the logarithmic ratio of high frequency components (40-47 Hz) with the total (1-47 Hz). Because the changes in bispectrum are affected by signal amplitude, we also calculated a third parameter (SFSbicoh) from the bicoherence, which is an amplitude-independent statistic.

RESULTS

The SynchFastSlow and PowerFastSlow were correlated (r=0.84) and neither was superior in predicting the awake or anaesthetized state (area under receiver operating characteristic curves = 0.85 vs 0.93). There was no change in the SFSbicoh over the induction period, and it did not correlate with SynchFastSlow (r=0.07).

CONCLUSIONS

We could not show that bispectral analysis gave more information than power spectral-based analysis. Most of the changes in the bispectral values result from decreases in the relative high frequency content of the EEG caused by anaesthesia.

Implicit memory formation in sedated ICU patients after cardiac surgery

BACKGROUND

Recent research into memory formation under sedation has generated conflicting results. We investigated explicit and implicit memory in ICU patients during moderate to deep propofol sedation following cardiac surgery.

METHODS

Two different methods of memory testing were used; (1). free-association (F-A) word-pair testing (n=33) to test conceptual implicit memory and (2). process dissociation procedure (PDP) (n=26) to detect perceptual implicit and explicit memory. One hour after surgery, whilst sedated, the F-A group received one of two lists of 10 category-exemplar word-pairs through headphones, while the PDP group was presented with one of two lists of 16 five-letter words. When awake and co-operative, the F-A group was tested using F-A testing, and the PDP group was tested using the PDP.

RESULTS

The F-A group had a mean (SD) correct response rate of 7 (9)% for the target list, and 9 (8)% for the distractor list. The PDP group had a mean (SD) correct response rate of 11 (14) and 10 (13)% for the inclusion and exclusion lists, respectively, with mean correct response rates of 13 (14)% for both the corresponding distractor lists. Neither group showed any significant differences between their responses and a list of distractor words (Wilcoxon tests).

CONCLUSION

We found no evidence for memory formation in post-cardiac surgery patients under moderate to deep propofol sedation.

Nociceptive and anaesthetic-induced changes in pulse transit time during general anaesthesia

BACKGROUND

Pulse transit time (rPTT), the interval between ventricular electrical activity and arrival of a peripheral pulse waveform, has been used to detect changes in autonomic tone. The aim of this observational pilot study was to measure changes in rPTT in response to general anaesthesia and noxious stimuli.

METHODS

Thirty-one healthy women undergoing gynaecological surgery were allocated to groups depending on the need for airway management with tracheal intubation (n=9), a laryngeal mask (LMA, n=17) or a facemask (n=5). During general anaesthesia, we measured changes in RR interval (RR-int) and rPTT after (i) induction of anaesthesia, (ii) airway manipulation and (iii) surgical stimulus. rPTT was estimated as the interval from the peak in the R-wave to detection of the pulse oximeter waveform in the periphery.

RESULTS

Mean baseline rPTT was 245 (SD 27) ms. Upon induction of anaesthesia, rPTT increased (by 28.2 (20.4) ms, P<0.001) in all but two patients. rPTT decreased in response to endotracheal intubation (by 43.1 (24.6) ms, P=0.001) but did not vary in response to insertion of LMA or surgical stimulus. Mean baseline RR-int was 865 (141) ms. A mean reduction in RR-int after tracheal intubation did not reach statistical significance. RR-int was unchanged with induction of anaesthesia, LMA insertion or surgical stimulus.

CONCLUSION

Variation in rPTT reflects autonomic responses to nociceptive stimulation and fluctuations in anaesthetic depth independently of heart rate.

The radiation resistance of ascospores and sclerotia of Pyronema domesticum

The Food and Drug Administration has become aware of several instances where supposedly sterile medical surgical products made of Chinese cotton have been found to contain viable Pyronema domesticum. The aim of this research was to determine the gamma and electron beam radiation resistance values for the two dormant phases (ascospores and sclerotia) of P. domesticum. The resistance values were obtained by developing a standardized system to cultivate, purify, and harvest biological indicators containing sclerotia or ascospores. Ascospores were more resistant to radiation than sclerotia. The D(10) values for sclerotia were 0.79 and 1.09 kGy for strains 32030 and 14881, respectively. The resistance value for wild type ascospores was 2.83 kGy. The current standard for assuring radiation sterilization of medical devices is ISO 11137. This standard was developed to address the propensity for highly radiation-resistant organisms such as P. domesticum. Prior to the standard, biological indicators such as Bacillus pumilus, having a nominal D(10) value or 1.7 kGy, were used to determine the sterility of many medical devices.

Variations in implementation of current national guidelines for the treatment of acute pancreatitis: implications for acute surgical service provision

OBJECTIVES

The aim of this study was to explore the implementation of the current national guidelines for the treatment of acute pancreatitis. By taking pooled data from all available individual and regional audits, the study aimed to identify areas of consistent variance from the 'best practice' stipulated in the guidelines.

METHODS

All published audits of the management of acute pancreatitis where treatment was compared to the current British Society of Gastroenterology guidelines for the treatment of acute pancreatitis were identified from a search of MEDLINE and the published abstracts of relevant specialty meetings.

RESULTS

Five audits providing pooled data on 545 patients were identified. Overall mortality from severe disease was 8% (range, 4-17%). Definitive treatment of gallstone disease within 4 weeks of index attack was performed in 49% (range, 16-65%). High dependency or intensive care facilities for severe disease were available in 52% (range, 20-100%).

CONCLUSION

This study demonstrates the presence of striking variations in the implementation of the current national guidelines for the treatment of acute pancreatitis.

Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS)

Despite reports of familial clustering of sarcoidosis, little empirical evidence exists that disease risk in family members of sarcoidosis cases is greater than that in the general population. To address this question, we estimated sarcoidosis familial relative risk using data on disease occurrence in 10,862 first- and 17,047 second-degree relatives of 706 age, sex, race, and geographically matched cases and controls who participated in the multicenter ACCESS (A Case-Control Etiology Study of Sarcoidosis) study from 1996 to 1999. Familial relative risk estimates were calculated using a logistic regression technique that accounted for the dependence between relatives. Sibs had the highest relative risk (odds ratio [OR] = 5.8; 95% confidence interval [CI] = 2.1-15.9), followed by avuncular relationships (OR = 5.7; 95% CI = 1.6-20.7), grandparents (OR = 5.2; 95% CI = 1.5-18.0), and then parents (OR = 3.8; 95% CI = 1.2-11.3). In a multivariate model fit to the parents and sibs data, the familial relative risk adjusted for age, sex, relative class, and shared environment was 4.7 (95% CI = 2.3-9.7). White cases had a markedly higher familial relative risk compared with African-American cases (18.0 versus 2.8; p = 0.098). In summary, a significant elevated risk of sarcoidosis was observed among first- and second-degree relatives of sarcoidosis cases compared with relatives of matched control subjects.