Assessment of changes in the international prostate symptom score for patients enrolled in a phase I trial of intravesical bacillus Calmette-Guérin combined with intravenous pembrolizumab for recurrent or persistent high-grade non-muscle-invasive bladder cancer after previous bacillus Calmette-Guérin treatment

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Background: We conducted the first phase I dose-escalation trial (NCT02324582) of intravesical Bacillus Calmette-Guérin (BCG) in combination with systemic pembrolizumab in patients with high-grade non-muscle-invasive bladder cancer who had persistent or recurrent disease after prior intravesical therapy with BCG. The International Prostate Symptom Score (IPSS) were administered to assess subjects’ urinary bother during the trial. Methods: Eighteen subjects were consented for the study, 13 were treated. The study population was comprised of 11 males, 2 females, with age range 42 - 92 years. The IPSS was assessed at pre-treatment, Week 10 (during combined BCG and pembrolizumab treatment), and at 3 and 6 months from treatment completion. IPSS outcomes were analyzed using a mixed-model repeated measures analysis with p-value < 0.05 considered statically significant. Results: For each time point, there was no significant change in any of the component variables of the IPSS. There was no increase in reported bother symptoms over the course of treatment, given median IPSS scores of 9, 11, 7, and 8 (IQR 1.75) for each time point, respectively. Furthermore, quality of life measurements demonstrated no significant change in subjective burden with 75% of subjects reporting that they were “mostly satisfied” with treatment outcomes, followed by 13% reporting “delighted” or “pleased” at 6 month follow-up. Conclusions: There is no significant change in quality of life or the perceived bother of symptoms indicated in the component variables of the IPSS for our study population before, during or after treatment.

GCK-MODY in the US National Monogenic Diabetes Registry: frequently misdiagnosed and unnecessarily treated

AIMS

GCK-MODY leads to mildly elevated blood glucose typically not requiring therapy. It has been described in all ethnicities, but mainly in Caucasian Europeans. Here we describe our US cohort of GCK-MODY.

METHODS

We examined the rates of detection of heterozygous mutations in the GCK gene in individuals referred to the US Monogenic Diabetes Registry with a phenotype consistent with GCK-MODY. We also assessed referral patterns, treatment and demography, including ethnicity, of the cohort.

RESULTS

Deleterious heterozygous GCK mutations were found in 54.7 % of Registry probands selected for GCK sequencing for this study. Forty-nine percent were previously unnecessarily treated with glucose-lowering agents, causing hypoglycemia and other adverse effects in some of the subjects. The proportion of probands found to have a GCK mutation through research-based testing was similar across each ethnic group. However, together African-American, Latino and Asian subjects represented only 20.5 % of screened probands and 17.2 % of those with GCK-MODY, despite higher overall diabetes prevalence in these groups.

CONCLUSIONS

Our data show that a high detection rate of GCK-MODY is possible based on clinical phenotype and that prior to genetic diagnosis, a large percentage are inappropriately treated with glucose-lowering therapies. We also find low minority representation in our Registry, which may be due to disparities in diagnostic diabetes genetic testing and is an area needing further investigation.

ID: 23: LONG DELAY IN ACCURATE DIAGNOSIS OF HNF1A-MODY IN THE US MONOGENIC DIABETES REGISTRY

Background

Maturity-onset diabetes of the young (MODY) is autosomal dominant, young-onset, non-insulin dependent diabetes accounting for 2% of diabetes cases and up to 10% before age 35 years. It is frequently misclassified as type 1 or type 2 diabetes. Genetic testing for accurate diagnosis is important to guide therapy and management decisions, which are distinct for the common types of MODY, and identifies affected family members who can benefit from genetic testing. HNF1A-MODY is the most common form worldwide and responds to low doses of sulfonylureas with equivalent or improved glycemic control as compared to insulin therapy.

Aim

Here we describe the US Monogenic Diabetes Registry HNF1A-MODY cohort, including phenotype, frequency and duration of diabetes misclassification, and treatment patterns.

Results

We currently follow 47 probands and 74 individuals with HNF1A-MODY. Current mean age of probands and the entire cohort is 31.5 years and 33.2 years, respectively. Mean age at diabetes diagnosis was 16.9 years for probands and 18.0 years for the entire cohort. 89% of probands were diagnosed with diabetes <25 years. 76.9% of probands had normal BMIs at time of diagnosis. 82% had 2 or more affected generations with diabetes. Despite the large majority having classic features of MODY, on average, the duration of diabetes diagnosis prior to genetic diagnosis of MODY was 11.8 years. Of the 41 probands providing historical data on medications, 31 (75.6%) report previous use of insulin therapy. Of the 24 probands with current treatment data, 79% are on mono- or combination therapy with sulfonylureas or glinides.

Conclusions

The clinical features of MODY have been formally described since the early 1970s with gene causes discovered starting in 1992. However, MODY frequently goes unrecognized. In our cohort, most probands were misclassified for years prior to referral for genetic testing for accurate diagnosis. Sulfonylureas are the established first-line therapy for HNF1A-MODY. A large percentage of subjects were treated with insulin prior to diagnosis with subsequent initiation of sulfonylureas or other insulin secretagogues in 79% of those with current treatment data. The duration of diabetes misclassification coupled with frequent insulin use prior to accurate genetic diagnosis in our HNF1A-MODY cohort underscore the need to increase recognition of MODY among providers.

A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation

OBJECTIVE

To determine whether continuous intrapartum electronic fetal heart rate monitoring (EFM) is associated with decreased perinatal mortality and morbidity compared with intermittent auscultation.

METHODS

The study was conducted simultaneously at two university hospitals in Athens, Greece (Alexandra and Marika Iliadi Hospitals) from October 1, 1990 to June 30, 1991. All patients with singleton living fetuses and gestational ages of 26 weeks or greater were eligible for inclusion. The participants were assigned to continuous EFM or intermittent auscultation based on the flip of a coin. Both groups were followed during labor according to the most recent ACOG guidelines. However, fetal scalp blood pH and crossover from one group to the other were not used.

RESULTS

A total of 1428 patients were included, 746 in the EFM group and 682 in the auscultation group. There were no differences between the groups in terms of maternal age, gravidity, parity, gestational age, and number of antepartum high-risk factors. More patients monitored electronically received oxytocin for either augmentation (52.4 versus 38.1%; P = .0001) or induction (15.6 versus 7%; P = .0001). The length of labor was longer in the EFM group (first stage 6.1 +/- 4.3 versus 5.5 +/- 3.7 hours; P = .006; second stage 29.4 +/- 18.6 versus 26.9 +/- 16.9 minutes; P = .01). There was a higher incidence of nonreassuring fetal heart rate patterns in the EFM group (23.4 versus 10.7%; P = .0001) and a higher rate of surgical intervention (11.2 versus 4.8%; P = .0001). This difference pertained to both vacuum extraction (5.8 versus 2.4%; P = .002) and cesarean delivery for suspected fetal distress (5.3 versus 2.3%; P = .005). There were no differences in 1- and 5-minute Apgar scores, fetal acidosis at birth, need for neonatal resuscitation, neonatal intensive care unit admission, use of assisted ventilation, neonatal hospital stay, or any other neonatal complications. Two neonatal deaths occurred in the EFM group and nine perinatal deaths in the auscultation group (two intrapartum and seven neonatal deaths). The perinatal mortality rates were 2.6 per 1000 and 13 per 1000 total births, respectively (P = .04). The two deaths in the EFM group and three of the neonatal deaths in the auscultation group may not have been prevented by intrapartum monitoring; however, four neonatal deaths from the auscultation group occurred in depressed (5-minute Apgar scores less than 7), acidotic (cord artery pH at or below 7.13) infants. The perinatal death rate related to fetal hypoxia was significantly less in the EFM group (zero of 746 versus six of 682; P = .03).

CONCLUSION

In this controlled trial, intrapartum EFM, as the primary and only method of intrapartum fetal surveillance, was associated with decreased perinatal mortality due to fetal hypoxia but also with higher rates of surgical intervention for suspected fetal distress.

Relationship between cyclic variation of fetal heart rate patterns and cord pH in preterm gestations

The presence or absence of cyclic variation (cyclicity) of fetal heart rate patterns was prospectively investigated in fetuses between 25 and 32 weeks' gestation. All fetuses were delivered by cesarean section before the onset of labor. The relationship between the presence or absence of fetal heart rate cyclicity and fetal acidosis, as determined by cord pH measurements, was investigated. The sensitivity, specificity, positive predictive value, and negative predictive value of this method in predicting fetal acidosis were: 100, 90, 50, and 100%, respectively. All fetuses with reactive nonstress tests also had fetal heart rate cyclicity present and none were acidotic at birth. The majority of fetuses (68.8%) with nonreactive nonstress tests had fetal heart rate cyclicity present and none were acidotic; fetuses with nonreactive nonstress tests and absence of fetal heart rate cyclicity were acidotic in 50% of the cases. These preliminary data suggest that the presence or absence of fetal heart rate cyclicity may help to select the healthy preterm fetuses with nonreactive nonstress testing who are in good condition and therefore in no need for further testing.

Telephone transmission of fetal heart rate monitor data. The experience at the University of Connecticut Health Center

This report reviews the experience at the University of Connecticut Health Center using the Fetal Assessment Consultative Transmission Service (FACTS) system during a 2 1/2-year period. This system, which permits direct transmission of antepartum and/or intrapartum fetal heart rate tracings via a telephone line, allows the obstetric staffs of smaller community hospitals to obtain an immediate consultation from the University of Connecticut Health Center on a 24 hour per day basis. A total of 511 fetal heart rate tracings were analyzed. Two hundred forty-five were intrapartum, 206 antepartum, and 60 were transmitted for educational purposes. The results indicate an imperative need for such a service from a tertiary care center to improve the quality of regional perinatal care and to determine the future direction of the regional educational program for physicians and nurses.

Sinusoidal fetal heart rate pattern after administration of nalbuphine hydrochloride: a case report

Nalbuphine hydrochloride (Nubain) is a synthetic analgesic available for use during labor. It is known to possibly cause respiratory depression in the neonate, but to date there are no published reports of any intrapartum alterations of fetal heart rate. A case presentation is given of a persistent sinusoidal pattern appearing after Nubain administration.

Mandated mental health benefits in private health insurance

Eleven states mandate coverage of inpatient and outpatient mental health care in private health insurance. Health insurers have objected to these laws on the grounds that they interfere with consumer choice of health insurance benefits and are too costly. This paper analyzes the benefits and costs of mandates for psychotherapy. The potential benefits considered have to do with adverse selection in insurance markets and the offset effects of psychotherapy. Arguments based on economic efficiency are presented to justify the possible appropriateness of overriding individuals' choice of health insurance benefits. Mandates are estimated econometrically to increase the cost of psychotherapy in a state by about 10-20 percent. We conclude that mandates for mental health benefits in private health insurance may be reasonable state policy.

Pulmonary embolism and infarction

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