Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Role of upfront autologous transplant for peripheral T-cell lymphoma patients achieving a complete remission with first-line therapy: a systematic review and meta-analysis

There is currently no consensus on the role of upfront autologous transplantation (ASCT) for patients with peripheral T-cell lymphomas (PTCL), especially in patients achieving first complete remission (CR1) following chemotherapy, and data in the literature is conflicting. A systematic review and meta-analysis was performed to address this question. We searched key databases from January 2000 to February 2022. Six prospective and eleven retrospective studies were included among 2959 unique records. Median follow up in these studies ranged from 22 to 94 months. There was a trend towards benefit in PFS (HR = 0.80, 95% CI 0.62-1.05, p = 0.11) and OS (HR = 0.79, 95% CI 0.57-1.09, p = 0.15) in the ASCT compared to chemotherapy only group. Importantly, in transplant eligible patients in CR1, a significant benefit was demonstrated in both OS (HR = 0.59, 95% CI 0.36-0.95, p = 0.03) and PFS (HR = 0.61, 95% CI 0.47-0.81, p = 0.0004) in the ASCT group. Amongst the nodal PTCL subgroups, ASCT showed a significant PFS benefit for the AITL subgroup (HR = 0.43, 95% CI 0.20-0.94, p < 0.03) but not PTCL-NOS or ALK-ve ALCL subgroups. Our findings support upfront ASCT for transplant eligible PTCL patients achieving CR1 post chemotherapy. In particular, patients with AITL exhibited a significantly better PFS after upfront ASCT.

Mass irradiation of adult Aedes mosquitoes using a coolable 3D printed canister

In the last decade, the use of the sterile insect technique (SIT) to suppress mosquito vectors have rapidly expanded in many countries facing the complexities of scaling up production and procedures to sustain large-scale operational programs. While many solutions have been proposed to improve mass production, sex separation and field release procedures, relatively little attention has been devoted to effective mass sterilization of mosquitoes. Since irradiation of pupae en masse has proven difficult to standardise with several variables affecting dose response uniformity, the manipulation of adult mosquitoes appears to be the most promising method to achieve effective and reliable sterilization of large quantities of mosquitoes. A 3D-printed phase change material based coolable canister was developed which can compact, immobilize and hold around 100,000 adult mosquitoes during mass radio sterilization procedures. The mass irradiation and compaction treatments affected the survival and the flight ability of Aedes albopictus and Aedes aegypti adult males but the use of the proposed irradiation canister under chilled conditions (6.7-11.3 °C) significantly improved their quality and performance. The use of this cooled canister will facilitate adult mass irradiation procedures in self-contained irradiators in operational mosquito SIT programmes.

Electrolyte imbalances as poor prognostic markers in COVID-19: a systemic review and meta-analysis

PURPOSE

Serum electrolyte imbalances are highly prevalent in COVID-19 patients. However, their associations with COVID-19 outcomes are inconsistent, and of unknown prognostic value. We aim to systematically clarify the associations and prognostic accuracy of electrolyte imbalances (sodium, calcium, potassium, magnesium, chloride and phosphate) in predicting poor COVID-19 clinical outcome.

METHODS

PubMed, Embase and Cochrane Library were searched. Odds of poor clinical outcome (a composite of mortality, intensive-care unit (ICU) admission, need for respiratory support and acute respiratory distress syndrome) were pooled using mixed-effects models. The associated prognostic sensitivity, positive and negative likelihood ratios (LR + , LR-) and predictive values (PPV, NPV; assuming 25% pre-test probability), and area under the curve (AUC) were computed.

RESULTS

We included 28 observational studies from 953 records with low to moderate risk-of-bias. Hyponatremia (OR = 2.08, 95% CI = 1.48-2.94, I² = 93%, N = 8), hypernatremia (OR = 4.32, 95% CI = 3.17-5.88, I² = 45%, N = 7) and hypocalcemia (OR = 3.31, 95% CI = 2.24-4.88, I² = 25%, N = 6) were associated with poor COVID-19 outcome. These associations remained significant on adjustment for covariates such as demographics and comorbidities. Hypernatremia was 97% specific in predicting poor outcome (LR + 4.0, PPV = 55%, AUC = 0.80) despite no differences in CRP and IL-6 levels between hypernatremic and normonatremic patients. Hypocalcemia was 76% sensitive in predicting poor outcome (LR- 0.44, NPV = 87%, AUC = 0.71). Overall quality of evidence ranged from very low to moderate.

CONCLUSION

Hyponatremia, hypernatremia and hypocalcemia are associated with poor COVID-19 clinical outcome. Hypernatremia is 97% specific for a poor outcome, and the association is independent of inflammatory marker levels. Further studies should evaluate if correcting these imbalances help improve clinical outcome.

Reduction in shock burden with catheter ablation versus escalated antiarrhythmic drug therapy: Insights from the VANISH trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1. Canadian Institutes of Health Research (CIHR)

2. Additional financial support from St. Jude Medical and Biosense Webster

Background

Recurrent shocks for ventricular tachycardia (VT) are associated with an increased risk of heart failure and mortality and have a negative influence on quality of life. Catheter ablation has been shown to improve VT event-free survival in patients with antiarrhythmic drug (AAD)-refractory VT and prior myocardial infarction (MI); however, the effects of ablation on shock burden has yet to be investigated.

Purpose

Our primary objectives were to compare the shock-treated VT event burden and appropriate shock burden following randomization to treatment with either catheter ablation or escalated AAD therapy among VT patients with prior MI in the Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in Ischemic Heart disease (VANISH) randomized trial.

Methods

Recurrent event analyses were performed using the intention-to-treat population of the VANISH trial. Shock-treated VT event burden was defined as the total number of VT events treated with ≥1 appropriate internal or external shocks. Appropriate shock burden was defined as the total number of appropriate internal and external shocks delivered, regardless of the number of VT events. All VT events and implantable cardioverter defibrillator (ICD) therapies were adjudicated by reviewers blinded to the treatment allocation. Three recurrent event models were used to compare the shock burden between treatment arms (Anderson-Gill (AG), Frailty, and Prentice, Williams, and Peterson Total Time (PWP-TT). Each model clustered by patient and accounted for competing risk of death with the Fine and Gray sub-distributions hazards model.

Results

Of the 259 patients enrolled in the VANISH trial [median age 69.8 (IQR 63.0-74.2) years, 7.0% women], 132 patients were randomized to ablation and 129 patients to escalated AAD therapy. Over a median follow-up of 23.4 (IQR 14.7-40.4) months, there were 138 shock-treated VT events [39.07 (95% CI 33.14-46.07) shock-treated VT events per 100 person-years] in the ablation arm and 218 shock-treated VT events [64.60 (95% CI 56.49–73.84) shock-treated VT events per 100 person-years] in the escalated AAD therapy arm (Figure 1). Ablation patients had a 40% lower shock-treated VT event burden (ie. number of shock-treated VT events) compared to patients randomized to escalated AAD therapy [Figure 1; AG HR 0.60 (95% 0.38-0.95)]. Further, there was also a statistically significant reduction in the appropriate shock burden (i.e. number of appropriate shocks) among ablation patients (169 appropriate shocks) compared to escalated AAD therapy patients (266 appropriate shocks) [Figure 1; AG HR 0.61 (95% CI 0.37-0.96)]. All results were consistent between the 3 recurrent event models.

Conclusion

Among patients with AAD-refractory VT and a prior MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared to escalated AAD therapy.

CFD analysis of operational flow nature of a wind turbine model using environmental wind data from Nigerian Defence Academy (NDA)

A wind turbine is a machine which converts the power in the wind into electricity. It operates under varying wind speeds depending on the environmental wind conditions. In this paper, we have presented the operational flow analysis of a proposed wind turbine model in Nigerian Defence Academy (NDA) Kaduna. The case study is for 5.6m/s, 7.5m/s and 9.5m/s wind speed. The model design and assembly of the components were done with the help of SolidWorks 2018 and the operational flow analysis done with ANSYS 15.0. The result showed that the flow nature of the turbine model grew from laminar flow to turbulent flow increasingly with the environmental wind speed. The flow nature remained laminar from 0.0356 to 1780 Reynolds at 5.6m/s. At 7.5m/s wind speed, from laminar 0.403 Reynolds to turbulent 4290 Reynolds and at 9.5m/s, from laminar 0.381 Reynolds to turbulent 4900 Reynolds. High turbulent flow and mass imbalance nature depicts that phenomenon like wake and vibration of the system occurred.

Comparative effectiveness of ventricular tachycardia ablation versus escalated antiarrhythmic drug therapy by location of myocardial infarction: A sub-study of the VANISH trial

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Fonds de recherché du Québec-Santé (FRQS) [post doctoral award for Dr. Samuel)

BACKGROUND

Complexity of ventricular tachycardia (VT) substrate, efficiency of lesion formation, and the size and thickness of infarction area border zones differ based on location of myocardial infarctions (MI). These differences may translate into heterogeneity in risk of events and effectiveness of treatments for VT. Small observational studies suggest that VT from inferior infarctions have higher risk of early recurrence despite smaller infarct areas. However, differential effectiveness of VT treatments based on location of MI not been definitively established.

PURPOSE

The objective of this sub-study of the Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in ISchemic Heart disease (VANISH) randomized trial was to compare the effectiveness of VT ablation by location of MI in reducing the composite endpoint of all-cause mortality, VT storm, or appropriate ICD therapy when compared to escalated pharmacological therapy in VT patients with a prior MI.

METHODS

VANISH participants were categorized into 3 subgroups based on MI location: 1. Inferior (may also have MI in other locations); 2. Non-inferior (no inferior MI, all patients not in group 1); and 3. Anterior (may also have MI in other locations). Inverse probability of treatment weighting was used to balance baseline characteristics (ie. age, sex, comorbidities, medications, and the location of additional infarctions) between patients randomized to ablation or escalated therapy within each subgroup. Weighted Cox proportional hazards models were calculated separately for each subgroup.

RESULTS

Of 259 patients enrolled in the VANISH trial [median age 69.8 (IQR 63.0-74.2) years, 7.0% women], 135 had an inferior MI, 124 a non-inferior MI, and 83 an anterior MI. Among patients with an inferior MI, no statistically significant difference in the primary outcome was detected between patients randomized to ablation or escalated therapy [aHR 0.78 (95% CI 0.51-1.20)]. In contrast, patients with non-inferior MIs had a statistically significant reduction in the incidence of the primary outcome with ablation [aHR 0.48 (95% CI 0.27-0.86)]; which was of greater magnitude than the reduction observed in the overall results of the VANISH trial [HR 0.72 (95% CI 0.53-0.98)]. In addition, a trend towards a reduction in the primary outcome with ablation was detected in patients with anterior MIs [aHR 0.50 (95% CI 0.23-1.09)].

CONCLUSION

The effectiveness of VT ablation versus escalated pharmacological therapy varies based on the location of the MI. Patients with MI scars located only in non-inferior regions of the ventricles derive greater benefit from VT ablation in reducing VT-related events. Further studies are required to explore reasons for this finding and to assess the impact of VT treatment strategies based on MI location in optimizing outcomes.

Personalized medicine and back-allogeneic exosomes for cancer immunotherapy

Extracellular vesicles, especially exosomes, have been explored for cancer immunotherapy. The initial studies made use of autologous B-cell or dendritic cell-derived exosomes, with the idea that MHC-peptide complexes on the exosomal surface would stimulate an MHC-restricted cancer-specific immune response. This was also verified in mouse systems, whilst the effects in human clinical systems were more modest. Several studies have explored the mechanisms for exosomal T-cell activation, and a picture emerges where the antigen-presenting cells, possibly both B cells and dendritic cells of the recipient, are needed to induce a potent T-cell response to exosomes. Therefore, the exosomes function more as an adjuvant-like delivery system of antigens, and we need to further understand the exact components that trigger the most broad and potent immune responses. Here, we describe the grounds for using allogeneic exosomes for cancer therapy, something that would greatly improve the feasibility of new exosome-based immunotherapeutic approaches to cure cancer.

Effect of immortal time bias on the association between atrial fibrillation ablation and incident stroke: a meta-analysis

Background/Introduction

In the era of big data and large observational studies, identification and prevention of immortal time bias (ITB) is essential to attain unbiased effect estimates. Immortal time refers to a period of follow-up in a cohort when the outcome cannot occur. Typically, it results when the exposure is initiated after the start of follow-up. The misclassification of person-time results in a systematic overestimation of the treatment effect. ITB is a common methodological issue in epidemiology studies. We sought to assess the presence and magnitude of bias due to ITB in observational studies evaluating the effectiveness of catheter ablation (CA) for atrial fibrillation.

Purpose

To compare the association between CA and stroke in 1) observational studies that controlled for ITB, 2) observational studies that did not address ITB, and 3) randomized controlled trials (RCT).

Methods

The PUBMED database was screened from inception to January 15, 2020 for publications with the following string of search terms: (“ablation” or “catheter ablation” or “pulmonary vein isolation”) and “atrial fibrillation” and (“stroke” or “thromboembolism”). Observational studies and RCTs comparing CA to medical therapy were eligible. Studies were excluded if: 1) evaluation of the association was limited to a subgroup of AF patients, 2) cryoablation was performed, 3) strokes were not reported, and 4) HRs or 95% CI were not presented. Information on study characteristics, HRs, and the potential for ITB was extracted. Subsequently, articles were classified based on the type of study and whether ITB was addressed. For each group of articles, HRs were logarithmically transformed and pooled using the random effects model.

Results

A total of 10 observational studies and 1 randomized controlled trial were included in the present analysis. Of the 10 observational studies, only 2 studies were designed to prevent ITB. The pooled HR for observational studies without ITB prevention showed a statistically significant reduction in risk of stroke (HR 0.66 (95% CI 0.58–0.74); I2=27.3%) in CA patients compared to non-CA patients. However, pooling the two observational studies that prevented ITB indicated no difference in the incidence of stroke [HR 0.75 (95% CI 0.49–1.02); I2=4.5%] among patients with and without CA, a finding similar to CABANA trial [HR 0.42 (95% CI 0.11–1.21)].

Conclusion

It is important to evaluate the effectiveness of procedures and medications using observational data to determine if the results from RCTs translate to the real-world. However, careful consideration needs to be taken in the design phase to avoid ITB and produce effect estimates that more accurately represent the true association between treatment and outcomes. Examples of design methods to prevent ITB include the use of a time-varying covariate or matching on pre-treatment exposure time.

Funding Acknowledgement

Type of funding source: None

P5707An evaluation of the use of propensity scores in cardiovascular literature: a systematic review and recommendations

Background

As randomized trials cannot always be conducted, propensity score (PS) methods are frequently used in cardiovascular observational studies. Previous evaluations found insufficient and inaccurate reporting of PS methods in the clinical literature, however; a comprehensive and current evaluation of their use and reporting is thus warranted.

Purpose

1) To conduct a systematic review of cardiovascular articles published in high-impact medical and cardiovascular journals to evaluate the use and reporting of PS methods, as well as interpretation of results. 2) To identify key reporting and analysis elements when using PS methods.

Methods

Cardiovascular articles using PS published between 2010 to 2017 in high-impact medical (5) and cardiovascular (3) journals were reviewed. Included studies used a PS-based method, and focused on cardiovascular diseases, outcomes, interventions, or techniques. Information was extracted on: (1) PS assumptions, (2) variable selection and assessment of model success, (3) specifics of each PS method, and (4) consistency of written interpretation with the causal effect estimated. Each article was evaluated by 2 reviewers. Recommendations for key elements to be included in publications were based on findings and PS methodological literature.

Results

Of the 296 included articles, most were published in Journal of the American College of Cardiology (83 articles; 28%), followed by Circulation (79 articles; 27%), European Heart Journal (46 articles; 14%), Journal of the American Medical Association (35 articles; 12%), British Medical Journal (30 articles; 10%), New England Journal of Medicine (10 articles; 3%), Annals of Internal Medicine (10 articles; 3%), and Lancet (3 articles; <1%). The most commonly used PS method was matching (53% of studies), followed by a combination of methods (19%), direct adjustment (13%), inverse probability weighting (IPW, 12%), and stratification (3%). Variables in the PS model were predefined in 77% of articles, selected with statistical testing in 17% of articles, or both in 5% of articles (no details for 1% of articles). Balance was not assessed in 16% of papers and 38% of articles that evaluated balance did not report standardized differences, the recommended measure to assess balance. For matching, most studies (85%) conducted a 1:1 match; however, 17% of studies had >50% of unmatched treated (or untreated) patients (based on targeted parameter). Overall, heterogeneity of effects was assessed in 89% of all articles. In 48% of the reviewed articles, however, interpretations of the effect estimates did not correspond to the PS method conducted or described.

Conclusions

Detailed reporting of PS methods is important to maintain transparency and reproducibility, evaluate the appropriateness of the method, and correctly interpret the results and the population to which they apply. This systematic review describes areas for improvement.

P1024Catheter ablation is associated with reduced all-cause mortality in a real-world cohort of patients with atrial fibrillation and heart failure

Background

Atrial fibrillation (AF) and heart failure (HF) are common co-existing conditions. Randomized trial data suggests a reduction in all-cause mortality with catheter ablation (CA) in selected patients, however, whether these results are replicable in a real-world population and persist in the long-term remains to be shown.

Purpose

To evaluate the long-term effectiveness of CA in AF-HF patients in reducing the incidence of: a) all-cause mortality b) HF hospitalizations, and c) major morbidities (stroke/transient ischemic attack (TIA) and major bleeding).

Methods

A population-based administrative cohort was created of AF-HF patients with government prescription coverage in Quebec, Canada (1999–2015). Patients who underwent CA (cases) were matched 1:2 to controls using risk-set sampling. Cases were matched on time in the cohort and frequency of hospitalizations. Measured time-invariant confounders were controlled for using inverse probability of treatment weighting (IPTW) and included age, sex, clinical characteristics, presence of cardiac implantable electronic devices, and medication use. Multivariable Cox models adjusted the association of CA with the outcomes for the time varying confounders of the presence of an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT), anticoagulation use (warfarin or direct oral anticoagulation), and any antiarrhythmic (AAD) use during follow-up. For non-fatal outcomes, the competing risk of death was accounted for using the Lunn-McNeil approach.

Results

Of the 87,676 AF-HF patients, 298 underwent CA and were matched to 591 controls. After IPTW, the distribution of covariates was balanced between cases and controls [age 65.6±11.0 vs 61.6±11.6; women 24% vs 20%; CHA2DS2-Vasc score 3.2±2.3 vs 2.9±2.1; CA vs non-CA, respectively; standardized mean differences <0.1 for all]. Over a median follow-up of 3.3 (IQR 1.1–6.4) years, 19 (7.3%) of CA patients died compared to 144 (24.6%) non-CA patients. After weighting and adjustment, CA was associated with a statistically significant reduction in the incidence of all-cause mortality [adjusted HR 0.5 (95% CI 0.3–0.9)]. In addition, there was no statistically significant difference in the incidence of HF hospitalizations over the follow-up [CA: 22.5% vs non-CA: 27.1%; adjusted HR 0.9 (95% CI 0.6–1.2)]. The incidences of stroke/TIA (1.7% vs 6.8%) and major bleeding (1.7% vs 4.9%) for CA vs non-CA were not statistically different.

Conclusion

In a matched population-based AF-HF cohort, CA was associated with a reduced risk of all-cause mortality compared to patients who did not undergo CA. Although no difference in the risk of HF hospitalizations, stroke/TIA, and major bleeding was detected between CA and non-CA patients, larger studies are warranted.

Acknowledgement/Funding

Canadian Institute of Health Research; Fonds de recherché du Quebec-Santé, Clinical Research Scholar Award (V. Essebag) and Doctoral Award (M. Samuel)

Experience of hormone replacement therapy in postmenopausal women living with HIV

Objective

To assess the uptake of hormone replacement therapy in women living with HIV (WLHIV) in particular acceptability, response to treatment and compliance.

Study design

Retrospective review of menopausal women attending a HIV medical gynaecology clinic in a tertiary referral London Hospital between 1 January 2011 and 31 December 2016.

Main outcome measures

Patient demographics, presenting symptoms, uptake of hormone replacement therapy, type of hormone replacement therapy used and bone density assessment findings at presentation.

Results

Seventy-three HIV patients were evaluated. Of them 64 (87%) were of black ethnicity and 9 (13%) were of white ethnicity. The commonest presenting complaints were vasomotor symptoms (40/73, (55%)) followed by low mood/irritability (20/73, (27%)). When offered hormone replacement therapy, this was accepted by 28/53 (52%) in WLHIV. The commonest regimen prescribed was transdermal oestradiol/micronised progesterone. A total of 22/24 (91%) women of black ethnicity reported good symptom control if they had started hormone replacement therapy, with 4/24 (17%) subsequently discontinuing it; 3/4 (75%) of white women reported good symptom control with hormone replacement therapy, with no one discontinuing it. The commonest reason for discontinuation was irregular bleeding. Of WLHIV who had a bone density assessment, 15/25 (60%) had osteopenia while 2/25 (8%) had osteoporosis.

Conclusion

Our data show that only around 50% WLHIV accepted hormone replacement therapy when offered and a high proportion of these women discontinued it. Further research is needed to explore the reason leading to low uptake and high rates of stopping hormone replacement therapy. In addition, there is a need to increase awareness of the benefits of hormone replacement therapy in WLHIV both in the context of preventing osteoporosis and menopausal symptom management.

Comparison of ultrasonic pachymetry and Fourier-domain optical coherence tomography for measurement of corneal thickness in dogs with and without corneal disease

Several ultrasonic and Fourier-domain optical coherence tomography (FD-OCT) pachymeters are used to measure corneal thickness in canine patients and research subjects. This study assessed the reliability of and consistency between two ultrasonic pachymetry (USP) devices, Pachette 3 and Accupach VI, as well as automated and manual measurements obtained using FD-OCT in dogs with and without corneal disease. Corneal thickness measurements were compiled from 108 dogs and analyzed using mixed effects linear regression, with Bonferonni adjustments for post-hoc comparisons, to determine the effects of age, weight and disease state. Data are presented as predicted mean±standard error. Canine corneal disease can result in marked increases in thickness that frequently exceed the upper limits of measurement of some pachymetry devices developed for human use. In this study, the corneas of dogs with endothelial disease or injury frequently exceeded the upper limits of quantitation of 999 and 800μm for the Accupach VI and automated FD-OCT pachymeters, respectively. Using values <800μm, the Pachette 3 generated significantly greater values for central corneal thickness (CCT) than the Accupach VI, manual FD-OCT and automated FD-OCT at 625±7.0, 615±7.2, 613±7.2, and 606±7.4μm respectively (P<0.001). Of the two devices where measurements >1000μm were obtained, manual FD-OCT demonstrated less variability than the Pachette 3. Corneal thickness increased linearly with age and weight with an increase of 6.9±1.8μm/year and 1.6±0.8μm/kg body weight (P<0.005 and P=0.038, respectively).

A replication study of 49 Type 2 diabetes risk variants in a Punjabi Pakistani population

AIM

The burden of Type 2 diabetes is alarmingly high in South Asia, a region that has many genetically diverse ethnic populations. Genome-wide association studies (GWAS) conducted largely in European populations have identified a number of loci predisposing to Type 2 diabetes risk, however, the relevance of such genetic loci in many South Asian sub-ethnicities remains elusive. The aim of this study was to replicate 49 single nucleotide polymorphisms (SNPs) previously identified through GWAS in Punjabis living in Pakistan.

METHODS

We examined the association of 49 SNPs in 853 Type 2 diabetes cases and 1945 controls using additive logistic regression models after adjusting for age and gender.

RESULTS

Of the 49 SNPs investigated, eight showed a nominal association (P < 0.05) that also remained significant after controlling for the false discovery rate. The most significant association was found for rs7903146 at the TCF7L2 locus. For a per unit increase in the risk score comprising of all the 49 SNPs, the odds ratio in association with Type 2 diabetes risk was 1.16 (95% CI 1.13-1.19, P < 2.0E-16).

CONCLUSION

These results suggest that some Type 2 diabetes susceptibility loci are shared between Europeans and Punjabis living in Pakistan.

A rare case of acquired lymphangioma circumscriptum of the penis

Acquired lymphangioma circumscriptum is a rare occurrence on the penis. We report a case of a 47-year-old man who presented with a single lesion of acquired lymphangioma circumscriptum on the penis resembling genital warts. We report the case to increase awareness of this rare condition which may mimic sexually transmitted infections such as genital warts.

Unmet need in the hyperlipidaemia population with high risk of cardiovascular disease: a targeted literature review of observational studies

Background

The aim of this study was to examine recommended target levels of low-density lipoprotein cholesterol (LDL-C) for hyperlipidaemia patients at high risk (i.e., with two or more risk factors or coronary heart disease or its risk equivalents) for cardiovascular disease (CVD); to determine LDL-C targets recommended by guidelines, and to examine the proportions of patients who do not achieve targeted LDL-C levels in real-world studies.

Methods

Electronic databases were searched: Medline, Medline In-Process, Embase, BIOSIS, and the Cochrane Library (1 January 2005 to 31 December 2013). Guideline searches were limited to publications in the last 5 years. There were no geographical or language restrictions.

Results

Seventeen guidelines and 42 observational studies that reported on high-risk hyperlipidaemia patients were identified. The National Cholesterol Education Program–Adult Treatment Panel III’s LDL-C target levels were the most common guidelines used for patients with very high hyperlipidaemia. However, between 68 and 96 % of patients in the studies did not achieve an LDL-C goal <70 mg/dL, except in one study conducted in China (16.9 %). In high-risk patients, 61.8 to 93.8 % did not achieve a target of <100 mg/dL. Regarding common comorbidities, patients with concomitant CVD or diabetes were least likely to reach their target LDL-C goals.

Conclusion

In patients with high risk for CVD, the majority of patients do not attain recommended LDL-C goals, highlighting worldwide suboptimal hyperlipidaemia management and missed opportunities for reduction of the patients CVD risk. Lipid-modifying management strategies need to be intensified.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0241-3) contains supplementary material, which is available to authorized users.

Anxiety and anxious-depression in Parkinson's disease over a 4-year period: a latent transition analysis

BACKGROUND

Depression and anxiety in Parkinson's disease are common and frequently co-morbid, with significant impact on health outcome. Nevertheless, management is complex and often suboptimal. The existence of clinical subtypes would support stratified approaches in both research and treatment.

METHOD

Five hundred and thirteen patients with Parkinson's disease were assessed annually for up to 4 years. Latent transition analysis (LTA) was used to identify classes that may conform to clinically meaningful subgroups, transitions between those classes over time, and baseline clinical and demographic features that predict common trajectories.

RESULTS

In total, 64.1% of the sample remained in the study at year 4. LTA identified four classes, a 'Psychologically healthy' class (approximately 50%), and three classes associated with psychological distress: one with moderate anxiety alone (approximately 20%), and two with moderate levels of depression plus moderate or severe anxiety. Class membership tended to be stable across years, with only about 15% of individuals transitioning between the healthy class and one of the distress classes. Stable distress was predicted by higher baseline depression and psychiatric history and younger age of onset of Parkinson's disease. Those with younger age of onset were also more likely to become distressed over the course of the study.

CONCLUSIONS

Psychopathology was characterized by relatively stable anxiety or anxious-depression over the 4-year period. Anxiety, with or without depression, appears to be the prominent psychopathological phenotype in Parkinson's disease suggesting a pressing need to understanding its mechanisms and improve management.

The Role of Speech and Language Therapy in Assessing and Managing Pharyngo-esophageal Diverticula

This study explores the contribution of Speech and Language Therapists (SLTs) to the assessment and management of patients presenting on videofluoroscopic swallow studies (VFSS) with a suspected pharyngo-oesophageal diverticulum. Records for all patients who attended for VFSS in an acute hospital over an eleven-year period were examined (N = 1820). Twenty patients were identified on VFSS as having a suspected diverticulum. Symptoms suggestive of a diverticulum were found during both bedside clinical examination and radiographic examination e.g. respiratory difficulties (n = 15; 75%), voice changes (n = 14; 70/0). VFSS confirmed a reduced risk of aspiration for 14 patients (70%) using a combination of fluid modification (n = 9; 45%), food modification (n = 13; 65%) and swallow strategies (n = 14; 70%). VFSS confirmed aspiration directly related to the diverticulum in 11 patients (55%). Findings indicate that SLTs have the opportunity to identify potential diverticula and implement behavioural management to reduce associated health risks. This is of particular importance to patients who are awaiting, or cannot undergo, surgical repair of their diverticulum.

The effects of age on associations between markers of HIV progression and markers of metabolic function including albumin, haemoglobin and lipid concentrations

OBJECTIVES

We investigated whether age modified associations between markers of HIV progression, CD4 T lymphocyte count and HIV RNA viral load (VL), and the following markers of metabolic function: albumin, haemoglobin, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC).

METHODS

A retrospective analysis of data from the United Kingdom Collaborative HIV Cohort was carried out. Analyses were limited to antiretroviral-naïve subjects to focus on the impact of HIV disease itself. A total of 16670 subjects were included in the analysis. Multilevel linear regression models assessed associations between CD4 count/VL and each of the outcomes. Statistical tests for interactions assessed whether associations differed among age groups.

RESULTS

After adjustment for gender and ethnicity, there was evidence that lower CD4 count and higher VL were associated with lower TC, LDL-C, haemoglobin and albumin concentrations but higher triglyceride concentrations. Age modified associations between CD4 count and albumin (P < 0.001) and haemoglobin (P = 0.001), but not between CD4 count and HDL-C, LDL-C and TC, or VL and any outcome. Among participants aged < 30, 30-50 and > 50 years, a 50 cells/μL lower CD4 count correlated with a 2.4 [95% confidence interval (CI) 1.7-3.0], 3.6 (95% CI 3.2-4.0) and 5.1 (95% CI 4.0-6.1) g/L lower haemoglobin concentration and a 0.09 (95% CI 0.07-0.11), 0.12 (95% CI 0.11-0.13) and 0.16 (95% CI 0.13-0.19) g/L lower albumin concentration, respectively.

CONCLUSIONS

We present evidence that age modifies associations between CD4 count and plasma albumin and haemoglobin levels. A given reduction in CD4 count was associated with a greater reduction in haemoglobin and albumin concentrations among older people living with HIV. These findings increase our understanding of how the metabolic impact of HIV is influenced by age.

Frequency, prevalence, incidence and risk factors associated with visual hallucinations in a sample of patients with Parkinson's disease: a longitudinal 4-year study

OBJECTIVE

To examine the prevalence, incidence and risk factors associated with visual hallucinations (VHs) amongst people suffering from Parkinson's disease (PD).

METHODS

We recruited 513 patients with PD from movement disorder and PD clinics within three sites in the UK. Patients were interviewed using a series of standardised clinical rating scales at baseline, 12, 24 and 36 months. Data relating to VHs were collected using the North-East Visual Hallucinations Interview. Prevalence rates for VHs at each assessment were recorded. Associations were determined using multiple regression analysis.

RESULTS

Cross-sectional prevalence rates for VHs at baseline, 12, 24 and 36 months indicated VHs in approximately 50% of patients. A cumulative frequency of 82.7% of cases at the end of the study period exhibited VHs. The incidence rate for VHs was 457 cases per 1000 population. Longer disease duration, greater impairment in activities of daily living and higher rates of anxiety were most commonly associated with VHs. No factors predictive of VHs could be ascertained.

CONCLUSIONS

When examined longitudinally, VHs affect more patients than is commonly assumed in cross-sectional prevalence studies. Clinicians should routinely screen for VHs throughout the disease course. Disease duration, impairment in activities of daily living and anxiety presented as co-morbidities associated with VHs in PD, and therefore those presenting with VHs should be screened for anxiety disorder and vice versa.

Coping in Parkinson's disease: an examination of the coping inventory for stressful situations

BACKGROUND

Parkinson's disease (PD) brings with it a range of stresses and challenges with which a patient must cope. The type of coping strategies employed can impact upon well-being, although findings from coping studies in PD remain inconsistent. The variety of coping scales used without validation in PD has been cited as a possible cause of this inconsistency. The present study sought to examine the validity of the coping inventory for stressful situations (CISS) in a sample of patients with PD.

METHODS

Five hundred and twenty-five patients with PD were recruited as part of a longitudinal investigation of mood states in PD. Four hundred and seventy-one participants completed the CISS. Confirmatory factor analysis was used to explore the structural validity of the scale. Internal reliability, test-retest reliability, convergent validity and discriminant validity were assessed using Cronbach's alpha, intraclass correlations and Pearson's correlations.

RESULTS

Both three and four factor solutions were examined. The four factor model was found to provide a better fit of the data than the three factor model. The internal reliability, discriminant validity, convergent validity, and test-retest reliability of the CISS scales were shown to be good. Use of emotion-focused coping was associated with greater depression and anxiety whilst, task-oriented coping was associated with better psychological well-being.

CONCLUSION

The results provide support for the validity and reliability of the CISS as a measure of coping in patients with PD. Further research into the relationship between coping and well-being is warranted. The identification of helpful and unhelpful coping strategies may guide the development of evidence-based therapies to improve well-being in patients with PD.

Relationships between deep brain stimulation and impulse control disorders in Parkinson's disease, with a literature review

Impulse control disorders (ICDs) are behavioural/neuropsychiatric complications of the pharmacological treatment of Parkinson's disease. Long term motor complications of PD can be effectively treated using deep brain stimulation (DBS) of subcortical nuclei. The relationships between ICDs and DBS treatment of the motor complications of Parkinson's disease remain unclear. We describe 50 consecutive patients in whom detailed neuropsychiatric assessments were performed as part of our routine pre-operative assessment. Eight had current or past ICDs during pre-operative assessment. These patients were more likely to be male and were younger than those without ICDs. Other psychosocial variables did not predict the presence of ICDs. Detailed neuropsychological examination failed to show any between-group differences. Our prevalence rate of 16% helps raise awareness of ICDs in this specialised clinic population and may reflect common denominators between significant motor fluctuations and dopaminergic drug - related behavioural disturbances. Four patients were deemed suitable for surgery after multi-disciplinary assessment. One had re-emergence of his ICD 18 months post-operatively, the ICD having resolved in the first 18 months. We also review published literature and the evidence regarding post-operative outcomes. We recommend the routine pre-operative examination of patients for psychopathology and emphasize the importance of post-operative psychiatric surveillance.

339 BIOENGINEERING OF THE MAMMARY GLAND OF LIVESTOCK: INCREASED PROPEPTIDE PROCESSING OF FACTOR IX IN THE MILK OF TRANSGENIC PIGS BY CO-EXPRESSION OF FURIN

Coagulation Factor IX is a vital protein that plays an important role in the blood coagulation cascade. Hereditary deficiency in the Factor IX gene can result in hemophilia type B, the second most common hemophilia. The milk of transgenic livestock can be an efficient vehicle for producing complex, post-translationally modified blood proteins. The advantages include decreased pathogen risk as well as 100-fold or more production efficiency over blood fractionation and cell culture biotechnology. Although the mammary gland can make many of the complex post-translational modifications necessary for biological function of blood proteins, improvements in propeptide cleavage and decreased proteolytic degradation are desirable. To explore the possibility of producing bioactive human Factor IX protein in pig milk, male and female Landrace fetal fibroblast cells were co-transfected by electroporation with 3 different transgene constructs, Factor IX (FIX), Furin, and SERPINA1. The SERPINA1 construct (containing a Neo selectable marker) was delivered into fetal fibroblasts at a 10-fold-lower molar concentration than the other 2 constructs. Following selection in Geneticin, the presence of all 3 genes was verified by PCR and then cells were used as donors for somatic cell nuclear transfer. Thirteen F0 female piglets from 3 potential different integrations were delivered, and 6 piglets were validated by PCR to be positive for all 3 genes. Among the 6 transgenic pigs, 3 are healthy and able to reach puberty. Milk was collected by induced lactation from 2 gilts. A short murine whey acidic protein promoter-Furin gene was used to limit Furin to the lowest levels needed for pro-FIX processing. Furin was expressed to increase propeptide cleavage efficiency, with the result being complete processing of pro-FIX to FIX at ∼0.3 g L–1 pro-FIX. Total FIX levels were ∼1 g L–1. SERPINA1 was also co-expressed at ∼1 g L–1 or more and this serine protease inhibitor did not seem to inhibit furin processing of the pro-FIX. Fifteen F0 male piglets from 3 potential different integration sites were delivered and all of them were positive for all 3 genes. Four F0 males were chosen to breed with wild-type females, and 5 litters of F1 piglets were born. Of 63 F1 piglets, 22 were tri-transgenic and 3 were di-transgenic (only carrying FIX and Furin). Two F1 females were mated with wild-type males, are confirmed to be pregnant, and will be used to determine the expression level and bioactivity of the Factor IX protein in the milk. Funded by the NIH NCRR (RR018877) and R01 HL078944.

Role of penile biopsy in the diagnosis of penile dermatoses

The aim of this study was to review the utility of penile biopsy in genitourinary (GU) medicine clinics, its acceptability and the range of penile dermatoses diagnosed histologically. A retrospective case-notes review of 401 cases attending a dedicated penile dermatoses clinic from 1 June 2001 to 30 November 2007 was carried out. In 115/401 (28.7%) of cases a biopsy was invoked to resolve ambiguities of diagnosis. In 60/401 (15%) of those cases differential diagnosis was resolved, in 26/401 (6.5%) clinically suspected diagnoses were confirmed and in 22/401 (5.5%) clinically unsuspected diagnoses were identified. In 7/401 (1.7%) of cases the biopsy was also the treatment. Targeted penile biopsy has an important role in the diagnosis of penile dermatoses, particularly where there is clinical uncertainty. As a diagnostic tool in GU medicine departments it should be readily available even if not for routine use. There were indications that circumcision may reduce the incidence of penile dermatoses. There was also some indication of a possible ethnic factor in the relative incidences of penile lichen sclerosus and lichen planus in biopsied patients.