Computed tomographic angiography measures of coronary plaque in clinical trials: opportunities and considerations to accelerate drug translation

Atherosclerotic coronary artery disease (CAD) is the causal pathological process driving most major adverse cardiovascular events (MACE) worldwide. The complex development of atherosclerosis manifests as intimal plaque which occurs in the presence or absence of traditional risk factors. There are numerous effective medications for modifying CAD but new pharmacologic therapies require increasingly large and expensive cardiovascular outcome trials to assess their potential impact on MACE and to obtain regulatory approval. For many disease areas, nearly a half of drugs are approved by the U.S. Food & Drug Administration based on beneficial effects on surrogate endpoints. For cardiovascular disease, only low-density lipoprotein cholesterol and blood pressure are approved as surrogates for cardiovascular disease. Valid surrogates of CAD are urgently needed to facilitate robust evaluation of novel, beneficial treatments and inspire investment. Fortunately, advances in non-invasive imaging offer new opportunity for accelerating CAD drug development. Coronary computed tomography angiography (CCTA) is the most advanced candidate, with the ability to measure accurately and reproducibly characterize the underlying causal disease itself. Indeed, favourable changes in plaque burden have been shown to be associated with improved outcomes, and CCTA may have a unique role as an effective surrogate endpoint for therapies that are designed to improve CAD outcomes. CCTA also has the potential to de-risk clinical endpoint-based trials both financially and by enrichment of participants at higher likelihood of MACE. Furthermore, total non-calcified, and high-risk plaque volume, and their change over time, provide a causally linked measure of coronary artery disease which is inextricably linked to MACE, and represents a robust surrogate imaging biomarker with potential to be endorsed by regulatory authorities. Global consensus on specific imaging endpoints and protocols for optimal clinical trial design is essential as we work towards a rigorous, sustainable and staged pathway for new CAD therapies.

The influence of natural disasters and multiple natural disasters on self-harm and suicidal behaviour: findings from a nationally representative cohort study of Australian adolescents

Few studies have examined the relationship between exposure to natural hazards and suicide and self-harm in youth. We extend prior research by investigating the association between multiple disasters and the risks of self-harm and suicide longitudinally in a nationally representative longitudinal cohort of adolescents 14 to 15 years to 18-19 years of age. Natural disasters were identified through parental self-reports for the local area. Different types of multiple disaster exposures were investigated including compound disasters (two or more disasters occurring in the last 12 months), cascading disasters (a disaster that leads to another disaster in the subsequent wave) and consecutive disasters (multiple disasters within the last two years or over an eight-year period). Using 8,714 person-waves of data from 2,908 adolescents, findings from random effect models suggest that parental reports of fire or floods increase the risk of self-harm ideation, self-harm, and suicidal ideation. Compound disasters of fire/flood and drought were also associated with increased risk of suicidal thoughts. Cascading disasters of drought followed by fire/flood increased the risks of self-harm but recurrent consecutive droughts were associated with lower risks of suicidal ideation. Australian adolescents are exposed to high rates of natural disasters that increase the risk of self-harm and thoughts of self-harm and suicide. Climate change will increase risk of natural disaster exposure for all countries. Despite these increased risks, there was resilience to disaster exposure particularly in the case of recurrent drought suggesting that youth, families and communities may well develop protective strategies to support mental health.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Multi-dimensional and region-specific planning for coal retirements

Early retirement of coal-fired power is essential for remaining in line with the 2°C target set in the Paris Agreement. Plant age plays the major role in designing retirement pathways, however, this overlooks the economic and health costs associated with coal-fired power. We introduce multi-dimensional retirement schedules that account for age, operating cost, and air pollution hazards. Results show that regional retirement pathways vary substantially with different weighting schemes. Schedules based on age would retire capacity mostly in the US and EU, whereas those based on cost or air pollution would shift the majority of near-term retirements to China and India, respectively. Our approach emphasizes that a "one-size-fits-all" strategy is ineffective in addressing global phase-out pathways. It provides the opportunity for devising region-specific pathways that are sound to the local context. Our results involve emerging economies and highlight incentives for early retirement that surpass climate change mitigation and address regional priorities.

Transferability of robotic console skills by early robotic surgeons: a multi-platform crossover trial of simulation training

Robotic surgical training is undergoing a period of transition now that new robotic operating platforms are entering clinical practice. As this occurs, training will need to be adapted to include strategies to train across various consoles. These new consoles differ in multiple ways, with some new vendors using flat screen open source 3D enhanced vision with glasses and differences in design will require surgeons to learn new skills. This process has parallels with aviation credentialling across different aircraft described as type rating. This study was designed to test the hypothesis that technical robotic console operating skills are transferrable across different robotic operating platforms. Ten participants sequentially completed four Mimic®(Surgical Science) simulation exercises on two different robotic operating platforms (DaVinci®, Intuitive Surgical and HUGO™ RAS, Medtronic). Ethical approval and informed consent were obtained for this study. Groups were balanced for key demographics including previous robotic simulator experience. Data for simulation metrics and time to proficiency were collected for each attempt at the simulated exercise and analysed. Qualitative feedback on multi-platform learning was sought via unstructured interviews and a questionnaire. Participants were divided into two groups of 5. Group 1 completed the simulation exercises on console A first then repeated these exercises on console B. Group 2 completed the simulated exercises on console B first then repeated these exercises on console A. Group 1 candidates adapted quicker to the second console and Group 2 candidates reached proficiency faster on the first console. Participants were slower on the second attempt of the final exercise regardless of their allocated group. Quality and efficiency metrics and risk and safety metrics were equivalent across consoles. The data from this investigation suggests that console operating skills are transferrable across different platforms. Overall risk and safety metrics are within acceptable limits regardless of the order of progression of console indicating that training can safely occur across multiple consoles contemporaneously. This data has implications for the design of training and certification as new platforms progress to market and supports a proficiency-based approach.

Culture-Free Phylogenetic Analysis of Legionella pneumophila Using Targeted CRISPR/Cas9 Next-Generation Sequencing

Currently available methods for the laboratory investigation of Legionella pneumophila outbreaks require organism culture. The ability to sequence L. pneumophila directly from clinical samples would significantly reduce delays. Here, we develop a method for targeted next-generation sequencing (NGS) of selected L. pneumophila genes utilizing a CRISPR/Cas9-based target enrichment system. We determine the method's utility by typing cultured L. pneumophila isolates and subsequently apply the method directly to patient samples. We sequenced 10 L. pneumophila isolates by 2 methods, (i) whole-genome sequencing (WGS) and (ii) targeted (CRISPR/Cas9-based) finding low-abundance sequences by hybridization (FLASH)-NGS, sequencing 57 selected genes. The targeted NGS of 57 genes was more efficient than WGS, and phylogenetic analysis of the 57 genes yielded the same classification of the L. pneumophila isolates as that based on analysis of whole-genome data. Furthermore, targeted NGS of L. pneumophila performed directly on patient respiratory samples correctly classified the patients according to their corresponding cultured isolates. This provides proof of concept that targeted NGS can be used to sequence L. pneumophila directly from patient samples. Studies on a larger number of patient samples will further validate this method. Nonetheless, CRISPR/Cas9 targeted NGS methods have the potential to be widely applicable to microbial-outbreak investigations in the future, particularly in the context of difficult and slow-growing organisms. IMPORTANCE The bacterium Legionella pneumophila is responsible for outbreaks of serious and life-threatening pneumonia called Legionnaires' disease. There is a need for new molecular methods that allow investigation of Legionella outbreaks directly from patient samples, without the need for prior microbiological culture, which causes delays. Our study aims to address this problem. We have utilized a CRISPR/Cas9-based targeted next-generation sequencing (NGS) method that can be applied directly on human specimens. Furthermore, we show that analysis of the sequences of a small number of targeted genes offers the same classification of L. pneumophila as that based on data derived from the whole genome. Given the rising interest globally in sequencing pathogens directly from human samples, CRISPR/Cas9 targeted NGS methods have the potential to be widely applicable to microbial-outbreak investigations in the future, particularly in the context of difficult and slow-growing organisms.

Kidney and Mortality Outcomes Associated with Ondansetron in Critically Ill Patients

Background: Ondansetron is a preferred anti-emetic in critical care to treat nausea and vomiting, and has historically been considered a largely safe option. A recent pharmacoepidemiology study reported that ondansetron may be associated with an increased risk for acute kidney injury (AKI). Methods: We interrogated the High-Density Intensive Care (HiDenIC-15) database containing intensive care data for 13 hospitals across Western Pennsylvania between Oct 2008-Dec 2014. AKI was defined using the Kidney Disease, Improving Global Outcomes 2012 guidelines. Ondansetron use was considered as receiving any form of ondansetron within 24 h of admission. The subsequent 48 h (hours 25-72 after admission) were analyzed for outcomes. Primary outcome was development of AKI; secondary outcomes included 90-day mortality and time to AKI. Propensity-matched, multivariate logistic regression was applied for both outcomes. Comparator groups were metoclopramide and prochlorperazine using the same exposure criteria. Results:AKI occurred in 965 (5.6%), 12 (3.0%), and 61 (6.5%) patients receiving ondansetron, prochlorperazine, and metoclopramide, respectively. In the adjusted analysis, no anti-emetic was associated with a significant change in the odds of developing AKI. Ondansetron was associated with a 5.48% decrease (CI -6.17--4.79) in death within 90 days of ICU-admission, which was independent of AKI status; an effect not seen with other anti-emetics. Anti-emetic usage was not associated with a change in the time to first AKI. Conclusion:Anti-emetic usage did not alter AKI risk. Ondansetron was associated with a significant decrease in 90-day mortality that was not seen by other anti-emetics, which requires further exploration.

Design, Synthesis, and Characterization of I-BET567, a Pan-Bromodomain and Extra Terminal (BET) Bromodomain Oral Candidate

Through regulation of the epigenome, the bromodomain and extra terminal (BET) family of proteins represent important therapeutic targets for the treatment of human disease. Through mimicking the endogenous N-acetyl-lysine group and disrupting the protein-protein interaction between histone tails and the bromodomain, several small molecule pan-BET inhibitors have progressed to oncology clinical trials. This work describes the medicinal chemistry strategy and execution to deliver an orally bioavailable tetrahydroquinoline (THQ) pan-BET candidate. Critical to the success of this endeavor was a potency agnostic analysis of a data set of 1999 THQ BET inhibitors within the GSK collection which enabled identification of appropriate lipophilicity space to deliver compounds with a higher probability of desired oral candidate quality properties. SAR knowledge was leveraged via Free-Wilson analysis within this design space to identify a small group of targets which ultimately delivered I-BET567 (27), a pan-BET candidate inhibitor that demonstrated efficacy in mouse models of oncology and inflammation.

Effectiveness of SPECT/CT Imaging for Sentinel Node Biopsy Staging of Primary Cutaneous Melanoma and Patient Outcomes

Purpose

Coregistered SPECT/CT can improve accuracy of sentinel node biopsy (SNB) for staging melanoma. This benefit has implications for pathology services and surgical practice with increased diagnostic and surgical workload. The purpose of this study was to investigate the effectiveness of SPECT/CT imaging.

Methods

SNB data were collected over a 10-year period. Preoperative SLN mapping was performed by using planar lymphoscintigraphy (LSG) for all patients (n = 1522) and after October 2015, patients underwent a second co-registered SPECT/CT scan (n = 559). The patients were stratified according to the imaging protocol. The number of nodes and nodal basins were assessed. The reasons for cancellation also were assessed.

Results

A total of 95% (1446/1522) of patients underwent a successful SNB procedure. Significantly more sentinel nodes were identified by the SPECT/CT protocol (3 vs. 2; p < 0.0001). More patients were cancelled in the SPECT/CT cohort (9.3% vs. 2.5%; p < 0.0001). Head & neck, lower limb, and AJCC IB primaries were significantly less likely to proceed to SNB. SPECT/CT identified significantly more positive SNBs (20.9% vs. 16.5%; p = 0.038). SPECT/CT imaging was associated with improved disease-free (hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.54–1.0); p = 0.048) and disease-specific survival (HR = 0.48; 95% CI: 0.3–0.78; p = 0.003). Patients who did not proceed to SNB had a significantly increased nodal relapse rate (23.5% vs. 6.8%; HR = 3.4; 95% CI: 1.9–6.2; p < 0.0001) compared with those who underwent SNB.

Conclusions

This large cohort study confirms the increased accuracy of SPECT/CT for identifying SLN metastases, which would appear to have a significant therapeutic benefit, although an increased risk of cancellation of the SNB procedure on the day of surgery.

Methods to Measure Antibody Neutralization of Live Human Coronavirus OC43

The human Betacoronavirus OC43 is a common cause of respiratory viral infections in adults and children. Lung infections with OC43 are associated with mortality, especially in hematopoietic stem cell transplant recipients. Neutralizing antibodies play a major role in protection against many respiratory viral infections, but to date a live viral neutralization assay for OC43 has not been described. We isolated a human monoclonal antibody (OC2) that binds to the spike protein of OC43 and neutralizes the live virus derived from the original isolate of OC43. We used this monoclonal antibody to develop and test the performance of two readily accessible in vitro assays for measuring antibody neutralization, one utilizing cytopathic effect and another utilizing an ELISA of infected cells. We used both methods to measure the neutralizing activity of the OC2 monoclonal antibody and of human plasma. These assays could prove useful for studying humoral responses to OC43 and cross-neutralization with other medically important betacoronaviruses.

Stroke or No Stroke: A Case Report of Bilingual Aphasia

Introduction

Bilingual aphasia is an atypical stroke presentation in the multilingual patient where an isolated aphasia occurs in one language while the other remains unaffected.

Case Report

A multilingual male presented to the emergency department with expressive aphasia to English but who was still able to speak fluently in French. Receptive English was preserved. While his National Institute of Health Stroke Scale score was technically zero, his pure aphasia component qualified him as an exception. He regained some repetitive English, so fibrinolyitic therapy was not initiated.

Conclusion

Bilingual aphasia is an indication for fibrinolysis given the impact that a pure aphasic stroke has on quality of life.

The influence of natural disasters on violence, mental health, food insecurity, and stunting in the Philippines: Findings from a nationally representative cohort

Background

Climate change is leading to an increased number of natural disasters. Children from low- and middle-income countries are disproportionately affected. The impacts of exposure to multiple natural disasters on the development of children are not well understood. The Philippines had 6.5 million people affected by natural disasters in 2018 and is therefore an ideal country in which to study the cumulative effects of natural disasters on human development.

Methods

We used wave 1 (2016–17) of the Longitudinal Cohort Study on the Filipino Child, a nationally representative cohort study of 4952 10-year-old children, to examine the impact of natural disasters. For caregivers, we examined mental health, family violence, and food insecurity. For children, we examined exposure to violence and stunting. We used random effects models to estimate the associations between natural disasters and children's development outcomes and caregivers' outcomes, after adjusting for neighbourhood, demographic, and geographic variables. Disaster exposure was measured using caregiver-reported measures of cumulative exposure and cumulative impact of disasters, average neighbourhood reports and data linked from the International Disaster Database (EM-DAT), an independent measure of community exposure to disaster.

Findings

We found that experiencing natural disasters, as measured by neighbourhood reports, was associated with higher levels of family violence in the previous 12 months, parenting stress, children witnessing physical violence, physical abuse of children, stunting in children, and greater food insecurity. Associations with individual self-reported exposure showed was similar. Associations with natural disasters measured using EM-DAT data showed a similar pattern: exposure to greater numbers of natural disasters was associated with higher levels of family violence, physical abuse of children, stunting in children, and food insecurity. Impacts of disasters was associated with higher levels of family violence, depression and food insecurity.

Interpretation

This is the first national study to document that cumulative measures of natural disasters had small, but wide-ranging, impacts on children and their caregivers. Further research is needed to identify factors that will protect populations who are at risk of high levels of natural disasters to ensure the optimal development of children.

Funding

The Philippines Project, The Australian National University.

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The implications of multiple natural disasters for child development are not well understood.

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First national study on the impact of multiple natural disasters on children.

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More natural disasters associated with child physical abuse and family violence.

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Exposure to a greater number of natural disasters associated with stunting and food insecurity.

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More natural disasters led to worse caregivers' depression and stress.

HIV-1 VRC01 Germline-Targeting Immunogens Select Distinct Epitope-Specific B Cell Receptors

Activating precursor B cell receptors of HIV-1 broadly neutralizing antibodies requires specifically designed immunogens. Here, we compared the abilities of three such germline-targeting immunogens against the VRC01-class receptors to activate the targeted B cells in transgenic mice expressing the germline VH of the VRC01 antibody but diverse mouse light chains. Immunogen-specific VRC01-like B cells were isolated at different time points after immunization, their VH and VL genes were sequenced, and the corresponding antibodies characterized. VRC01 B cell sub-populations with distinct cross-reactivity properties were activated by each immunogen, and these differences correlated with distinct biophysical and biochemical features of the germline-targeting immunogens. Our study indicates that the design of effective immunogens to activate B cell receptors leading to protective HIV-1 antibodies will require a better understanding of how the biophysical properties of the epitope and its surrounding surface on the germline-targeting immunogen influence its interaction with the available receptor variants in vivo.

COVID-19 vaccine hesitancy and resistance: Correlates in a nationally representative longitudinal survey of the Australian population

BACKGROUND

High levels of vaccination coverage in populations will be required even with vaccines that have high levels of effectiveness to prevent and stop outbreaks of coronavirus. The World Health Organisation has suggested that governments take a proactive response to vaccine hesitancy 'hotspots' based on social and behavioural insights.

METHODS

Representative longitudinal online survey of over 3000 adults from Australia that examines the demographic, attitudinal, political and social attitudes and COVID-19 health behavior correlates of vaccine hesitance and resistance to a COVID-19 vaccine.

RESULTS

Overall, 59% would definitely get the vaccine, 29% had low levels of hesitancy, 7% had high levels of hesitancy and 6% were resistant. Females, those living in disadvantaged areas, those who reported that risks of COVID-19 was overstated, those who had more populist views and higher levels of religiosity were more likely to be hesitant or resistant while those who had higher levels of household income, those who had higher levels of social distancing, who downloaded the COVID-Safe App, who had more confidence in their state or territory government or confidence in their hospitals, or were more supportive of migration were more likely to intend to get vaccinated.

CONCLUSIONS

Our findings suggest that vaccine hesitancy, which accounts for a significant proportion of the population can be addressed by public health messaging but for a significant minority of the population with strongly held beliefs, alternative policy measures may well be needed to achieve sufficient vaccination coverage to end the pandemic.

Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial

Adaptive Disclosure (AD) is a new emotion-focused psychotherapy for combat-related PTSD. As a second step in the evaluation process, we conducted a non-inferiority (NI) trial of AD, relative to Cognitive Processing Therapy - Cognitive Therapy version (CPT-C), an established first-line psychotherapy. Participants were 122 U.S. Marines and Sailors. The primary endpoint was PTSD symptom severity change from pre- to posttreatment, using the Clinician Administered PTSD Scale for DSM-IV. Secondary endpoints were depression (Patient Health Questionnaire-9; PHQ-9) and functioning (Veterans Rand Health Survey-12; VR-12). For cases with complete data, the mean difference in CAPS-IV change scores was 0.33 and the confidence interval (CI) did not include the predefined NI margin (95% CI =-10.10, 9.44). The mean difference in PHQ-9 change scores was -1.01 and the CI did not include the predefined margin (95% CI = -3.31, 1.28), as was the case for the VR-12 Physical Component and VR-12 Mental Component subscale scores (0.27; 95% CI = -4.50, 3.95, and -2.10; 95% CI = -7.03, 2.83, respectively). A series of intent-to-treat sensitivity analyses confirmed these results. The differential effect size for CAPS-IV was d = 0.01 (nonsignificant). As predicted, Adaptive Disclosure was found to be no less effective than a first-line psychotherapy.

(Sub)stellar companions shape the winds of evolved stars

Binary interactions dominate the evolution of massive stars, but their role is less clear for low- and intermediate-mass stars. The evolution of a spherical wind from an asymptotic giant branch (AGB) star into a nonspherical planetary nebula (PN) could be due to binary interactions. We observed a sample of AGB stars with the Atacama Large Millimeter/submillimeter Array (ALMA) and found that their winds exhibit distinct nonspherical geometries with morphological similarities to planetary nebulae (PNe). We infer that the same physics shapes both AGB winds and PNe; additionally, the morphology and AGB mass-loss rate are correlated. These characteristics can be explained by binary interaction. We propose an evolutionary scenario for AGB morphologies that is consistent with observed phenomena in AGB stars and PNe.

Randomized, Placebo Controlled Trial of NPT088, A Phage-Derived, Amyloid-Targeted Treatment for Alzheimer's Disease

The engineered fusion protein NPT088 targets amyloid in vitro and in animal models of Alzheimer's disease. Previous studies showed that NPT088 treatment reduced β-amyloid plaque and tau aggregate loads in mouse disease models. Here, we present the results from an initial clinical study of NPT088 in patients with mild to moderate Alzheimer's disease. Patients were treated with 4 dose levels of NPT088 for 6 months to evaluate its safety and tolerability. Exploratory measurements included measurement of change in β-amyloid plaque and tau burden utilizing Positron Emission Tomography imaging as well as measures of Alzheimer's disease symptoms. At endpoint NPT088 was generally safe and well-tolerated with the most prominent finding being infusion reactions in a minority of patients. No effect of NPT088 on brain plaques, tau aggregates or Alzheimer's disease symptoms was observed.

Perceived Anxiety is Negligible in Medical Students Receiving Video Feedback During Simulated Core Practical Skills Teaching: A Randomised Trial Comparing Two Feedback Modalities

Introduction

The ability to undertake simple practical procedures is essential for graduating medical students and is typically assessed using simulated models. Feedback is a key component of the learning process in developing proficiency in these key skills. Video feedback (VF) has previously shown promise, however, negative effects of VF-related anxiety on performance have been previously reported. Our aim was to investigate for a difference in participant anxiety between supervised individualised video feedback (SIVF) and unsupervised generic video feedback (UGVF) when undertaking simulated basic practical procedures.

Methods

Undergraduate medical students participating in a clinical skills study to compare UGVF and SIVF completed a Likert scale questionnaire detailing perceived anxiety. During the study, students were recorded performing three basic surgical skills (simple interrupted suturing, intravenous cannulation, urinary catheterisation). Feedback was then provided by one of two methods: (1) SIVF - participant video footage reviewed together with a tutor providing targeted feedback, and (2) UGVF - participant video footage reviewed alone with concurrent access to a generic pre-recorded ‘expert tips' video clip for comparison. Each participant received SIVF and UGVF at least once.

Results

The majority of participants did not find either SIVF (81.7%) or UGVF (78.8%) stressful. Students had a strong preference for SIVF (77.5%) and disagreed that similar ‘face-to-face’ feedback had impaired learning in the past (80.3%).

Conclusion

Medical student-perceived anxiety is negligible when video feedback is employed during simulated core practical skill training.

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (&lt;10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Modified Immunodiffusion Method for Detection of Salmonella in Raw Flesh and Highly Contaminated Foods: Collaborative Study

A total of 19 government and private industry laboratories in Canada and the United States participated in the collaborative study. Naturally contaminated ground poultry and animal meals, as well as inoculated raw shrimp, were examined for presence of Salmonella by both the modified immunodiffusion method and the Bacteriological Analytical Manual culture method, resulting in an agreement rate of 93.1%. The 2 methods are statistically equivalent for all food types at each inoculation level and for all lots of naturally contaminated foods evaluated in this study. The modification of the AOAC Official Method 989.13, immunodiffusion (1–2 TEST) method for detection of motile Salmonella in all foods, has been adopted revised first action by AOAC INTERNATIONAL.

A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study)

INTRODUCTION

Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes.

MATERIALS AND METHODS

A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22.

RESULTS

A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity.

DISCUSSION

Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.

Overcoming Steric Restrictions of VRC01 HIV-1 Neutralizing Antibodies through Immunization

Broadly HIV-1 neutralizing VRC01 class antibodies target the CD4-binding site of Env. They are derived from VH1-2∗02 antibody heavy chains paired with rare light chains expressing 5-amino acid-long CDRL3s. They have been isolated from infected subjects but have not yet been elicited by immunization. Env-derived immunogens capable of binding the germline forms of VRC01 B cell receptors on naive B cells have been designed and evaluated in knockin mice. However, the elicited antibodies cannot bypass glycans present on the conserved position N276 of Env, which restricts access to the CD4-binding site. Efforts to guide the appropriate maturation of these antibodies by sequential immunization have not yet been successful. Here, we report on a two-step immunization scheme that leads to the maturation of VRC01-like antibodies capable of accommodating the N276 glycan and displaying autologous tier 2 neutralizing activities. Our results are relevant to clinical trials aiming to elicit VRC01 antibodies.

Creating a common language: defining individualized, personalized and precision prevention in public health

Background

Because of the limited success of population-based prevention methods and due to developments in genomic screening, public health professionals and health policy makers are increasingly interested in more individualized prevention strategies. However, the terminology applied in this field is still ambiguous and thus has the potential to create misunderstandings.

Methods

A narrative literature review was conducted to identify how individualized, personalized and precision prevention are used in research papers and documents. Based on the findings a set of definitions were created that distinguish between these activities in a meaningful way.

Results

Definitions were found only for precision prevention, not for individualized or personalized prevention. The definitions of individualized, personalized and precision medicine were therefore used to create the definitions for their prevention counterparts. By these definitions, individualized prevention consists of all types of prevention that are individual-based; personalized prevention also consists of at least one form of -omic screening; and precision prevention further includes psychological, behavioral and socioeconomic data for each patient.

Conclusions

By defining these three key terms for different types of individual-based prevention both researchers and health policy makers can differentiate and use them in their proper context.

Transcriptional Programming of Normal and Inflamed Human Epidermis at Single-Cell Resolution

Perturbations in the transcriptional programs specifying epidermal differentiation cause diverse skin pathologies ranging from impaired barrier function to inflammatory skin disease. However, the global scope and organization of this complex cellular program remain undefined. Here we report single-cell RNA sequencing profiles of 92,889 human epidermal cells from 9 normal and 3 inflamed skin samples. Transcriptomics-derived keratinocyte subpopulations reflect classic epidermal strata but also sharply compartmentalize epithelial functions such as cell-cell communication, inflammation, and WNT pathway modulation. In keratinocytes, ~12% of assessed transcript expression varies in coordinate patterns, revealing undescribed gene expression programs governing epidermal homeostasis. We also identify molecular fingerprints of inflammatory skin states, including S100 activation in the interfollicular epidermis of normal scalp, enrichment of a CD1C⁺CD301A⁺ myeloid dendritic cell population in psoriatic epidermis, and IL1β^hiCCL3^hiCD14⁺ monocyte-derived macrophages enriched in foreskin. This compendium of RNA profiles provides a critical step toward elucidating epidermal diseases of development, differentiation, and inflammation.

Cheng et al. report single-cell RNA sequencing of normal and inflamed human epidermis, revealing a discrete set of specialized keratinocytes that exhibit a distinct composition at different anatomic sites. Myeloid dendritic cells and macrophages also vary sharply with epidermal anatomic site and inflammation, indicating dynamic programming of antigen-presenting cells.

An X-Ray Diffraction Study of Triglyceride Polymorphism

The polymorphism of an homologous series of highly purified mixed triglycerides has been studied using powder and single crystal X-ray diffraction techniques, in conjunction with thermal analysis and infrared spectroscopy. From thermal analysis, three polymorphs were identified. Single crystals of the most stable polymorph were obtained for two members of the series, 2-acetodimyristin (14-2-14) and 2-acetodipalmitin (16-2-16). Their unit-cell and sub-cell dimensions were used to interpret the powder data, and to provide preliminary general information about the crystal packing for this polymorph. Of the two other polymorphs identified, the first one (obtained by rapid cooling of the melt) is disordered, and transforms on standing, to a second, unstable intermediate polymorph. Infrared spectroscopy showed that for at least two of the three polymorphs, the long chain acyl groups of the triglycerides are in a parallel packing arrangement.

Abstract P3-12-24: Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer

Background:In breast cancer (BC), radiotherapy (RT) is used adjuvantly to prevent recurrence and also in the palliative setting. Clinical signs of RT response are often not apparent for several weeks post-treatment and we currently lack tools to predict or monitor tumor response to RT early during treatment. The aim was to identify tumor-secreted biomarkers whose release reflects response to RT, which could be monitored during treatment in the blood or intratumorally by an implantable biosensor, currently under development within the Implantable Microsystems for Personalised Anti-Cancer Therapy (IMPACT) program.

Methods: A series of experiments assessed the effect of different radiation doses (2-10Gy) on 3 human BC cell lines – MDA-MB-231 (ER-), MCF-7 (ER+) and HBL-100 (ER-) –, 1 canine breast cancer and 2 sheep lung cancer lines. Culture media was collected from each dose experiment at a range of post-radiation time-points (1-24 hours). Proteins were isolated from collected media for secretome mass spectrometry (MS) analysis. A subset of treatment/time conditions were repeated in the same BC cell lines and radioresistant (RR) derivatives from which RNA was extracted and analysed using Lexogen QuantSeq for whole-genome transcriptomics.In-lab candidate biomarker validation was carried out using immuhistochemistry (IHC), immunofluorescence (IF) and western blotting (WB) using validated antibodies. Levels of candidate biomarkers were also assessed in normal and untreated BC tissues using IHC. ELISA-based methods are currently under investigation for detection of the lead candidate biomarkers in the blood of large animal cancer models treated with RT.

Results: Biomarker discovery using the MS data revealed 4 promising candidates: EIF3G, SEC24C, YBX3 and TK1. These are released from BC and animal cancer cells sensitive to radiation in a dose-dependent manner 24 hours after treatment. Analysis of the transcriptomic data showed an 8-fold higher expression of the genes encoding the 4 candidates in the radio-sensitive parental cell lines compared to the RR cell lines. IF and WB confirmed lower intracellular expression of the 4 proteins in RR cells compared to the parental lines. WB of collected culture media confirmed release of each of the 4 candidates 24 hours after a 2Gy dose of radiation in only the parental lines. GAPDH was not found in these media samples, demonstrating that protein release was not due to cell lysis.

Conclusions:

· We have identified 4 promising biomarkers which are released from cancer cells sensitive to RT and not released from RR derivatives.

· All 4 candidates are released 24 hours after a 2Gy radiation dose, which fits with the current clinical dosing schedule where radiation is administered at 24 hour intervals. Ongoing work will elucidate if these biomarkers can be reliably detected in blood or intratumorally using implantable biosensors.

· There are currently no validated predictive tools to monitor RT response during treatment. If successfully validated, these biomarkers could have a clinical role in personalising RT dosing schedules and durations for solid tumors in the neoadjuvant and palliative setting, thus optimising treatment and preventing the administration of ineffective RT and its associated side effects.

Citation Format: Meehan J, Gray M, Turnbull AK, Martinez-Perez C, Bonello M, Ward C, Langdon SP, McLaughlin S, MacLennan M, Dixon JM, Wills J, Quinn N, Finich AJ, von Kriegsheim A, Cameron D, Kunkler IH, Murray A, Argyle D. Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-24.

A20 and ABIN1 Suppression of a Keratinocyte Inflammatory Program with a Shared Single-Cell Expression Signature in Diverse Human Rashes

Genetic variation in the NF-κB inhibitors, ABIN1 and A20, increase risk for psoriasis. While critical for hematopoietic immune cell function, these genes are believed to additionally inhibit psoriasis by dampening inflammatory signaling in keratinocytes. We dissected ABIN1 and A20's regulatory role in human keratinocyte inflammation using an RNA sequencing-based comparative genomic approach. Here we show subsets of the IL-17 and tumor necrosis factor-α signaling pathways are robustly restricted by A20 overexpression. In contrast, ABIN1 overexpression inhibits these genes more modestly for IL-17, and weakly for tumor necrosis factor-α. Our genome-scale analysis also indicates that inflammatory program suppression appears to be the major transcriptional influence of A20/ABIN1 overexpression, without obvious influence on keratinocyte viability genes. Our findings thus enable dissection of the differing anti-inflammatory mechanisms of two distinct psoriasis modifiers, which may be directly exploited for therapeutic purposes. Importantly, we report that IL-17-induced targets of A20 show similar aberrant epidermal layer-specific transcriptional upregulation in keratinocytes from diseases as diverse as psoriasis, atopic dermatitis, and erythrokeratodermia variabilis, suggesting a contributory role for epidermal inflammation in a broad spectrum of rashes.

Asynchronous Unsupervised Video-Enhanced Feedback As Effective As Direct Expert Feedback in the Long-Term Retention of Practical Clinical Skills: Randomised Trial Comparing 2 Feedback Methods in a Cohort of Novice Medical Students

OBJECTIVES

To determine the degree of practical clinical skills' retention over a 7-week period after receiving either video-enhanced direct expert feedback (DEF) or asynchronous unsupervised video-enhanced feedback (UVF).

DESIGN

A prospective single-blinded randomized trial was conducted over a 7-week period with novice medical students. Following a generic introduction, PowerPoint presentation and live demonstration of intravenous cannulation was given by an expert, and candidates performed the same task in isolation while being recorded and were randomized to receive either DEF or UVF. Further, 20 students were randomized to receive UVF and 22 to receive DEF. Candidates returned to repeat the video-recorded task at week 1, 4, and 7, with no further feedback provision on these occasions. Performances were fully anonymized and independently marked by 2 expert assessors.

SETTING

Newcastle University, Medical School, England, United Kingdom.

PARTICIPANTS

A total of 42 novice medical students from the preclinical years were selected, with no prior experience of intravenous cannulation.

RESULTS

No significant difference existed between demographics of either cohort. Good between-assessor score correlation was noted, with an intraclass correlation coefficient (ICC) of 0.89. The DEF arm significantly improved from their prefeedback performance at Day 1 on repeating the skill a week later (p < 0.0001); this improved score was maintained throughout the duration of the study. The UVF arm showed a nonsignificant improvement; however, there was no significant difference in the scores between the UVF and the DEF groups at any point in the trial.

CONCLUSIONS

Video-technology may play a significant role in the provision of feedback for practical skills. The ability for experts to provide remotely delivered but individualized feedback can be an efficient use of valuable resources, while students being able to self-assess their own performance alongside an expert video have the potential to provide students with an excellent opportunity to learn clinical skills without requiring intensive educator involvement.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Dosimetry-based treatment for Graves' disease

Objective

The aim of this retrospective study was to assess the long-term outcome of a personalized dosimetry approach in Graves’ disease aiming to render patients euthyroid from a planned thyroid absorbed dose of 60 Gy.

Patients and methods

A total of 284 patients with Graves’ disease were followed prospectively following administration of radioiodine calculated to deliver an absorbed dose of 60 Gy. Patients with cardiac disease were excluded. Outcomes were analysed at yearly intervals for up to 10 years with a median follow-up of 37.5 months.

Results

A single radioiodine administration was sufficient to render a patient either euthyroid or hypothyroid in 175 (62%) patients, the remainder requiring further radioiodine. The median radioactivity required to deliver 60 Gy was 77 MBq. Less than 2% patients required 400–600 MBq, the standard activity administered in many centres. In the cohort receiving a single administration, 38, 32 and 26% were euthyroid on no specific thyroid medication at 3, 5 and 10 years, respectively. Larger thyroid volumes were associated with the need for further therapy. The presence of nodules on ultrasonography did not adversely affect treatment outcome.

Conclusion

A personalized dosimetric approach delayed the long-term onset of hypothyroidism in 26% of patients. This was achieved using much lower administered activities than currently recommended. Future studies will aim to identify those patients who would benefit most from this approach.

Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis

Background There is growing evidence that sleep duration and quality may be associated with cardiovascular harm and mortality. Methods and Results We conducted a systematic review, meta-analysis, and spline analysis of prospective cohort studies that evaluate the association between sleep duration and quality and cardiovascular outcomes. We searched MEDLINE and EMBASE for these studies and extracted data from identified studies. We utilized linear and nonlinear dose-response meta-analysis models and used DerSimonian-Laird random-effects meta-analysis models of risk ratios, with inverse variance weighting, and the I2 statistic to quantify heterogeneity. Seventy-four studies including 3 340 684 participants with 242 240 deaths among 2 564 029 participants who reported death events were reviewed. Findings were broadly similar across both linear and nonlinear dose-response models in 30 studies with >1 000 000 participants, and we report results from the linear model. Self-reported duration of sleep >8 hours was associated with a moderate increased risk of all-cause mortality, with risk ratio , 1.14 (1.05-1.25) for 9 hours, risk ratio, 1.30 (1.19-1.42) for 10 hours, and risk ratio, 1.47 (1.33-1.64) for 11 hours. No significant difference was identified for periods of self-reported sleep <7 hours, whereas similar patterns were observed for stroke and cardiovascular disease mortality. Subjective poor sleep quality was associated with coronary heart disease (risk ratio , 1.44; 95% confidence interval, 1.09-1.90), but no difference in mortality and other outcomes. Conclusions Divergence from the recommended 7 to 8 hours of sleep is associated with a higher risk of mortality and cardiovascular events. Longer duration of sleep may be more associated with adverse outcomes compared with shorter sleep durations.