On the prediction of SAV transmission among Norwegian aquaculture sites

Pancreas Disease (PD) is a viral disease that affects Atlantic salmon (Salmo salar) in Norwegian, Scottish and Irish aquaculture. It is caused by salmonid alphavirus (SAV) and represents a significant problem in salmonid farming. Infection with SAV leads to reduced growth, mortality, product downgrading, and has a significant financial impact for the farms. The overall aim of this study is to evaluate the effect of various factors on the transmission of SAV and to create a predictive model capable of providing an early warning system for salmon farms within the Norwegian waters. Using a combination of publicly available databases, specifically BarentsWatch, and privately held PCR analyses a feature set consisting of 11 unique features was created based on the input parameters of the databases. An ensemble model was developed based on this feature set using XG-Boost, Ada-Boost, Random Forest and a Multilayer Perceptron. It was possible to successfully predict SAV transmission with 94.4% accuracy. Moreover, it was possible to predict SAV transmission 8 weeks in advance of a 'PD registration' at individual aquaculture salmon farming sites. Important predictors included well boat movement, environmental factors, proximity to sites with a 'PD registration' and seasonality.

The health inequity and socioeconomic inequality faced by adolescent girls and women on the move living with or at high risk of HIV infection, during the COVID-19 pandemic in Nigeria

BACKGROUND

We assessed if women and girls on the move living with or at high risk of HIV faced increased health inequity and socioeconomic inequalities during the COVID-19 pandemic compared with other vulnerable women and girls.

METHODS

We used data collected through a survey conducted in Nigeria between June and October 2021. Women and girls living with or at risk of HIV were recruited voluntarily, using a combination of venue-based and snowball sampling. We performed multivariable logistic regression models per mobility and HIV status to determine associations between health inequity, socioeconomic inequalities and macrosocial characteristics.

FINDINGS

There were 3442 participants, of which 700 were on the move. We found no statistical difference between HIV-negative women and girls on the move and those not on the move. On the opposite, we found substantial differences in health inequity and socioeconomic inequalities between women and girls on the move living with HIV and those not on the move living with HIV. There are very strong associations between being a woman or girl on the move living with HIV and facing economic precarity (aOR 6.08, 95% CI 1.94 to 19.03), food insecurity (aOR 5.96, 95% CI 2.16 to 16.50) and experiencing more gender-based violence since COVID-19 started (aOR 5.61, 95% CI 3.01 to 10.47).

INTERPRETATION

Being a woman or girl on the move and living with HIV compound increased health and socioeconomic vulnerabilities. The COVID-19 crisis seems to have exacerbated inequalities and gender-based violence. These findings call for more feminist interventions to protect women on the move living with HIV during health crises.

Drivers of HIV treatment interruption: Early findings from community-led monitoring program in Haiti

BACKGROUND

Failure to retain people living with HIV (PLHIV) in care remains a significant barrier to achieving epidemic control in Haiti, with as many as 30% lost from care within one year of starting treatment. Community-led monitoring (CLM) is an emerging approach of improving healthcare and accountability to service users, through a cycle of monitoring and advocacy. In 2020, a CLM program was launched in Haiti to identify barriers to retention and advocating for better health services.

METHODS

Data from the community-led monitoring program in Haiti were analyzed, from a sample of 65 healthcare facilities in the Nord, Artibonite, and Ouest departments collected from April 2021 to February 2022. Qualitative data from six community-based focus groups and 45 semi-structured individual interviews were analyzed.

RESULTS

Confidentiality and stigmatization emerged as barriers to care, particularly due to the separation of PLHIV from other patients in view of community members. To avoid identification, patients described traveling long distances, with the reimbursement of transportation costs described as being insufficient or unavailable. Costs of non-HIV clinical services were a frequent concern and respondents described a need for clinics to provide food during all patient visits. Stock-outs were a regular challenge; by contrast, treatment literacy did not emerge as a major barrier to retention.

CONCLUSIONS

These findings represent the first instance, to our knowledge, of original data from a community-led monitoring program being published in any country. These findings suggest that improving treatment retention for PLHIV is dependent on improving the acceptability and affordability of healthcare services. Ensuring confidentiality is critical, particularly where stigma is high. Retention could be improved by systematically strengthening patient confidentiality protections throughout the healthcare system, providing patients with sufficient travel compensation and other incentives, and delivering wraparound services provided for free. Addressing these challenges will require ongoing advocacy for community-developed recommendations and solutions.

Income inequality and pandemics: insights from HIV/AIDS and COVID-19-a multicountry observational study

OBJECTIVES

Assess the relationship between income inequality and HIV incidence, AIDS mortality and COVID-19 mortality.

DESIGN

Multicountry observational study.

SETTING

217 countries for HIV/AIDS analysis, 151 countries for COVID-19 analysis.

PARTICIPANTS

Used three samples of national-level data: a sample of all countries with available data (global sample), a subsample of African countries (African sample) and a subsample excluding African countries (excluding African sample).

MAIN OUTCOME MEASURES

HIV incidence rate per 1000 people, AIDS mortality rate per 100 000 people and COVID-19 excess mortality rate per 100 000 people. The Gini index of income inequality was the primary explanatory variable.

RESULTS

A positive and significant relationship exists between the Gini index of income inequality and HIV incidence across all three samples (p<0.01), with the effect of income inequality on HIV incidence being higher in the African sample than in the rest of the world. Also, a statistically positive association exists for all samples between income inequality and the AIDS mortality rate, as higher income inequality increases AIDS mortality (p<0.01). For COVID-19 excess mortality rate, a positive and statistically significant relationship exists with the Gini index for the entire sample and the excluding African sample (p<0.05), but the African sample alone did not deliver significant results (p<0.1).

CONCLUSION

COVID-19 excess deaths, HIV incidence and AIDS mortality are significantly associated with income inequality globally-more unequal countries have a higher HIV incidence, AIDS mortality and COVID-19 excess deaths than their more equal counterparts. Income inequality undercuts effective pandemic response. There is an urgent need for concerted efforts to tackle income inequality and to build pandemic preparedness and responses that are adapted and responsive to highly unequal societies, prioritising income inequality among other social determinants of health.

Health Economics Research on Non-surgical Biomedical HIV Prevention: Identifying Gaps and Proposing a Way Forward

BACKGROUND AND OBJECTIVE

Although HIV prevention science has advanced over the last four decades, evidence suggests that prevention technologies do not always reach their full potential. Critical health economics evidence at appropriate decision-making junctures, particularly early in the development process, could help identify and address potential barriers to the eventual uptake of future HIV prevention products. This paper aims to identify key evidence gaps and propose health economics research priorities for the field of HIV non-surgical biomedical prevention.

METHODS

We used a mixed-methods approach with three distinct components: (i) three systematic literature reviews (costs and cost effectiveness, HIV transmission modelling and quantitative preference elicitation) to understand health economics evidence and gaps in the peer-reviewed literature; (ii) an online survey with researchers working in this field to capture gaps in yet-to-be published research (recently completed, ongoing and future); and (iii) a stakeholder meeting with key global and national players in HIV prevention, including experts in product development, health economics research and policy uptake, to uncover further gaps, as well as to elicit views on priorities and recommendations based on (i) and (ii).

RESULTS

Gaps in the scope of available health economics evidence were identified. Little research has been carried out on certain key populations (e.g. transgender people and people who inject drugs) and other vulnerable groups (e.g. pregnant people and people who breastfeed). Research is also lacking on preferences of community actors who often influence or enable access to health services among priority populations. Oral pre-exposure prophylaxis, which has been rolled out in many settings, has been studied in depth. However, research on newer promising technologies, such as long-acting pre-exposure prophylaxis formulations, broadly neutralising antibodies and multipurpose prevention technologies, is lacking. Interventions focussing on reducing intravenous and vertical transmission are also understudied. A disproportionate amount of evidence on low- and middle-income countries comes from two countries (South Africa and Kenya); evidence from other countries in sub-Saharan Africa as well as other low- and middle-income countries is needed. Further, data are needed on non-facility-based service delivery modalities, integrated service delivery and ancillary services. Key methodological gaps were also identified. An emphasis on equity and representation of heterogeneous populations was lacking. Research rarely acknowledged the complex and dynamic use of prevention technologies over time. Greater efforts are needed to collect primary data, quantify uncertainty, systematically compare the full range of prevention options available, and validate pilot and modelling data once interventions are scaled up. Clarity on appropriate cost-effectiveness outcome measures and thresholds is also lacking. Lastly, research often fails to reflect policy-relevant questions and approaches.

CONCLUSIONS

Despite a large body of health economics evidence on non-surgical biomedical HIV prevention technologies, important gaps in the scope of evidence and methodology remain. To ensure that high-quality research influences key decision-making junctures and facilitates the delivery of prevention products in a way that maximises impact, we make five broad recommendations related to: improved study design, an increased focus on service delivery, greater community and stakeholder engagement, the fostering of an active network of partners across sectors and an enhanced application of research.

Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey

BACKGROUND

Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments.

METHODS

This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs.

FINDINGS

Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings.

INTERPRETATION

Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV.

FUNDING

National Institutes of Health.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Single-center experience in implementation of endoscopic surveillance protocol after esophagectomy

Esophageal cancer has a notably high recurrence rate with a paucity of robust evidence in defining the optimal surveillance strategy. The surveillance protocol at our institution comprises of annual esophagogastroduodenoscopy (OGD) from years 1 to 5 postoperatively. This study aims to evaluate the implementation of the endoscopic surveillance at our center and ascertain the value of endoscopy in detecting local recurrence after esophagectomy. A retrospective cohort review of all patients (320 patients) who underwent esophagectomy between 2013 and 2018 was conducted. The local esophageal cancer database and corresponding OGD reports were accessed to obtain data on demographics, operation details, local recurrence, and endoscopy performed. 1086 OGDs were performed between 2014 and 2020, broadly categorized to surveillance and symptomatic OGDs; 555 and 531, respectively. Surveillance OGDs detected four asymptomatic local recurrences, of which only one was treated with curative intent. Symptomatic OGDs resulted in a higher yield for the detection of local recurrence compared with surveillance endoscopy; 5% versus 0.7%, with overall median time-to-recurrence of 11.5 months (95% confidence interval 9-17). Of local recurrences, 85.7% occurred within the first 2 years postoperatively. The proportion of endoscopic findings differed between intensive and ad hoc surveillance cohorts for strictures, esophagitis, Barrett's esophagus, and sloughing. Thirteen patients were diagnosed with histologically confirmed Barrett's with no subsequent local recurrences. Surveillance endoscopy had a low positive yield rate with subsequent minimal survival benefits. Therefore, it is prudent to consider an alternative protocol that focuses on the period with the highest risk of recurrence and symptom presentation.

51 VITAMIN D DEFICIENCY IS ASSOCIATED WITH INCREASED RISK OF ATRIAL FIBRILLATION: A CROSS-SECTIONAL ANALYSIS

Background

Atrial Fibrillation (AF) is prevalent (up to 10.9%) in Irish adults aged over 65 and significantly increases stroke risk, as well as being associated with greater stroke severity. Identifying potential contributing factors to development of AF offers opportunity for AF prevention and reduction in associated morbidity. Low vitamin D status has been associated with AF but studies are inconsistent. We aimed to assess the potential relationship between vitamin D deficiency and self-reported AF in older Irish adults.

Methods

Participants were from a large cross-sectional study of Irish adults aged &gt;60 years, recruited from hospital outpatient services and GP practises. The diagnosis of AF was based on self-report so those with a Mini Mental State Examination (MMSE) &lt;25 were excluded. Vitamin D deficiency was defined as a 25(OH)D &lt;30 nmol/l. The relationship between deficiency and AF was explored in regression models.

Results

4264 participants, mean age 73.1± 8.0 years, female (67.4%) and 11.9% had AF. There was a higher prevalence of AF in those who were deficient vs non-deficient (17.2% vs 10.9%, P&lt;0.0001). In a subsample (n = 4043), increased risk remained after adjusting for age, gender, season, vitamin D supplement use, body mass index, timed up and go, alcohol intake, smoking status, hypertension, diabetes, and heart disease (coronary artery disease and/or heart failure) (OR: 1.3, 1.1- 1.7 , P =0.023).

Conclusion

We identified that vitamin D deficiency was independently associated with a 30% increased likelihood of self-reported AF in older adults. Vitamin D is known to inhibit the renin angiotensin, aldosterone system which may play a role in both structural and electrical remodelling of the atrium. It may also have anti-inflammatory properties which could protect against AF. We were not able to distinguish between valvular and non-valvular AF though findings offer an interesting insight for potential further investigation.

P-102 Progesterone luteal-phase support during IUI cycle should be added depending on women age and/or on previous mid-luteal progesterone assessment to promote live births

Study question

To determine the Mid-luteal progesterone (MLP) threshold which could condition live-birth (LB) after IUI, and effects of additional progesterone luteal-phase support (LPS) in subsequent cycles.

Summary answer

MLP threshold is age-dependant. LPS should only be used if previous MLP is below the age related threshold, as its inappropriate use reduces LB rate.

What is known already

Progesterone is essential to prepare and maintain the uterus suitable for a possible pregnancy. During IUI, it is not clear if LPS is beneficial to obtain a live birth, and whether it should be introduced systematically or only in women with a low MLP assessment during a previous cycle.

Study design, size, duration

In an audit purpose, we performed a retrospective uni-centric analysis of 705 IUl cycles performed from January 2015 to March 2020 in couples which fertility work-up concluded to unexplained infertility, mild male infertility or PCOS with no pregnancy after 3 cycles of clomiphene citrate. Our primary outcome was LB.

Participants/materials, setting, methods

IUI was performed after ovarian stimulation with gonadotrophins. MLP was assessed using immuno assay method, days 7 post-IUI. LPS (Cyclogest® 200 mg/day) was added when consultant considered former cycle’s MLP was too low. MLP thresholds were defined without LPS using a ROC Curve, considering subgroups of patient’s age. LB rate was analyzed using Multivariate Gill Andersen models to take into account repetitions of IUI cycles. Prognostic factors for LBR were investigated using a Cox model.

Main results and the role of chance

Women were 33.6±3.9 years old. We obtained 99 (14%) LB.

In women who didn’t receive LPS, regardless of their age, MLP threshold was 57.5 nmo/l (AUC=0.57). Multivariate logistic regression modeling identified MLP assessment as a significant prognostic factor for obtaining LB after IUI (OR = 1.668, CI95%[1.023; 2.721], p = 0.0402).

When also considering women’s age, a cut-off of 36 years old was computed which allowed more fitted age-related MLP thresholds for obtaining LB after IUI. In women &lt;36 years old, MLP threshold was 39.5 nmol/l (AUC=0.57) whereas it was 60.5 nmol/L (AUC=0.57) for age ≥36. Age-related thresholds were more predictive of LB than initial age independent threshold according to Akaike Criteria (1168.48 versus 1198.96, respectively).

Using the whole population (i.e. receiving or not LPS), the multivariate analysis highlighted that, compared to women with MLP above their age related threshold who (appropriately) didn’t receive LPS:

- Women below their age-related MLP threshold who appropriately receive LPS had similar LB rate: OR = 0.5474, CI95%[0.1857-1.6138], p = 0.2747. - Women below their age-related MLP threshold who didn’t receive LPS (inappropriately) had a significantly lower LB rate: OR = 0.4794, CI95%[0.2727-0.8427], p = 0.0106. - Women above their age-related MLP threshold who received LPS (inappropriately) had a significantly lower LB rate: OR = 0.5627, CI95%[0.3302-09587], p = 0.0433.

Limitations, reasons for caution

Because of the retrospective design of our study and because of the limited number of included couples, our results should be considered with caution. Confirmation is needed with further prospective studies with a larger number of participants.

Wider implications of the findings

Our study highlight for the first time the impact of age on the LPS strategy after IUI, and emphases the need for personalized fertility medicine based on previous MLP assessment when considering LPS.

Trial registration number

No needed, NHS Audit

Common patterns in the public reporting of waiting time and waiting list information: Findings from a sample of OECD jurisdictions

We present findings from a review of published literature and administrative documentation on waiting time and waiting list reporting models for elective treatment in a sample of international jurisdictions (a subset of OECD countries, with regional reporting regimes treated as distinct jurisdictions). In this paper we identified common patterns in the measurement and reporting of waiting time and waiting list information for elective treatment. We mapped the waiting time, waiting list, and key performance indicator statistics reported by 15 English-speaking international jurisdictions. Three distinct patterns of maximum waiting time target measures for elective treatment were identified amongst our international sample following our patient pathway event time-point analysis: (i) full-pathway maximum wait time targets; (ii) separate wait time targets for "time-to-diagnosis" and "time-to-treatment"; and (iii) "Time-to-Treatment" waiting time target only. Our review also revealed common patterns in the reporting of waiting time and waiting list statistics as well as KPI measures amongst a sub-sample of English-speaking jurisdictions. These common patterns provide a starting point towards more standardised measurement and reporting of waiting time and waiting list statistics in benchmarking access to elective care internationally.

AB0756 IMMUNE-MEDIATED BASIS FOR A PHASE 2A CLINICAL STUDY COMPARING RILZABRUTINIB VS GLUCOCORTICOIDS IN RITUXIMAB-REFRACTORY PATIENTS WITH IGG4-RELATED DISEASE

Background:

IgG4-related disease (IgG4-RD) is an immune-mediated disorder causing fibro-inflammatory lesions. Although the cause remains unknown, it may be driven by interactions between B lymphocytes and CD4+ cytotoxic and regulatory T cells and is characterized by an increase in short-lived plasmablasts, circulating antibodies, and macrophages. Standard therapy mainly includes glucocorticoids (GC), limited by toxicity with long-term use (> 6 mo), and to a lesser extent, immunosuppressives (eg, rituximab). Bruton tyrosine kinase (BTK) plays an important role in the activation of multiple immune effector cells such as B cells, mast cells, eosinophils, basophils, monocytes/macrophages, and neutrophils. Dysregulation of the activation of these immune cells results in autoimmune inflammation, tissue damage, and development of fibrosis. Rilzabrutinib is a highly selective oral BTK inhibitor that targets multiple pathways of innate and adaptive immunity (with direct effects on B-cell and FcR pathways) and has the potential to inhibit antigen presentation to autoreactive T cells.

Objectives:

To provide the biological rationale for rilzabrutinib in IgG4-RD.

Methods:

Rilzabrutinib has been evaluated in biochemical, in vitro studies, and in vivo models of inflammatory diseases. Additional support is provided by the phase 2 trial for oral rilzabrutinib in patients with pemphigus vulgaris and the phase 2 trial for oral rilzabrutinib in patients with immune thrombocytopenia (ITP).

Results:

Rilzabrutinib inhibited the activity of BTK and B-cell receptor in B cells (IC50 5-123 nM) and Fc gamma receptor in IgG/Fc gamma receptor-stimulated monocytes (IC50 56 nM) and blocked IgG- and IgM-mediated antibody production in enriched B cells when stimulated in T-cell dependent (anti-CD40+IL-21) and T-cell independent (TLR-9/CpG and TNP-LPS) pathways. The impact of rilzabrutinib on innate cell pathways was further confirmed by significant dose-dependent inhibition of macrophage and neutrophil-driven passive rat Arthus reaction (P < 0.01 vs vehicle) and antibody-induced murine ITP (P < 0.05 vs vehicle). In a 12-week phase 2 pemphigus vulgaris trial, 54% of patients achieved the primary endpoint, control of disease activity (CDA) on low-dose corticosteroids by week 4, and 73% achieved it by week 12. In the phase 2 trial of ITP patients (median 6 prior therapies), rilzabrutinib 400 mg bid showed rapid and sustained improvement in platelet counts and only grade 1/2-related adverse events1. In responders, platelet counts increased as early as day 8, potentially due to innate immune mechanisms. Collectively, results in both B and innate immune cells provide an initial basis for evaluating rilzabrutinib in IgG4-RD. The ongoing phase 2a study (NCT04520451) is investigating rilzabrutinib 400 mg bid (+tapered GC) vs GC control (3:1) for 12 weeks in IgG4-RD patients refractory to rituximab. The primary objective is to evaluate the safety and ability of rilzabrutinib to induce GC-free remission at week 12. Coupled with known preclinical/clinical findings, mechanistic analyses in this ongoing IgG4-RD study will profile B and other immune cell effects pre-/post-rilzabrutinib dosing to enhance the clinical understanding of rilzabrutinib in IgG4-RD.

Conclusion:

Studies of rilzabrutinib that show beneficial effects on both B-cell and innate cell pathways provide support for its therapeutic role in immune-mediated diseases and for targeting the underlying pathophysiological effects of IgG4-RD. Effective and safe therapies that rapidly induce and maintain clinical responses, while minimizing the need for continuous GC treatment, remain an unmet need for patients with IgG4-RD.

References:

[1]Kuter et al. Res Pract Thromb Haemost. 2020;4(suppl 1): PB1318.

Disclosure of Interests:

Li Long Employee of: Principia Biopharma, a Sanofi Company, Matthew Baker: None declared, Mollie Carruthers: None declared, Alireza Meysami: None declared, Robert Spiera Consultant of: research funding and personal fees for consulting from Chemocentryx, Formation Biologics, Roche-Genentech, and Sanofi, Grant/research support from: research funding fees from BMS, Boehringer Ingelheim, Corbus, GSK, and Inflarx; personal fees from AbbVie, CSL Behring, GSK, and Janssen, Mamatha Reddy Employee of: Principia Biopharma, a Sanofi Company, Marianne Kavanagh Employee of: Principia Biopharma, a Sanofi Company, Michelle Francesco Employee of: Principia Biopharma, a Sanofi Company, Claire Langrish Employee of: Principia Biopharma, a Sanofi Company, Ann Neale Employee of: Principia Biopharma, a Sanofi Company, Puneet Arora Employee of: Principia Biopharma, a Sanofi Company, John H. Stone Consultant of: research funding and personal fees for consulting from Principia and Sanofi

The artificial pancreas: evaluating risk of hypoglycaemia following errors that can be expected with prolonged at-home use

AIMS

Artificial pancreas systems show benefit in closely monitored at-home studies, but may not have sufficient power to assess safety during infrequent, but expected, system or user errors. The aim of this study was to assess the safety of an artificial pancreas system emulating the β-cell when the glucose value used for control is improperly calibrated and participants forget to administer pre-meal insulin boluses.

METHODS

Artificial pancreas control was performed in a clinic research centre on three separate occasions each lasting from 10 p.m. to 2 p.m. Sensor glucose values normally used for artificial pancreas control were replaced with scaled blood glucose values calculated to be 20% lower than, equal to or 33% higher than the true blood glucose. Safe control was defined as blood glucose between 3.9 and 8.3 mmol/l.

RESULTS

Artificial pancreas control resulted in fasting scaled blood glucose values not different from target (6.67 mmol/l) at any scaling factor. Meal control with scaled blood glucose 33% higher than blood glucose resulted in supplemental carbohydrate to prevent hypoglycaemia in four of six participants during breakfast, and one participant during the night. In all instances, scaled blood glucose reported blood glucose as safe.

CONCLUSIONS

Outpatient trials evaluating artificial pancreas performance based on sensor glucose may not detect hypoglycaemia when sensor glucose reads higher than blood glucose. Because these errors are expected to occur, in-hospital artificial pancreas studies using supplemental carbohydrate in anticipation of hypoglycaemia, which allow safety to be assessed in a controlled non-significant environment should be considered as an alternative. Inpatient studies provide a definitive alternative to model-based computer simulations and can be conducted in parallel with closely monitored outpatient artificial pancreas studies used to assess benefit.

Subchronic Oral Toxicity Study of Furan in B6C3F1 Mice

Furan is a heterocyclic organic compound formed during heat treatment for processing and preservation of various types of food. Rodent studies have previously shown that furan is a hepatocarcinogen. Those studies were conducted over a high dose range, which induced tumors at nearly 100% incidence at all doses. This ninety-day gavage study in mice was conducted to extend the dose to a lower range (0.0, 0.03, 0.12, 0.5, 2.0, and 8.0 mg/kg body weight [bw] per day) to identify a no-observed adverse effect level for hepatotoxicity and to characterize non-neoplastic effects, including those affecting clinical biochemistry, hematology, tissue morphology, and histopathology. The liver was the primary target organ with dose-dependent toxicity. Liver weights were increased at the 8.0 mg/kg bw dose in females only. Levels of the serum enzyme alanine transaminase, representative of liver damage, were increased three-fold at the highest dose. Histological changes in the liver were observed at 2.0 and 8.0 mg/kg bw in both sexes. Although clinical parameters were also altered for the kidney, these differences were not accompanied by histological changes. Based on these clinical biochemical and histological changes, a no-observed adverse effect level of 0.12 mg/kg bw per day of furan in mice is suggested.

Subchronic Oral Toxicity Study of Furan in Fischer-344 Rats

Rodent studies have shown that furan is a hepatocarcinogen. Previous studies conducted with high doses showed tumors at nearly 100% incidence at all doses. In this paper, a ninety-day gavage experiment conducted with lower doses (0.0, 0.03, 0.12, 0.5, 2.0, and 8.0 mg/kg bw) to identify a no-observed adverse effect level for hepatotoxicity and to characterize non-neoplastic effects including gross changes and histopathology, clinical biochemistry, hematology, and immunotoxicology is reported. As indicated by changes in serum biomarkers, increased liver weights and gross and histological lesions, the liver is the major target organ affected by furan. There were no changes in body weights, food consumption, or histology in other organs. Some of the serum electrolyte markers, including phosphorus, were altered. There was a significant increase in serum thyroxine and triidothyronine in males. This increase was not accompanied by histological thyroid changes. Immunophenotypic analysis showed that thymic lymphocyte maturation was altered in male rats. Although altered clinical biochemistry and hematological parameters were observed at a dose of > 0.5 mg/kg bw, mild histological lesions in the liver were observed at > 0.12 mg/kg bw. Based on this finding, a furan dose of 0.03 mg/kg bw was proposed as the no-observed adverse effect level for hepatic toxicity.

Endometrial cancer survivorship in obese patients: A lifestyle intervention program

5596

Background: The majority of early stage endometrial cancer (EC) survivors are obese, have cardiovascular disease and are at significant risk of death from causes other than cancer. The purpose of this study was to examine outcomes at 6 and 12 months in obese EC survivors enrolled in a randomized trial of a nutrition and exercise counseling program. Methods: Patients (pts) with early stage (I or II) EC with a body mass index ≥ 25 diagnosed from 1999–2005 were invited to participate. The intervention (I) group received 6 months of nutritional and exercise counseling while the control (C) group received an informational brochure only. Primary outcome variable was weight loss. Quality of life (QoL) was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and Medical Outcomes Short-form (SF-36) survey. Exercise [leisure score index (LSI)] and eating patterns (quantitative food records) were assessed at baseline, 3, 6 and 12 mos. Repeated measures ANOVA and independent samples t-test were used for analysis. A sample size of 50 pts with a type1=0.05 and type 2=0.20 error rate was used to test the hypothesis that pts in the I group would lose weight as compared to the C group. Results: 45 pts were enrolled and 23 were randomized to I and 22 to the C group, stratified by BMI. Baseline QoL was decreased in morbidly obese pts (BMI ≥ 40) as compared to pts with a BMI < 40 (FACT-G: 78.0 vs. 83.7; p=0.140; physical SF-36: 40.6 vs. 49.1 p=0.008). Women in the I group lost weight and increased exercise over the 12 mos as compared to controls ( Table ). Repeated measures ANOVA demonstrated a borderline significant interaction effect for weight (F=2.7, p=.074) and a significant interaction effect for exercise (F=5.0; p=.005) over time. The I group had lower intake of calories and total fat during the intervention. Conclusions: Obese EC survivors can undergo and maintain positive lifestyle changes. Future studies will examine long-term changes in co-morbidities and mortality.

[Table: see text]

No significant financial relationships to disclose.

Lessons learned from two decades of sentinel node biopsies for melanoma

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Background: The long term prognosis for patients with melanoma staged by sentinel node biopsy (SNB) remains unclear, largely due to limited follow-up from a variety of small single institution studies. We evaluated our extensive 20-year experience to evaluate the long term prognostic significance of SNB. Methods: We retrospectively reviewed the records of 2001 successive patients who underwent LM/SNB at our center from 1985 until 2004. After preoperative lymphoscintigraphy, blue dye and a hand-held gamma probe were used for intraoperative identification of sentinel nodes (SN). SN were evaluated for metastases by hemotoxylin and eosin and immunohistochemical staining with HMB45, S-100, and more recently with antibodies to melanA. Patients with tumor-positive SN underwent completion dissection (SCLND). Clinicopathological features of the patients, primaries and SN status were evaluated for their influence on survival using multivariate Cox regression analysis. Results: After median follow-up of 49 months (range 1–237). Median age for our patients was 51 years (range 10–91). Of the 2,001 patients, 1584 (79%) had tumor-negative and 417 (21%) had tumor-positive SN. Survival rates were higher in patients with tumor-negative vs. tumor-positive SN (91 + 2% vs. 72 + 5% at 5 years, log-rank p<0.0001; and 84 + 3% vs. 64 + 7% at 10 years, log-rank p<0.0001). Of the 417 patients with SN metastases, 293 (70%) had a single tumor-positive node, 101 (24%) had 2–3 positive nodes, and 25 (6%) had at least 4 positive nodes (sentinel plus nonsentinel). Overall survival was significantly better when metastases were confined to single vs. multiple nodes (77 + 3% vs. 63 + 5%; p=0.0017). Multivariate analysis with Cox regression identified SN status (p<0.0001) as the most important prognostic factor, Hazard Ratio 3.44 (2.47–4.79). Breslow thickness (p<0.0001) and ulceration (p=0.0001) are also independently significant for survival. Gender and primary site were not significant. Conclusions: Our results demonstrate the long term prognostic significance of SN status. LM/SNB should become standard of care for primary melanoma because it is the most accurate factor for the quantification of the risk for recurrence and death available.

No significant financial relationships to disclose.

Effect of ABT-627 (A-147627), a potent selective ET(A) receptor antagonist, on the cardiopulmonary profile of newborn lambs with surgically-induced diaphragmatic hernia

1. Postnatal mortality in isolated congenital diaphragmatic hernia (CDH) is mainly related to the associated pulmonary hypertension (PH) and to right-to-left shunting. 2. Endothelins (ETs) are potent vasoconstrictors and pro-mitogenic peptides. Strong evidences support their participation in CDH and in the etiology of PH via the activation of ET(A) receptors (ET(A)-Rs). 3. Evaluation of the effect of ABT-627, a selective non-peptidic ET(A)-R antagonist, given from -15 to 210 min post-delivery (1 mg kg(-1) bolus +0.01 mg kg(-1) h(-1) infusion, i.v.), was conducted in the lamb model of CDH. 4. Severity of CDH was assessed in comparison to untreated controls (n=5). Untreated CDH lambs (n=7) had a higher mean pulmonary arterial pressure (MPAP; P<0.0001), lower mean blood pressure (MBP; P=0.0004), higher MPAP / MBP ratio (P<0.0001), lower arterial pH (P<0.0001), higher paCO(2) (P<0.0001), lower paO(2) (P<0.0001) and lower post-ductal pulsatile SaO(2) (P<0.0001) than untreated controls. 5. Treated controls (n=7) showed a higher MPAP, lower MBP, higher MPAP/MBP ratio, lower arterial pH, higher paCO(2), lower paO(2), lower post-ductal pulsatile SaO(2) and lower plasmatic ir-ET ratios compared to untreated controls (P<0.0001). 6. Treated CDH lambs (n=8) showed a higher MBP (P<0.0001), lower MPAP / MBP ratio (P<0.0001), higher arterial pH (P<0.0001), lower paCO(2) (P<0.0001), higher paO(2) (P=0.0228), higher post-ductal pulsatile SaO(2) (P=0.0016) and lower plasmatic ir-ET ratios (P=0.0247) when compared to untreated CDH lambs. 7. These observations revealed that, although acute perinatal treatment with a selective non-peptidic ET(A)-R antagonist had some adverse effects in controls, it attenuated the progressive cardiopulmonary deterioration that occurred after birth in CDH lambs.

Effect of CGS 26303, an endothelin-converting enzyme-neutral endopeptidase inhibitor, on nitrofen-induced congenital diaphragmatic hernia in the rat

BACKGROUND/PURPOSE

The pathophysiology of congenital diaphragmatic hernia (CDH) associated with lung hypoplasia and pulmonary hypertension is not understood fully. Endothelins (ETs) are the most potent vasoconstrictors that also act as promitogenic agents. They may play a role during pregnancy in leading to the condition found at birth and ongoing mortality in CDH. Therefore, the authors studied the effect of CGS 26303, a nonselective endothelin-converting enzyme and neutral endopeptidase inhibitor, in the rat model of CDH.

METHODS

Pregnant Sprague-Dawley rats were divided into 3 groups: group 1 (n = 4) received CGS 26303 (50 mg/kg, subcutaneously, twice a day), from gestational day 12 until term (21 to 23 days); group 2 (n = 8) received nitrofen (100 mg/kg, orally) at gestational day 11.5; group 3 (n = 8) received both nitrofen and CGS 26303. The survival of the newborn rats was monitored up to 240 minutes. After natural death or euthanasia, they were weighed and microdissected. The degree of hernia was quantified as small, moderate, or severe, and lungs and liver were harvested and weighed.

RESULTS

Newborn rats from mothers of group 3 (n = 81) survived 196 +/- 8 minutes compared with 173 +/- 9 minutes of those of group 2 (n = 97). Severe CDH from group 3 (n = 20) had a mean survival time of 66 +/- 13 minutes compared with 26 +/- 4 minutes for those of group 2 (n = 27). Lung index in severe CDH pups of group 3 was increased by 13% compared with those from group 2 (P < .0001), whereas their liver index went down by 8% (P < .05).

CONCLUSIONS

These results suggest that CGS 26303 might have a beneficial effect when given during pregnancy in increasing survival at birth and reducing the severity of the pulmonary hypoplasia in newborn rats with nitrofen-induced CDH.

Tibiotarsal fracture repair in a scarlet macaw using external skeletal fixation

Surgical repair of a fractured tibiotarsus in a scarlet macaw (Ara macao) is described. The forces imposed on the fracture site are discussed and the unique features of avian bone emphasised. Advantages of external skeletal fixation and specific details of the frame construction are highlighted.

Surgery for locally aggressive bone tumours

Treatment of 16 patients with aggressive benign bone tumours and one patient with a low grade malignancy with a combined regimen of cryosurgery, phenolization and acrylic cementation is reported. Patients were aged between 9 and 51 years and were treated by this method between the years 1986 and 1993. Minimal follow up was 13 months. The commonest histological diagnosis was giant cell tumour (7), followed by aneurysmal bone cyst (6), chondromyxoidfibroma (3) and low grade chondrosarcoma (1). Patients were assessed for functional outcome and local recurrence. On average 86 per cent of premorbid function was restored at follow up and there was one local recurrence (6.29 per cent). We conclude that this is a satisfactory method of gaining local control of these tumours.

New developments in sustained-release antihypertensive therapy: formulation and pharmacokinetic considerations

In order to achieve a consistently absorbed form of nifedipine over 24 hours, a novel formulation approach, INDAS, was used to develop a once-daily, sustained-release (SR) form of nifedipine that could provide effective control of blood pressure at a low total daily dose. The pharmacokinetic characteristics of this new formulation of nifedipine-SR were compared with those of divided doses of conventional nifedipine. The SR formulation was shown to achieve a lower peak plasma nifedipine level but with a prolonged plasma profile characterized by an extended time to peak plasma levels (Tmax), a higher trough plasma level, a longer apparent half-life, and a markedly lower peak-to-trough fluctuation in plasma nifedipine concentrations. In a separate study, the gastrointestinal transit parameters and physical characteristics of the SR tablet were evaluated. This study established that the large intestine is the major site of residence and absorption for this dosage form. The physical erosion and disintegration characteristics of the SR formulation are such that a well-maintained absorption of nifedipine is consistently achieved over the 24 hour dosing interval.

The effects of lipid lowering on diabetic retinopathy

The effect of lipid lowering on hard exudates was determined in six consecutive patients with insulin-dependent diabetes mellitus. Diet and hypolipidemic drug therapy including the use of pravastatin, a new inhibitor of 3-hydroxy-3-methylglutaryl coenzyme-A reductase, were used to treat patients for one year. The total cholesterol concentration decreased from a mean baseline value of 231 mg/dl to a treatment mean value of 165 mg/dl. The mean low-density lipoprotein cholesterol concentration decreased from 157 mg/dl to 93 mg/dl. Masked grading of fundus photographs indicated an improvement in hard exudates in all six patients and a decrease in microaneurysms in four patients. Visual acuity improved in one patient and did not change (one line or less change) in five patients. No remarkable side effects resulting from treatment were observed. Our pilot study suggests that aggressive therapy of diabetic patients with hyperlipidemia may have a beneficial effect on background retinopathy.

Prevalence of dental caries and dental fluorosis in students, 11-17 years of age, in fluoridated and non-fluoridated cities in Quebec

The purpose of this study was to evaluate the difference in dental caries and fluorosis prevalence in 936 randomly selected life-long residents selected from public and private schools in Trois-Rivières (1.0 ppm F in 1987) and Sherbrooke (less than 0.1 ppm F), Que., Canada. Students, 11-17 years of age, were examined for dental caries using the National Institute for Dental Research criteria and for dental fluorosis using the Tooth Surface Index of Fluorosis. Because of an inconsistent fluoridation history in Trois-Rivières, comparisons were carried out between two age strata: students 11-14 years of age who consumed for a longer duration suboptimally fluoridated water than those in the second stratum: students 15-17 years of age. Only public school students, 15-17 years of age, from Trois-Rivières had significantly lower mean filled surface and decayed, missing, and filled tooth surface (DMFS) scores (28 and 24%, respectively) than similar students in Sherbrooke. Among private school students, differences were not found, except in the youngest age group in Sherbrooke who had significantly lower mean DMFS than similar students from Trois-Rivières. The prevalence of fluorosis was 45.6% and 58.0% in Trois-Rivières public and private schools, respectively, and 31.1% and 30.1% in Sherbrooke public and private schools, respectively. The use of fluoride tablets was significantly associated with fluorosis. This study showed that water fluoridation benefitted students from public schools and that the risk factors for dental fluorosis were the use of fluoridated water and fluoride tablets.

Transdermal delivery of nicotine in normal human volunteers: a single dose and multiple dose study

The absorption of nicotine delivered by a transdermal delivery system (TDS) was investigated in two separate studies, (A) a dose proportionality study and (B) a multiple dose study. In the dose range of 15-60 mg nicotine, the AUC and Cmax values were proportional to the dose. The levels achieved were in the same range as reported in smokers, following absorption from nicotine chewing gum. The TDS used in the present study produced sustained levels of nicotine for 24 h. No significant accumulation of nicotine was evident as a result of multiple dose administration using a 30-mg nicotine patch. Absorption of nicotine from the TDS was 80-90% and the rate of delivery was similar during both studies.

Are indices of free radical damage related to exercise intensity

The possibility that plasma levels of malonaldehyde (MDA) are altered by exercise has been examined. The presence of MDA has been recognized to reflect peroxidation of lipids resulting from reactions with free radicals. Maximal exercise, eliciting 100% of maximal oxygen consumption (VO2max) resulted in a 26% increase in plasma MDA (P less than 0.005). Short periods of intermittent exercise, the intensity of which was varied, indicated a correlation between lactate and MDA (r2 = 0.51) (p less than 0.001). Blood lactate concentrations increased throughout this exercise regimen. A significant decrease (10.3%) in plasma MDA occurred at 40% VO2max. At 70% VO2max plasma MDA was still below resting values, however the trend to an increase in MDA with exercise intensity was evident. At exhaustion, plasma MDA and lactate were significantly greater than at rest. These results suggest, that exhaustive maximal exercise induces free radical generation while short periods of submaximal exercise (i.e. less than 70% VO2max) may inhibit it and lipid peroxidation.

Variable territoriality among tantalus monkeys in Cameroon

The socio-ecology of representative groups of tantalus monkeys (Cercopithecus aethiops tantalus) was observed during 1974–1975 in three habitats in Cameroon. Observations took place during the wet and dry seasons in sahelian savannah, guinea savannah and farmed forest. In the sahel, large groups did not appear to defend territories. In the other two habitats, smaller groups did so. The different patterns of territoriality and group size appeared to be the result of differences in food supply and predation pressures.

The diet and feeding behaviour of Cercopithecus aethiops tantalus

The feeding behaviour of representative groups of tantalus monkeys (Cercopithecus aethiops tantalus) was observed during 1974-1975 in three habitats in Cameroon. Observations took place during the wet and dry seasons in sahelian savannah, guinea savannah and farmed forest. The tantalus monkeys were similar to other races of C.aethiops that have been studied in that they were omnivorous and lacked any narrow specialisations of either diet or feeding techniques. The dietary range was similar in all three habitats, although considerable seasonal variation occurred. About one third of all feeding took place on the ground.