Emulating Control Arms for Cancer Clinical Trials Using External Cohorts Created From Electronic Health Record-Derived Real-World Data

Electronic health record (EHR)-derived real-world data (RWD) can be sourced to create external comparator cohorts to oncology clinical trials. This exploratory study assessed whether EHR-derived patient cohorts could emulate select clinical trial control arms across multiple tumor types. The impact of analytic decisions on emulation results was also evaluated. By digitizing Kaplan-Meier curves, we reconstructed published control arm results from 15 trials that supported drug approvals from January 1, 2016, to April 30, 2018. RWD cohorts were constructed using a nationwide EHR-derived de-identified database by aligning eligibility criteria and weighting to trial baseline characteristics. Trial data and RWD cohorts were compared using Kaplan-Meier and Cox proportional hazards regression models for progression-free survival (PFS) and overall survival (OS; individual cohorts) and multitumor random effects models of hazard ratios (HRs) for median endpoint correlations (across cohorts). Post hoc, the impact of specific analytic decisions on endpoints was assessed using a case study. Comparing trial data and weighted RWD cohorts, PFS results were more similar (HR range = 0.63-1.18, pooled HR = 0.84, correlation of median = 0.91) compared to OS (HR range = 0.36-1.09, pooled HR = 0.76, correlation of median = 0.85). OS HRs were more variable and trended toward worse for RWD cohorts. The post hoc case study had OS HR ranging from 0.67 (95% confidence interval (CI): 0.56-0.79) to 0.92 (95% CI: 0.78-1.09) depending on specific analytic decisions. EHR-derived RWD can emulate oncology clinical trial control arm results, although with variability. Visibility into clinical trial cohort characteristics may shape and refine analytic approaches.

γδ T cells compose a developmentally regulated intrauterine population and protect against vaginal candidiasis

This most comprehensive analysis to date of γδ T cells in the murine uterus reveals them to compose a unique local T-cell compartment. Consistent with earlier reports, most cells expressed a canonical Vγ6Vδ1 TCR, and produced interleukin (IL)-17A upon stimulation. Nonetheless, contrasting with earlier reports, uterine γδ T cells were not obviously intraepithelial, being more akin to sub-epithelial Vγ6Vδ1+ T cells at several other anatomical sites. By contrast to other tissues however, the uterine compartment also included non-Vγ6+, IFN-γ-producing cells; was strikingly enriched in young mice; expressed genes hitherto associated with the uterus, including the progesterone receptor; and did not require microbes for development and/or maintenance. This notwithstanding, γδ T-cell deficiency severely impaired resistance to reproductive tract infection by Candida albicans, associated with decreased responses of IL-17-dependent neutrophils. These findings emphasise tissue-specific complexities of different mucosal γδ cell compartments, and their evident importance in lymphoid stress-surveillance against barrier infection.

Optimising default radiographic exposure factors using Deviation Index

INTRODUCTION

Radiographers have a duty to ensure that radiation doses to patients are as low as reasonably achievable. With digital technologies, exposure factors which achieve the optimum balance between image noise and patient dose must be sought. In digital radiography, Deviation Index (DI) values provide the radiographer with feedback on the appropriateness of individual exposures but can also be tracked as part of a departmental quality assurance programme.

METHODS

In November 2017, exposure logs were extracted from six digital radiography (DR) x-ray systems, collated and analysed. Five examinations were identified which frequently produced DI values outside the manufacturer's recommended Optimal Range (-3 to +2). Incremental improvements were made to the default exposure settings for these examinations via a cyclical process of modification and re-evaluation. A full data collection exercise was then repeated in April 2019.

RESULTS

At baseline, 10,658 out of 29,637 (36.0%) exposures had DI values outside the manufacturer's recommended Optimal Range, but for some individual examinations the proportion was as high as 547 out of 725 (74.5%). Following multiple optimisation cycles, the overall proportion of examinations outside the Optimal Range had fallen to 7611 out of 26,759 (28.4%). Default milliampere-seconds (mAs) values for these examinations were reduced by between 22% and 50%.

CONCLUSION

A marked reduction in patient doses can be achieved through a departmental programme of DI value monitoring and targeted optimisation of default exposure settings.

IMPLICATIONS FOR PRACTICE

DI values should be routinely monitored as part of routine quality assurance programmes. Radiographers have a responsibility to ensure that they possess a clear understanding of DI values and that appropriate exposure settings are selected for each individual patient.

Driving safety improves after individualized training: An RCT involving older drivers in an urban area

Objective: This study aimed to reproduce the results of a previous investigation on the safety benefits of individualized training for older drivers. We modified our method to address validity and generalizability issues. Methods: Older drivers were randomly assigned to one of the 3 arms: (1) education alone, (2) education + on road training, and (3) education + on road + simulator training. Older drivers were recruited from a larger urban community. At the pre- and posttests (separated by 4 to 8 weeks) participants followed driving directions using a Global Positioning System (GPS) navigation system. Results: Our findings support the positive influence of individualized on-road training for urban-dwelling older drivers. Overall, driving safety improved among drivers who received on-road training over those who were only exposed to an education session, F(1, 40) = 11.66, P = .001 (26% reduction in total unsafe driving actions [UDAs]). Statistically significant improvements were observed on observation UDAs (e.g., scanning at intersections, etc.), compliance UDAs (e.g., incomplete stop), and procedural UDAs (e.g., position in lane). Conclusion: This study adds to the growing evidence base in support of individualized older driver training to optimize older drivers' safety and promote continued safe driving.

103 Hormonal stimulation and post-breeding sperm induction in the mountain yellow-legged frog, Rana muscosa

The first choice of any captive animal program should be to promote natural breeding through appropriate diet and environmental conditions. However, in cases of poor reproductive performance, the administration of exogenous hormones can induce breeding behaviours and gamete release. Part of the approach to the Mountain yellow-legged frog recovery program is the collection of sperm for cryobanking as a means of preserving genetic diversity in a cost- and space-effective manner. To develop a protocol for induction of sperm release from Mountain yellow-legged frogs, we tested the administration of gonadotropin-releasing hormone agonist (d-Ala6, des-Gly10 ethylamide LHRH derivative) and hCG singly or in combination. Once a month, animals were injected with a single dose of saline amphibian ringers (control) or 1 of 10 hormone treatments. Groups 1-4 received a single intraperitoneal injection of gonadotropin-releasing hormone agonist administered in 4 different doses: (1) 0.3 μg/g body weight (bw); (2) 0.4 μg/g bw; (3) 0.6 μg/g bw; and (4) 1 μg/g bw. Groups 5 and 6 were injected with 5 and 10IU hCG/g bw, respectively, and groups 7-10 received a combined injection of hCG and GnRH in four different doses: (7) 5 IU/g hCG with 0.3 μg/g GnRH; (8) 10 IU/g hCG with 0.3 μg/g GnRH; (9) 5 IU/g hCG and 0.6 μg/g GnRH; and (10) 10 IU/g hCG and 0.6 μg/g GnRH. Hormone treatments began in July 2015, 2 months after the end of the breeding season to allow males a post-breeding recovery time. Monthly administration continued from July until December 2015, ending before the brumation period. In 2016, treatments resumed again in July, after another breeding period. In 2017, hormone treatments began in April, during the reproductive season, and continued until July. From July 2015 through November 2016, sperm concentration and motility were examined in response to hormones treatment groups 1, 3, 5, 6, and 7-10. In April 2017, based on previous results, experiments were redesigned to include group 9 from 2015-16, and two new groups, 2 and 4. Spermiation was not easily hormonally induced when administered from August-October 2015, August-September 2016, and in July 2017. These low-response periods coincided with post-breeding months when only 3.7% (3/81) of males responded to either 10 IU/g hCG, 0.6 μg/g GnRH, or a combination of 5 IU/g hCG and 0.6 μg/g GnRH. Sperm production was significantly affected (P<0.05) by the month of hormone administration and hormone treatments during the responsive periods (P<0.0001) of April-June and October-November. However, hormone doses and treatments had no significant effect on the average or total sperm concentration per male (P<0.05). Motility and speed of forward progression were not significantly affected by treatment (P<0.05). This study demonstrates the seasonality of sperm production in this species, which may be attributed to testicular recrudescence during the summer months following breeding. Without hormonal stimulation, spermiation did not occur during the nonreproductive part of the year.

"Reversible" myelodysplastic syndrome or ineffectual clonal haematopoiesis? - add(6p) myeloid neoplasm with a spontaneous cytogenetic remission

Cytotoxic chemotherapy has inherent mutagenic potential and alters the bone marrow microenvironment after therapy. In some cases, this potentiates expansion of an aberrant clone and may lead to a therapy-related myeloid neoplasm if the clone overcomes selective pressure. We present the case of a 43-year-old woman diagnosed with an indolent, therapy-related myeloid neoplasm with an isolated chromosome 6p abnormality following treatment for de novo Acute Myeloid Leukaemia (AML), who manifest a sustained spontaneous cytogenetic remission two years later, possibly due to an ineffectual or non-dominant founding clone. This case reminds us to be mindful of the possibility that clonal haematopoiesis may not always equate to clinically relevant disease, even in the setting of an abnormal clonal karyotype.

The genetic diversity of hepatitis A genotype I in Bulgaria

The purpose of this study was to analyze sequences of hepatitis A virus (HAV) Ia and Ib genotypes from Bulgarian patients to investigate the molecular epidemiology of HAV genotype I during the years 2012 to 2014. Around 105 serum samples were collected by the Department of Virology of the National Center of Infectious and Parasitic Diseases in Bulgaria. The sequenced region encompassed the VP1/2A region of HAV genome. The sequences obtained from the samples were 103. For the phylogenetic analyses, 5 datasets were built to investigate the viral gene in/out flow among distinct HAV subpopulations in different geographic areas and to build a Bayesian dated tree, Bayesian phylogenetic and migration pattern analyses were performed. HAV Ib Bulgarian sequences mostly grouped into a single clade. This indicates that the Bulgarian epidemic is partially compartmentalized. It originated from a limited number of viruses and then spread through fecal-oral local transmission. HAV Ia Bulgarian sequences were intermixed with European sequences, suggesting that an Ia epidemic is not restricted to Bulgaria but can affect other European countries. The time-scaled phylogeny reconstruction showed the root of the tree dating in 2008 for genotype Ib and in 1999 for genotype Ia with a second epidemic entrance in 2003. The Bayesian skyline plot for genotype Ib showed a slow but continuous growth, sustained by fecal-oral route transmission. For genotype Ia, there was an exponential growth followed by a plateau, which suggests better infection control. Bidirectional viral flow for Ib genotype, involving different Bulgarian areas, was observed, whereas a unidirectional flow from Sofia to Ihtiman for genotype Ia was highlighted, suggesting the fecal-oral transmission route for Ia.

Development of an Intact Blood-Brain Barrier in Brain Tissue Transplants is Dependent on the Site of Transplantation

Transplantation of fetal septal forebrain tissue was performed to the anterior chamber of the eye, or intracranially to the rostral hippocampal formation in rats, to evaluate the impact of transplantation site on the development of an intact blood–brain barrier (BBB). The tissue was studied at 1, 2, 3, and 4 wk following transplantation by means of intravenous injection of Trypan blue, which is a vital stain not normally penetrating the BBB, as well as with an antibody specifically directed against the rat BBB, SMI71. In the intraocular septal transplants, there was a significant leakage of Trypan blue 1 wk postgrafting, associated with a few laminin-immunoreactive blood vessels that did not contain any SMI71-immunoreactivity. However, at 2 wk postgrafting, the intraocular grats exhibited an extensive plexus of thin-walled blood vessels expressing SMI71 immunoreactivity and no Trypan blue leakage. Thus, it appeared that a BBB had developed to some degree by 2 wk postgrafting in oculo. In the intracranial grafts, on the other hand, Trypan blue leakage could be seen as long as 3 wk postgrafting, and a dense plexus of blood vessels with SMI71 immunoreactivity was first seen at 4 wk postgrafting. Thus, the development of Trypan blue impermeability was delayed with 1 to 2 wk in the intracranial versus the intraocular grafts. Control experiments using psychological stress in adult rats as a means to transiently disrupt the BBB revealed that an increase in Trypan blue leakage correlated well with the disappearance of SMI71 immunoreactivity. Taken together, these studies demonstrate that the site of transplantation can influence the development of an intact BBB in neural tissue grafts.

Rates of PD-L1 expression testing in U.S. community-based oncology practices (USCPs) for patients with metastatic non-small cell lung cancer (mNSCLC) receiving nivolumab (N) or pembrolizumab (P)

11596

Background: FDA approved N for previously treated squamous mNSCLC in 3/2015 and non-squamous mNSCLC in 10/2015 regardless of PD-L1 expression. P was approved for previously treated mNSCLC in 10/2015 for patients whose tumors express PD-L1 as determined by an FDA-approved companion diagnostic (CoDx). Post-FDA approval treatment patterns of N and P, including PD-L1 testing patterns, remain unclear. Methods: We conducted a retrospective analysis using de-identified patient-level electronic health record (EHR) data aggregated from USCPs by Flatiron Health in accordance to an institutional review board approved protocol. Data was abstracted using both structured and unstructured EHR content with 10% duplicate abstraction to confirm data quality. All patients in the database with clinically-confirmed mNSCLC diagnosed from 1/1/11 to 3/31/16 and documented order or administration of N or P were included in the analyses. PD-L1 expression testing results were abstracted from unstructured data in EHR documents. Results: Within the first year of FDA approval, 1,362 mNSCLC patients received N or P (96.2% N; 3.3% P, 0.5% N+P). The median duration of treatment was 113 days. Overall, 11.3% of patients were tested for PD-L1 expression, 42.2% of whom tested positive. PD-L1 expression testing increased quarterly (Q) from 3.0% in Q2 2015 to 12.8% in Q1 2016. An FDA-approved CoDx was used 30.5% of the time. Among patients who received N, 90.5% were not tested for PD-L1 expression, 3.2% tested positive, and 4.7% tested negative for PD-L1. Among patients who received P, 32.7% were not tested for PD-L1 expression, 50.0% tested positive, and 1.9% tested negative. Conclusions: We observed low rates of PD-L1 expression testing in USCPs for patients with mNSCLC receiving N or P. Testing rates increased quarterly following FDA-approval. The majority of patients were not tested using FDA-approved CoDx. Most patients who were not tested for PD-L1 expression or tested negative received N. Clinician education will be important as data on optimal PD-L1 testing strategies guiding immunotherapy treatment decisions accumulates.

Integrative proteomic profiling of ovarian cancer cell lines reveals precursor cell associated proteins and functional status

A cell line representative of human high-grade serous ovarian cancer (HGSOC) should not only resemble its tumour of origin at the molecular level, but also demonstrate functional utility in pre-clinical investigations. Here, we report the integrated proteomic analysis of 26 ovarian cancer cell lines, HGSOC tumours, immortalized ovarian surface epithelial cells and fallopian tube epithelial cells via a single-run mass spectrometric workflow. The in-depth quantification of >10,000 proteins results in three distinct cell line categories: epithelial (group I), clear cell (group II) and mesenchymal (group III). We identify a 67-protein cell line signature, which separates our entire proteomic data set, as well as a confirmatory publicly available CPTAC/TCGA tumour proteome data set, into a predominantly epithelial and mesenchymal HGSOC tumour cluster. This proteomics-based epithelial/mesenchymal stratification of cell lines and human tumours indicates a possible origin of HGSOC either from the fallopian tube or from the ovarian surface epithelium.

High-grade serous ovarian cancer is the most common and aggressive ovarian cancer, with uncertain cell of origin. Here, the authors undertake a mass spectrometric analysis of 26 cancer cell lines and identify a protein signature that classifies ovarian cancer tissues into epithelial and mesenchymal groups.

Factors Affecting Choice of Community Residential Care Setting

To investigate factors associated with residents’ choice of type of Medicaid-funded community residential care setting in western Washington State. Method: Prospective cohort design including residents new to any of three setting types (264 residents entering 170 different facilities), using data from state and Medicaid databases and in-person interviews. The authors used analysis of variance and multinomial logistic regression to examine bivariate associations and estimate effects of resident and facility characteristics on choice of facility type at baseline. Results: Several resident characteristics appear to be associated with choice of community residential care setting, including age, marital status, education, functional status, and reported memory and behavior problems. Facility policies differ significantly among types of facilities and also appear to be associated with choice of setting. Discussion: Selection processes operate in choice of community residential care setting, with residents choosing facility type based on the fit of their needs with facility characteristics.

Health spending, illicit financial flows and tax incentives in Malawi

This analysis examines the gaps in health care financing in Malawi and how foregone taxes could fill these gaps. It begins with an assessment of the disease burden and government health expenditure. Then it analyses the tax revenues foregone by the government of Malawi by two main routes: Illicit financial flows (IFF) from the country, Tax incentives. We find that there are significant financing gaps in the health sector; for example, government expenditure is United States Dollars (USD) 177 million for 2013/2014 while projected donor contribution in 2013/2014 is USD 207 million and the total cost for the minimal health package is USD 535 million. Thus the funding gap between the government budget for health and the required spending to provide the minimal package for 2013/2014 is USD 358 million. On the other hand we estimate that almost USD 400 million is lost through IFF and corporate utilization of tax incentives each year. The revenues foregone plus the current government health spending would be sufficient to cover the minimal public health package for all Malawians and would help tackle Malawi's disease burden. Every effort must be made, including improving transparency and revising laws, to curtail IFF and moderate tax incentives.

109 DEVELOPMENT OF A SPERM CRYOPRESERVATION PROTOCOL FOR THE ARGENTINE BLACK AND WHITE TEGU (TUPINAMBIS MERIANAE)

Only 891 of the approximately 5600 lizard species have been evaluated by the International Union for Conservation of Nature (IUCN). Of those, at least one-third are threatened with extinction. However, there is no organised effort to preserve their genetic diversity through semen banking. As part of an invasive species monitoring program, Argentine black and white tegus were captured in the Florida Everglades. Following postmortem examination, sperm was collected by flushing the vas deferens and used as a model for the development of sperm cryopreservation protocols for related endangered lizards. Initial motility score (IMS; % motile × speed of progression2), plasma membrane integrity (IPL) and acrosome integrity (IAC) were recorded before freezing. Sperm was extended in TES and Tris (TEST)-yolk buffer with a final glycerol or dimethyl sulfoxide (DMSO) concentration of 8, 12, or 16%, and frozen in vials at 0.3, 1, or 6.3°C min–1. Vials were thawed at 37°C for 90 s. Cryoprotectant (CPA) was removed by centrifugation and resuspension of the sperm pellet in M199, at which time (T0) all variables were assessed and expressed as the percentage of initial (%IMS, %IPL, and %IAC). Statistical tests included multivariate ANOVA (MANOVA) and Student's t-test. Over all CPA concentrations and freeze methods, DMSO was significantly better than glycerol in maintaining %IMS (P = 0.01; 37.32 ± 3.5 and 25.44 ± 3.09, respectively) and %IAC (P < 0.01; 81.45 ± 3.45 and 22.99 ± 3.03, respectively). The 2 CPA were equally successful in protecting %IPL (P = 0.77; 56.61 ± 5.62 and 54.42 ± 4.93, respectively). The slowest freeze rate of 0.3°C min–1 was more successful than 1 and 6.3°C min–1 in preserving %IMS (P = 0.01; 37.85 ± 3.29, 26.03 ± 4.45, and 21.91 ± 4.45, respectively) and %IPL (P < 0.01; 77.43 ± 2.54, 27.99 ± 3.44, and 42.32 ± 3.44, respectively). The %IAC was not significantly affected by freeze rate (P = 0.14; 58.06 ± 6.89, 36.14 ± 9.33, and 42.99 ± 9.33, respectively). The interaction between CPA and freeze method affected %IMS (P < 0.01) and %IAC (P < 0.01), but did not affect %IPL (P = 0.28). All variables were affected (P < 0.05) by concentration of cryoprotectant as well as the interaction between freeze method and cryoprotectant concentration. To simplify these analyses and to determine the best overall freeze method for this species, a sperm quality index (SQI) was calculated, giving equal weight to each of the 3 measured indicators of cryosurvival. Table 1 depicts the product of %IMS, %IPL, and %IAC for each treatment. Because there were significant interactions between treatment parameters, each treatment was compared with all others (a–f). The SQI analysis revealed that tegu sperm frozen at 0.3°C min–1 in 8% DMSO exhibited a significantly higher post-thaw viability compared with all other treatments. Table 1.Sperm quality index (SQI) of thawed tegu sperm

Loop-Mediated Isothermal Amplification and Polymerase Chain Reaction Methods for Specific and Rapid Detection of Rhodococcus fascians

Rhodococcus fascians is a phytopathogenic actinobacterium which causes leafy galls and other plant distortions that result in economically significant losses to nurseries producing ornamental plants. Traditional assays for detection and identification are time-consuming and laborious. We developed a rapid polymerase chain reaction (PCR) diagnostic assay based on two primer pairs, p450 and fas, which target the fasA and fasD genes, respectively, that are essential for pathogenicity. We also developed a faster, more convenient, loop-mediated isothermal amplification (LAMP) assay targeting the fasR gene, which regulates expression of virulence genes. Both assays were evaluated for sensitivity and specificity in vitro and in planta. The p450 and fas primers amplified DNA only from pure cultures of pathogenic reference isolates of R. fascians. Nonpathogenic isolates and 51 other plant-associated bacteria were not amplified. The PCR primers correctly detected pathogenic R. fascians from 73 of 75 (97%) bacterial strains isolated from naturally infected plants. The PCR assay correctly discriminated between pathogenic R. fascians and other bacteria in 132 of 139 (95%) naturally infected plants, and in 34 of 34 (100%) artificially inoculated plants. The fas primers were slightly more accurate than the p450 primers. The LAMP assay accurately detected pathogenic R. fascians in 26 of 28 (93%) naturally infected plants and did not react with 23 asymptomatic plants. The LAMP primers also amplified product for DNA extracts of 40 of 41 bacterial strains isolated from plants with leafy galls. The detection limit of both the PCR and LAMP assays was approximately 10³ CFU/30-μl reaction. These new tools allow fast, reliable, and accurate detection of R. fascians in vitro and in planta. The LAMP assay in particular is a significant advancement in rapid R. fascians diagnostics, and enables those with limited laboratory facilities to confirm the presence of this pathogen in infected plants.

Hepatitis B virus wild-type and rtN236T populations show similar early HBV DNA decline in adefovir refractory patients on a tenofovir-based regimen

Hepatitis B virus (HBV) pol/RT mutations that confer clinical resistance to tenofovir disoproxil fumarate (TDF) have not been detected to date. In vitro, the rtN236T adefovir dipivoxil (ADV)-associated resistance mutation confers low-level cross-resistance to tenofovir: 3- to 13-fold changes in EC(50) from wild type. This study evaluated the clinical response of rtN236T mutant viruses by comparing their early viral load decay kinetics to wild-type viruses in chronic HBV monoinfected patients harbouring rtN236T prior to initiating TDF or emtricitabine (FTC)/TDF therapy. Baseline samples (n = 105) from adefovir refractory patients were tested for the presence of rtN236T using a highly sensitive allele-specific PCR assay with an rtN236T detection cut-off of 0.5%. The rtN236T mutation was detected at baseline in 14.3% (14/98) of analysable patient samples (0.5-93.2%, rtN236T percentage range). The median change in total HBV DNA at week 24 was comparable for patients with rtN236T detected at baseline (-3.7 log(10) copies/mL, n = 14) as compared to patients with wild-type HBV (-3.2 log(10) copies/mL, n = 90). In patients with rtN236T, wild-type and rtN236T mutant virus showed similar rates of HBV DNA decline with no statistically significant difference observed at week 4. Moreover, the proportion of rtN236T remained unchanged in patients in either arm of the study during treatment. In conclusion, the rtN236T mutant virus showed similar HBV DNA decline kinetics to wild-type virus in adefovir refractory patients who switched to TDF or FTC/TDF. Despite low levels of cross-resistance in vitro, TDF similarly suppresses wild-type and rtN236T mutant viruses in vivo.

Tricking the guard: exploiting plant defense for disease susceptibility

Typically, pathogens deploy virulence effectors to disable defense. Plants defeat effectors with resistance proteins that guard effector targets. We found that a pathogen exploits a resistance protein by activating it to confer susceptibility in Arabidopsis. The guard mechanism of plant defense is recapitulated by interactions among victorin (an effector produced by the necrotrophic fungus Cochliobolus victoriae), TRX-h5 (a defense-associated thioredoxin), and LOV1 (an Arabidopsis susceptibility protein). In LOV1's absence, victorin inhibits TRX-h5, resulting in compromised defense but not disease by C. victoriae. In LOV1's presence, victorin binding to TRX-h5 activates LOV1 and elicits a resistance-like response that confers disease susceptibility. We propose that victorin is, or mimics, a conventional pathogen virulence effector that was defeated by LOV1 and confers virulence to C. victoriae solely because it incites defense.

Implications of dredging induced changes in sediment particle size composition for the structure and function of marine benthic macrofaunal communities

A meta-analysis approach was used to assess the effect of dredging induced changes in sediment composition, under different conditions of natural physical disturbance, for the structure and function of marine benthic macrofaunal communities. Results showed the sensitivity of macrofaunal communities increased as both the proportion of gravel increased and the level of natural physical disturbance decreased. These findings may be explained by the close association of certain taxa with the gravel fraction, and the influence of natural physical disturbance which, as it increases, tends to restrict the colonisation by these species. We conclude that maintaining the gravel content of surface sediments after dredging and, where practicable, locating extraction sites in areas of higher natural disturbance will minimise the potential for long-term negative impacts on the macrofauna.

The contribution of alcohol to fatal traumatic head injuries in the forensic setting

Excessive drinking increases the risk of dying unnaturally. In the Republic of Ireland such deaths are referred to the State Pathologist. Blood alcohol concentration (BAC) is routinely measured. We created a database of cases presenting to the State Pathologist over a nine year period (2000-2008 inclusive) to evaluate the relationship between alcohol and fatal traumatic brain injuries (FTBI). Of a total of 1778 cases, 332 (275 Male [M]; 57 Female [F]) died of head injuries. Fatalities were highest in males aged 36-50 (N = 97) and 26-35 (N = 73). Assaults (N = 147), falls (N = 95), road traffic accidents (RTA) (N = 50) and suicide (N = 15) were the commonest modes of presentation. A positive blood alcohol concentration (BAC) was found in 36% of assaults, 41% of falls and 40% of suicides. In the RTA group BAC was positive in 59% of pedestrians, 33% of drivers and 14% of passengers. Alcohol clearly plays a significant role in FTBI in the forensic setting.

Treatment of lateral epicondylitis using skin-derived tenocyte-like cells

OBJECTIVES

To culture collagen-producing cells derived from skin fibroblasts and o evaluate prospectively the safety and potential use of this cell preparation for treatment of refractory lateral epicondylitis in a pilot study.

DESIGN

Prospective clinical pilot study.

SETTING

Institution-based clinical research.

PATIENTS

A total of 12 patients (5 men and 7 women; mean age 39.1 years) with clinical diagnosis of refractory lateral epicondylitis.

INTERVENTIONS

Laboratory-prepared collagen-producing cells derived from dermal fibroblasts were injected into the sites of intrasubstance tears and fibrillar discontinuity of the common extensor origin under ultrasonography guidance.

MAIN OUTCOME MEASURES

The outcome assessment was performed over 6 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale was used to assess pain severity and functional disability. Tendon healing response was measured using four criteria on ultrasonography: tendon thickness, hypoechogenicity, intrasubstance tears and neovascularity.

RESULTS

Cell cultures rich in collagen-producing cells was successfully prepared. After injection, the median PRTEE score decreased from 78 before the procedure to 47 at 6 weeks, 35 at 3 months and 12 at 6 months after the procedure (p<0.05). The healing response on ultrasonography showed median decrease in: (1) number of tears, from 5 to 2; (2) number of new vessels, from 3 to 1; and (3) tendon thickness, from 4.35 to 4.2 (p<0.05). Of the 12 patients, 11 had a satisfactory outcome, and only one patient proceeded to surgery after failure of treatment at the end of 3 months.

CONCLUSIONS

Skin-derived tenocyte-like cells can be cultured in the laboratory to yield a rich preparation of collagen-producing cells. Our pilot study suggests that these collagen-producing cells can be injected safely into patients and may have therapeutic value in patients with refractory lateral epicondylitis.

BMP-silk composite matrices heal critically sized femoral defects

Clinical drawbacks of bone grafting prompt the search for alternative bone augmentation technologies such as use of growth and differentiation factors, gene therapy, and cell therapy. Osteopromotive matrices are frequently employed for the local delivery and controlled release of these augmentation agents. Some matrices also provide an osteoconductive scaffold to support new bone growth. In this study, silkworm-derived silk fibroin was evaluated as an osteoconductive matrix for healing critical sized mid-femoral segmental defects in nude rats. Four treatment groups were assessed over eight weeks: silk scaffolds (SS) with recombinant human BMP-2 (rhBMP-2) and human mesenchymal stem cells (HMSC) that had been pre-differentiated along an osteoblastic lineage ex vivo (Group I; pdHMSC/rhBMP-2/SS); SS with rhBMP-2 and undifferentiated HMSCs (Group II; udHMSC/rhBMP-2/SS); SS and rhBMP-2 alone (Group III; rhBMP-2/SS); and empty defects (Group IV). Bi-weekly radiographs revealed a progressive and similar increase in Group I-III mean defect mineralization through post-operative week (POW) 8. Radiographs, dual energy x-ray absorptiometry, and micro-computed tomography confirmed that Groups I-III exhibited similar substantial and significantly (p<0.05) greater defect mineralization at POW 8 than the unfilled Group IV defects which remained void of bone. No significant differences in Groups I-III defect healing at POW 8 were apparent using these same assays or mechanical testing. Histology at POW 8 revealed moderately good bridging of the parent diaphyseal cortices with woven and lamellar bone bridging islands of silk matrix in Groups I and III. Group II defects possessed comparatively less new bone which was most abundant adjacent to the parent bone margins. Elsewhere the silk matrix was more often enveloped by poorly differentiated loose fibrous connective tissue. Group IV defects showed minimal new bone formation. None of the treatment groups attained the mean mineralization or the mean biomechanical strength of identical defects implanted with SS and pdHMSCs alone in a previous study. However, addition of rhBMP-2 to SS prompted more bone than was previously generated using udHMSC/SS or SS alone. These data imply the clinical potential of silk scaffolds and rhBMP-2 as composite osteopromotive implants when used alone or with select stem cell populations. Additional studies in larger species are now warranted.

Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF121 (AdVEGF121) versus maximum medical treatment

The demonstration that angiogenic growth factors can stimulate new blood vessel growth and restore perfusion in animal models of myocardial ischemia has led to the development of strategies designed for the local production of angiogenic growth factors in patients who are not candidates for conventional revascularization. The results of recent clinical trials of proangiogenesis gene therapy have been disappointing; however, significant limitations in experimental design, in particular in gene transfer strategies, preclude drawing definitive conclusions. In the REVASC study cardiac gene transfer was optimized by direct intramyocardial delivery of a replication-deficient adenovirus-containing vascular endothelial growth factor (AdVEGF121, 4 x 10(10) particle units (p.u.)). Sixty-seven patients with severe angina due to coronary artery disease and no conventional options for revascularization were randomized to AdVEGF121 gene transfer via mini-thoracotomy or continuation of maximal medical treatment. Exercise time to 1 mm ST-segment depression, the predefined primary end-point analysis, was significantly increased in the AdVEGF121 group compared to control at 26 weeks (P=0.026), but not at 12 weeks. As well, total exercise duration and time to moderate angina at weeks 12 and 26, and in angina symptoms as measured by the Canadian Cardiovascular Society Angina Class and Seattle Angina Questionnaire were all improved by VEGF gene transfer (all P-values at 12 and 26 weeks < or =0.001). However, if anything the results of nuclear perfusion imaging favored the control group, although the AdVEGF121 group achieved higher workloads. Overall there was no significant difference in adverse events between the two groups, despite the fact that procedure-related events were seen only in the thoracotomy group. Therefore, administration of AdVEGF121 by direct intramyocardial injections resulted in objective improvement in exercise-induced ischemia in patients with refractory ischemic heart disease.

A comparison of competing methods for the detection of surgical-site infections in patients undergoing total arthroplasty of the knee, partial and total arthroplasty of hip and femoral or similar vascular bypass

Recent research suggests that the retrospective review of the International Classification of Disease (ICD-9-CM) codes assigned to a patient episode will identify a similar number of healthcare-acquired surgical-site infections as compared with prospective surveillance by infection control practitioners (ICP). We tested this finding by replicating the methods for 380 surgical procedures. The sensitivity and specificity of the ICP undertaking prospective surveillance was 80% and 100%, and the sensitivity and specificity of the review of ICD-10-AM codes was 60% and 98.9%. Based on these results we do not support retrospective review of ICD-10-AM codes in preference prospective surveillance for SSI.

Maternal uniparental disomy 16 and genetic counseling: new case and survey of published cases

Uniparental disomy (UPD) is the occurrence of both homologous chromosomes from one parent. Maternal UPD(16) is the most often reported UPD other than UPD(15); almost all cases are associated with confined placental mosaicism (CPM). Most of maternal UPD(16) cases are characterised by intrauterine growth retardation (IUGR) and different congenital malformations. Maternal UPD(16) has therefore been suspected to have clinical effects: however, the lack of uniqueness and specificity of the birth defects observed suggests that the phenotype may be related in parts to placental insufficiency. We report on a new case of maternal UPD(16) associated with low level trisomy 16 mosaicism in placenta and fetus. IUGR was noticed at 19 gestational weeks and the fetus died intrauterine. Apart from different craniofacial dysmorphisms she showed anal atresia. While IUGR is probably associated with trisomy 16 mosaicism, anal atresia is more characteristic for maternal UPD( 16). Considering the features in our patient as well as those in maternal UPD (16) cases from the literature, indications for UPD (16) testing can be defined: They include trisomy 16 mosaicism, IUGR and congenital anomalies (anal atresia, congenital heart defects). However, there is an overlap of clinical signs in mosaic trisomy 16 cases mosaic for maternal UPD(16) as opposed to those mosaic for biparental disomy 16. The management of trisomy 16 pregnancies should not differ from those in which maternal UPD(16) is confirmed. Therefore, a prenatal testing for UPD(16) is not useful, but it should be offered postnatally. The molecular genetic proof of maternal UPD(16) excludes an increased recurrence risk for the family for further pregnancies.

Turlock-like bunyavirus associated with encephalomyelitis and myocarditis in an ostrich chick

In the fall of 1995, a 20-day-old female ostrich chick, 1 of a group of 20, was presented live with clinical signs of 2 days duration characterized by unsteady gait, circling to the left, and walking backward. Another bird with similar clinical signs had died and another had recovered. The bird was euthanized and examined at necropsy. Twenty-five milliliters of serous fluid was in the abdominal cavity and there was increased pericardial fluid. Histopathology of the brain revealed mild to moderate nonsuppurative encephalitis characterized by mild multifocal malacia, perivascular cuffing by lymphocytes, and gliosis. The heart had multifocal infiltrations of lymphocytes mixed with macrophages and a few plasma cells throughout the myocardium. Cytopathic effects were observed in primary chicken embryo liver cells following inoculation with a tissue homogenate prepared from the brain of the affected ostrich. Virus particles the size and morphology of the family Bunyaviridae were observed in cell culture lysate by negative-stain electron microscopy. Viral characterization demonstrated that the virus isolate is a previously unknown serotypic variant (subtype) of Turlock virus. Twelve of 65 sera collected over a 3-year period from ostriches aged from 1 month to 4 years were positive for neutralizing antibody to both the Turlock prototype strain and the new subtype of Turlock virus described in this report.

Concomitant progressive multifocal leucoencephalopathy and primary central nervous system lymphoma expressing JC virus oncogenic protein, large T antigen

This report describes the concomitant occurrence of the JC virus (JCV) induced demyelinating disease progressive multifocal leucoencephalopathy (PML) and a primary central nervous system lymphoma (PCNS-L) in a patient with AIDS. Postmortem neuropathological examination revealed characteristic features of PML including multiple lesions of demyelination, enlarged oligodendrocytes with hyperchromatic nuclei (many containing eosinophilic intranuclear inclusions), and enlarged astrocytes with bizarre hyperchromatic nuclei. Immunohistochemical analysis demonstrated the expression of the JCV capsid protein VP-1 in the nuclei of infected oligodendrocytes and astrocytes. The PCNS-L lesion located in the basal ganglia was highly cellular, distributed perivascularly, and consisted of large atypical plasmacytoid lymphocytes. Immunohistochemical examination of this neoplasm identified it to be of B cell origin. Moreover, expression of the JCV oncogenic protein, T antigen, was detected in the nuclei of the neoplastic lymphocytes. This study provides the first evidence for a possible association between JCV and PCNS-L.