Expansion of endogenous T cells in CSF of pediatric CNS tumor patients undergoing locoregional delivery of IL13R〿2-targeting CAR T cells: an interim analysis

Outcomes for pediatric brain tumor patients remain poor, and there is optimism that chimeric antigen receptor (CAR) T cell therapy can improve prognosis. Here, we present interim results from the first six pediatric patients treated on an ongoing phase I clinical trial (NCT04510051) of IL13BBζ-CAR T cells delivered weekly into the lateral cerebral ventricles, identifying clonal expansion of endogenous CAR-negative CD8+ T cells in the cerebrospinal fluid (CSF) over time. Additionally, of the five patients evaluable for disease response, three experienced transient radiographic and/or clinical benefit not meeting protocol criteria for response. The first three patients received CAR T cells alone; later patients received lymphodepletion before the first infusion. There were no dose limiting toxicities (DLTs). Aside from expected cytopenias in patients receiving lymphodepletion, serious adverse events possibly attributed to CAR T cell infusion were limited to one episode of headache and one of liver enzyme elevation. One patient withdrew from treatment during the DLT period due to a Grade 3 catheter-related infection and was not evaluable for disease response, although this was not attributed to CAR T cell infusion. Importantly, scRNA- and scTCR-sequence analyses provided insights into CAR T cell interaction with the endogenous immune system. In particular, clonally expanded endogenous CAR- T cells were recovered from the CSF, but not the peripheral blood, of patients who received intraventricular IL13BBζ-CAR T cell therapy. Additionally, although immune infiltrates in CSF and post-therapy tumor did not generally correlate, a fraction of expanded T cell receptors (TCRs) was seen to overlap between CSF and tumor. This has important implications for what samples are collected on these trials and how they are analyzed. These initial findings provide support for continued investigation into locoregionally-delivered IL13BBζ-CAR T cells for children with brain tumors.

CLOSING THE GAP BETWEEN MEDICAL KNOWLEDGE AND PATIENT OUTCOMES THROUGH NEW TRAINING INFRASTRUCTURE

The biomedical research infrastructure of our academic medical centers elucidates disease mechanisms and develops diagnostic tests and treatments with scientific rigor, but the mechanism for reliably moving these findings into clinical settings lacks careful design. Hence, there is a wide gap between medical discoveries and the health benefit realized by the U.S. population. Performance improvement (PI) is a discipline that focuses on intentional redesign of core processes in our health system to close these gaps. The application of PI science is more consequential to health outcomes as is traditional biomedical research. This article describes why application and recognition of PI science as a discipline is imperative and why we should require training with similar intensity in undergraduate medical education (UME) and graduate medical education (GME). It also proposes investment in infrastructure (developing faculty expertise) and rigorous fellowships, which are, perhaps, more likely to thrive in teaching hospitals with a strong clinical mission.

OP0004 AUTOMATED RECOGNITION AND MONITORING OF DORSAL SKIN FOLDS BY A CONVOLUTIONAL NEURAL NETWORK AS A POTENTIAL DIGITAL BIOMARKER FOR JOINT SWELLING IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

To monitor rheumatic diseases, digital biomarkers such as wearables are of increasing interest, but they lack disease specificity.

Objectives

In this study, we apply convolution neural networks (CNN) to real world hand photographs in order to automatically detect, extract and analyse dorsal finger folds lines as a correlate of proximal interphalangeal (PIP) joint swelling in patients with rheumatoid arthritis (RA).

Methods

Hand photographs from 190 RA patients were taken by a smartphone camera in a standardized manner. PIP joints were categorised as either swollen or not swollen based on clinical judgement and ultrasound. Images were automatically preprocessed by cropping PIP joints and extracting dorsal finger folds. Subsequently, metrical analysis of dorsal finger folds was performed and a CNN was trained to classify the dorsal finger lines into swollen versus non-swollen joints. Representative horizontal finger folds were also quantified in a subset of patients before and after resolution of PIP swelling and in patients with disease flares, respectively.

Results

In swollen joints, the number of automatically extracted double-contoured, deep skinfold imprints was significantly reduced compared to non-swollen joints (1.3, SD 0.8 vs. 3.3, SD 0.49). The joint diameter / deep skinfold ratio was significantly higher in swollen (4.1, SD 1.4) versus non-swollen joints (2.1 SD 0.6). The CNN model successfully differentiated swollen from non-swollen joints based on finger fold patterns with a validation accuracy of 0.84. A heatmap of the original images obtained by an extraction algorithm confirmed finger folds as the region of interest for correct classification. After significant response to DMARD +/- corticosteroid therapy, longitudinal metrical analysis of eight representative deep finger folds showed a decrease of the mean diameter/ finger fold length (finger fold index, FFl) from 3.03 (SD 0.68) to 2.08 (SD 0.57). Conversely, the FFI increased in patients with a flare of joint swelling.

Conclusion

Automated preprocessing and the application of CNN algorithms in combination with longitudinal metrical analysis of dorsal finger fold patterns extracted from real world hand photos might serve as a digital biomarker in RA.

Figure 1.

Automated finger fold recognition to monitor rheumatoid arthritis (RA). Hand photographs are taken by a smartphone (A). Hands, and subsequently proximal interphalangeal (PIP) joints, are automatically recognized and extracted. Finger fold lines are isolated from the images, measured and related to the joint diameter (B,C). A convolutional deep neural network was used to train a model for classification of extracted finger fold patterns into swollen vs. non swollen joints (D). On cropped PIP joint images, the heatmap of the same classification task confirms finger folds as the region of interest (E).

Disclosure of Interests

Thomas Hügle Shareholder of: Atreon SA., Speakers bureau: Multiple. Not relevant for this work., Grant/research support from: Multiple. Not for this work., Leo Caratsch: None declared, Matteo Matteo Caorsi Employee of: MC is an employee of L2F., Jules Maglione: None declared, Diana Dan: None declared, Alexandre Dumusc Speakers bureau: Multiple. Not relevant for this work., Marc Blanchard Shareholder of: Atreon SA., Gabriel Kalweit: None declared, Maria Kalweit: None declared.

OP0199 EX VIVO BIOMARKER PROFILING IDENTIFIES ONCOSTATIN-M AS SPINE OSTEOARTHRITIS-SPECIFIC OSTEOIMMUNOLOGICAL TARGET

Background:

Disease heterogeneity, both clinically and molecularly, has been a major hurdle in the development of efficacious disease-modifying osteoarthritis drugs (DMOADs). Biomechanical, inflammatory, osteoporotic and metabolic OA have been proposed as clinically relevant subtypes for stratification of knee OA patients, yet this remains to be included in clinical trial design. Disease heterogeneity does not only occur within, but also between joint types. However, robust data on joint-specific pathomechanisms of OA are still lacking.

Objectives:

In this study, we performed ex vivo biomarker profiling of human osteochondral tissue of knee and spine OA to identify joint-specific pathomechanisms and DMOAD treatment responses.

Methods:

Facet joint and tibial plateaus were obtained from patients undergoing lumbar spinal fusion (n=11, mean age 72.8) and total joint arthroplasty (n=8, mean age 73.0) respectively. Osteochondral specimens were cut in equal-sized samples (100-300 mg wet weight) and randomly assigned to treatment groups: control (DMSO), inflammation (1 μg/mL LPS) or inflammation + DMOAD (TGF-beta

type I receptor inhibitor,10 μM SB-505124). Explant culture was conducted for one week and biomarkers of bone metabolism (Pro-Col-Ia, SOST, OPG, SPP1), inflammation (MCP-1, IL-6, MMP3, OSM, TIMP1, VEGFA) and cartilage metabolism (ACAN, COMP) were determined by ELISA. Normalized biomarker secretion was analysed using clusteranalyses and ANOVA. Cartilage proteoglycans were assessed by whole mount Alcian blue staining. Expression of Oncostatin-M (OSM) and its receptors OSMR and LIFR in joint tissues was assessed by RT-PCR and immunohistochemistry.

Results:

Clusteranalyses revealed that LPS stimulation increased IL-6 and MCP-1 secretion by both facet joint (FJ) and knee joint (KJ) tissues. Interestingly, Oncostatin-M (OSM) and its downstream mediators MMP3 and TIMP1 were increased in the majority of FJ, but not KJ specimens. Statistical analyses corroborated increased OSM, MMP3 and TIMP1 levels in a spine-specific fashion (Figure).

Whole mount Alcian blue staining revealed heterogeneous effects of LPS treatment on cartilage proteoglycans, which was negatively correlated with OSM (r=-0.54) and TIMP1 levels (r=-0.45) – yet poorly associated with ACAN (r=0.19). Inhibition of TGF-beta type I receptor signalling in osteochondral tissues led to a drastic reduction of Pro-Collagen-Ia and IL-6 secretion in both spine and knee OA specimens. Interestingly, DMOAD treatment significantly reduced OSM, TIMP1 and MMP3 levels in FJ specimens only. Vice versa, KJ tissues revealed a specific upregulation of monocyte chemoattractant protein-1 (MCP-1) and osteopontin (SPP1) upon inhibition of TGF-beta signalling. OSM was exclusively expressed in subchondral bone marrow macrophages. Isolated chondrocytes and osteoblasts expressed both LIFR and OSMR, yet intact cartilage only showed OSMR expression, while OSMR and LIFR was expressed in marrow tissue

Conclusion:

Oncostatin-M expression and signalling was uncovered as specific pathomechanism of spine OA. DMOAD treatment effects suggested interplay of OSM and TGF-beta signalling pathways in facet joint osteoarthritis. Known to be predominantly expressed by macrophages and immune cells, OSM may be an important osteoimmunological mediator of tissue damage and remodelling in spine, but not knee OA. This study also highlights the value of ex vivo human tissue models for OA phenotyping and preclinical evaluation of DMOADs.

Disclosure of Interests:

None declared

Outcome for bilateral cochlear implantation in patients with congenital Cytomegalovirus infection

OBJECTIVES

To analyze the impact of bilateral cochlear implantation (CI) on perceptual and linguistic development in hearing-impaired children with congenital Cytomegalovirus (CMV) infection.

PATIENTS AND METHOD

A retrospective study was performed for the period 1991-2016 in a pediatric CI reference center. Closed Set Word (CSW) recognition scores, Categories of Auditory Performance (CAP) and linguistic level on the MT Lenormand scale (MTL) were compared between bilateral (Bi) and unilateral (Uni) groups 12, 24 and 36 months after first CI (CI-1).

RESULTS

84 patients with congenital CMV infection who underwent CI were included, in 2 groups: sequential or simultaneous bilateral CI (Bi) (N=20), and unilateral CI (Uni) (N=64). Twelve, 24 and 36 months after CI-1, CSW scores were 35.56%, 64.52% and 82.93% in Uni and 60.3%, 85% (P=0.0084*), and 100% (P=0.00085*) in Bi. CAP scores 12, 24 and 36 months after CI-1 were 2.57, 3.85 and 4.3 in Uni and 3.91 (P=0.0068*), 5.00 (p=0.029*) and 5.50 (P=0.051*) in Bi. MTL linguistic level scores at 12, 24 and 36 months were 0.72, 1.25 and 1.65 in Uni, and 1.72, 3 (P=0.033) and 3.11 (P=0.045) in Bi. These significantly better scores in Bi at 24 and 36 months after CI-1 were also found on analysis of subgroups with no associated neurologic disorder (P=0.046* and P=0.032*), no associated psychiatric pathology (P=0.0055* and P=0.0073*), and no other associated disorder (P=0.0018* and P=0.035*), and for all subgroups together (P=0.0036 and P=0.037).

CONCLUSION

Bilateral CI is a faster way than unilateral CI for patients with congenital CMV infection to achieve structured fluent oral language. 50% of the series showed cerebral abnormalities on MRI, without difference between groups. This was not in itself predictive of poor progression of oral communication, unless associated with major neurologic disorder. Some children made little or no use of their CI in the medium term.

FC16-04 - The clinical effectiveness of individual cognitive behaviour therapy for depressed older people in primary care and the use of a talking control (TC)

Objective

To determine the clinical effectiveness of Cognitive Behaviour Therapy (CBT) delivered in primary care for older people with depression and evaluation of a talking control (TC).

Methods

A single-blind, randomized, controlled trial with 4- and 10-month follow-up. 204 people, aged 65 years or more, with a Geriatric Mental State diagnosis of depression were recruited from primary care. The interventions were: treatment as usual (TAU), TAU plus TC, or TAU plus CBT. The TC and CBT were offered over 4 months. The TC was to control for common effects in therapy. The Beck Depression Inventory-II (BDI-II) was the main outcome. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intention to treat analysis (ITT) and Compliance Average Causal Effect (CACE) analyses was employed. The Cognitive therapy scale (CTS) evaluated common and specific factors in therapy.

Results

A mean of 7 sessions of TC or CBT were delivered. ITT analysis found improvements of −3.07 (95% confidence interval [CI], −5.73 to −0.42) and −3.65 (95% CI, −6.18 to −1.12) in BDI-II scores in favour of CBT vs TAU and TC respectively. CACE analysis found a benefit of 0.4 points (95% CI, 0.01 to 0.72) per therapy session of CBT over TC. Ratings for CBT on the CTS were high (mean [SD], 54.2 [4.1]) and showed no difference for nonspecific, but significant differences for specific factors in therapy.

Conclusion

CBT is an effective treatment for depressed older people. Improvement appears to be associated with specific factors in CBT.

Paroxysmal strabismus and stridor acquired in childhood: Do not overlook calcemia!

Hypocalcemia is known to induce stridor but was rarely reported to cause strabismus. We report the case of a 4-year-old girl who presented with paroxysmal stridor and strabismus with diplopia, persisting for several weeks. Severe hypocalcemia (1.25 mmol/L) was finally diagnosed and was related to hypoparathyroidism, which was the first manifestation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in this patient. Strabismus and stridor both resolved after normalization of calcemia. This case report is a rare observation of paroxysmal strabismus caused by hypocalcemia and it highlights the importance of calcium monitoring in any situation of atypical neurological symptoms.

Mental health in spouses of U.S. Gulf War veterans

Veterans' spouses are at risk for mental distress and substance use. We examined long term psychological functioning in spouses from a national cohort of 1991 Gulf War era veterans. From clinical interviews, spouses of deployed veterans (n = 488) did not have a greater prevalence of post-war mental disorders compared to spouses of non-deployed veterans (n = 536); however, in couples that were living together since the war, there was an increased risk of anxiety disorders or any one disorder. On questionnaires, the impact varied but was most consistently observed in more severe depression and greater functional impairment in spouses of deployed compared to non-deployed veterans. If a veteran developed post-war anxious/depressive disorders or any one mental disorder, the matched spouse was more likely to develop post-war anxious/depressive disorders or any one mental disorder, respectively. Veteran combat exposure did not similarly increase the risk of spouse post-war mental disorders. Greater spouse self-reported symptomatology was observed in spouses of veterans with anxious/depressive disorders even when controlling for deployment. In summary, the war conferred greater risk for spouse mental disorders and distress for spouses of veterans with mental health disorders, with some increased risk for spouses of deployed veterans, especially in couples together since the war.

Medical Correlates of Chronic Multisymptom Illness in Gulf War Veterans

BACKGROUND

Chronic multisymptom illness (CMI) is more prevalent among deployed than nondeployed veterans from the first Gulf War. Objective physiologic markers of CMI are lacking. The purpose of this study is to determine whether measurable abnormalities in the autonomic nervous system or hypothalamic-pituitary adrenal axis would distinguish CMI cases (CMI+) from controls (CMI-) among deployed veterans of the 1990-1991 Gulf War.

METHODS

This is a cross-sectional case-control cohort study that examined deployed veterans who participated in the Phase III study: National Health Survey of Gulf War Veterans and Their Families. Autonomic nervous system and hypothalamic-pituitary adrenal axis function-related measures included: 24-hour heart-rate variability, urinary catecholamines and cortisol, hypertension, insulin sensitivity, dyslipidemia, body fat, bone mineral density, and ultrasensitive C-reactive protein.

RESULTS

Veterans of the first Gulf War with CMI (n = 73) and without the condition (n = 111) were studied. Sociodemographic characteristics were similar. Veterans with CMI reported poorer mental and physical functioning, greater use of prescription medications, and more nonroutine clinic visits. These veterans were also more likely to have fibromyalgia syndrome, irritable bowel syndrome, metabolic syndrome, and among males, a larger waist-to-hip ratio. Lower values for a nonlinear heart-rate-variability parameter-the short-term fractal scaling exponent (DFA1), reflecting an increased randomness of beat-to-beat changes in heart rate-were observed in veterans with CMI than those veterans without it (1.28±0.16vs 1.35±0.15; p=0.005). Hypothalamic-pituitary-adrenal axis function measures were similar between the two groups.

CONCLUSION

In this cohort of deployed veterans from the first Gulf War, we identified abnormal heart-rate variability in veterans with CMI compared to veterans without the condition, which suggests abnormal functioning of the autonomic nervous system and possible long-term cardiovascular effects.

Training the physician-scientist: views from program directors and aspiring young investigators

There is growing concern that the physician-scientist is endangered due to a leaky training pipeline and prolonged time to scientific independence (1). The NIH Physician-Scientist Workforce Working Group has concluded that as many as 1,000 individuals will need to enter the pipeline each year to sustain the workforce (2). Moreover, surveys of postgraduate training programs document considerable variability in disposition and infrastructure (3). Programs can be broadly grouped into two classes: physician-scientist training programs (PSTPs) that span residency and fellowship training, and research-in-residency programs (RiRs), which are limited to residency but trainees are able to match into PSTPs upon transitioning to fellowship (Figure 1). Funding sources for RiRs and PSTPs are varied and include NIH KL2 and T32 awards, charitable foundations, philanthropy, and institutional support. Furthermore, standards for research training and tools for evaluating programmatic success are lacking. Here, we share consensus generated from iterative workshops hosted by the Alliance of Academic Internal Medicine (AAIM) and the student-led American Physician Scientists Association (APSA).

Effectiveness of a novel, automated telephone intervention on time to hospitalisation in patients with COPD: A randomised controlled trial

Introduction

Owing to its capacity to perform remote assessments, telemedicine is rising as a new force in chronic obstructive pulmonary disease (COPD) management. We conducted an eight month randomised-controlled-trial to study the effect of an automated telemedicine intervention on patients’ time-to-hospitalisation.

Methods

A total of 168 patients with a diagnosis of COPD in the past 24 months were enrolled to receive the intervention at a primary care clinic. The treatment group received daily phone messages from an automated system asking them to report if they were breathing better than, worse than, or the same as the day prior. Patients reported their breathing status by responding to the text message or call. If a patient reported breathing worse, an alert was sent directly to that patient’s provider within the clinic. The control group received the same daily phone messages as the treatment group. However, no proactive breathing alerts were ever generated to the provider for these subjects. The primary outcome was the subjects’ time-to-first-COPD-related hospitalisation following the start of messages.

Results

The treatment group’s time-to-hospitalisation was significantly different than the control group’s with a hazard ratio of 2.36 (95% confidence interval 1.02–5.45, p = 0.0443). The number needed-to-treat ratio was 8.62. Subject engagement consistently ranged between 60% and 75%. The treatment group received both proactive monitoring and follow-up care from the providers.

Discussion

Active monitoring with provider feedback enables the detection of exacerbation events early enough for subjects to avoid admissions. The use of non-smartphone interventions reduces barriers to care presented by more complicated and expensive technologies. This intervention represents a simple, innovative, and inexpensive tool for improved COPD management.

Pediatric cochlear reimplantation: Decision-tree efficacy

OBJECTIVES

The context leading to pediatric cochlear reimplantation (CreI) can be complex. The objectives of this study were to define initial CreI indications, analyze final diagnosis and draw up a decision-tree.

METHODS

A retrospective study included patients undergoing CreI between 2005 and 2015. Demographic characteristics, CreI circumstances and technical reports were collected. Circumstances indicating CreI were classified in 3 groups: performance decrement, suspected device failure, or medical. After CreI, final diagnoses were classified in 2 groups: confirmed failure (DFail) or medical (DMed).

RESULTS

69 out of 734 cochlear implantation surgeries were for CreI (8%). Manufacturers' reports were available in 64 cases (93%). Two principal causes were found: trauma and infection. Initial indications were: performance decrement: 27%; device failure: 56%; and medical: 17%. Final diagnoses were: DFail: 72%; and DMed: 28%. Initial indication and final diagnosis were similar in 86% of cases. The majority of the 14% initial indication errors belonged to the "performance decrement" group. Traumatic causes correlated with risk of initial indication error (P=0.039).

CONCLUSION

Apart from spontaneous device failure, the two causes of CreI were infection and trauma. Using the present decision algorithm, half of the complex cases were resolved after CreI.

U.S. Physician-Scientist Workforce in the 21st Century: Recommendations to Attract and Sustain the Pipeline

The U.S. physician-scientist (PS) workforce is invaluable to the nation's biomedical research effort. It is through biomedical research that certain diseases have been eliminated, cures for others have been discovered, and medical procedures and therapies that save lives have been developed. Yet, the U.S. PS workforce has both declined and aged over the last several years. The resulting decreased inflow and outflow to the PS pipeline renders the system vulnerable to collapsing suddenly as the senior workforce retires. In November 2015, the Alliance for Academic Internal Medicine hosted a consensus conference on the PS workforce to address issues impacting academic medical schools, with input from early-career PSs based on their individual experiences and concerns. One of the goals of the conference was to identify current impediments in attracting and supporting PSs and to develop a new set of recommendations for sustaining the PS workforce in 2016 and beyond. This Perspective reports on the opportunities and factors identified at the conference and presents five recommendations designed to increase entry into the PS pipeline and nine recommendations designed to decrease attrition from the PS workflow.

Abstract 13: Consistent Remote Monitoring of Patients With Heart Failure Using Epxheartfailure: A Telemedicine Tool

Introduction: Heart failure (HF) is among the most common reasons for hospital admissions, presenting a significant cost burden to the medical system. Patients are monitored at the hospital but often go home without enough long-term management. Chronic care involving consistent symptom monitoring and patient-provider communication is essential to HF management. Though careful management can improve patient quality of life and reduce hospital readmission costs, it may be time consuming and expensive. To address this, we created a SMS text-based platform, EpxHeartFailure (EpxHF), which allows for remote patient monitoring. Our novel platform seeks to improve chronic care management by simplifying patient self-care and patient-provider communication. The goal of this low-cost intervention is to gain patient and provider acceptability and improve patient symptom stability.

Methods: We conducted a retrospective review of a commercial implementation of EpxHF. Data was collected from patients over a 30-week trial period. EpxHF prompted patients to self-report body weight and symptoms of dyspnea/pedal edema (DPE), orthopnea, and edema compared to the previous day. Weight gain (>5lbs over 1 week) plus 1 other worsening symptom triggered an alert (text or call) to the patient’s provider. Providers could then contact the patient and initiate follow up care. The intervention modified message frequency to parallel each patient’s symptom stability and sent providers bimonthly triaged reports that prioritized the most unstable patients. Patients were also asked a question adapted from Kansas City Cardiomyopathy Questionnaire (KCCQ) to assess quality of life and how often a patient’s symptoms interfere with daily functioning (0 - never, 5- all the time).

Results: One-hundred seventy patients in St. Louis were enrolled onto EpxHF at hospitals using care managers within risk sharing and capacitated value models. A total of 3244 texts were sent, 87 alerts were generated, and 99 communications between providers and patients were documented following alerts. The average patient engagement rate was 81%, indicating acceptability. Normalized data for DPE, orthopnea, and excessive weight gain on a scale of -1 to +1 (+1 representing symptom improvement, 0 no change, -1 worsening symptoms) indicated a clear trend of improvement on a weekly basis (avg for all patients: 0.24 DPE, 0.21 orthopnea, 0.07 excessive weight gain). At week 30, the average KCCQ score decreased by 1.38 from baseline (95% CI: 1.299-1.467), which indicates an increase in perceived quality of life.

Discussion: The results demonstrate the ability of the system to engage patients, track their symptomatology and improve quality of life. EpxHF is a cost-effective tool that uses basic texting technology to help providers monitor HF patient’s fluctuating symptoms, with the goal of enabling medical intervention before a HF exacerbation occurs.

Increased Risk of Chronic Multisymptom Illness in Spouses of Gulf War Era Veterans

OBJECTIVE

In 1995, the Centers for Disease Control and Prevention defined chronic multisymptom illness (CMI), a symptom complex in deployed veterans (DVs) of the 1991 Gulf War 1. The specific aim of this work is to determine the prevalence of CMI in spouses of DV and nondeployed veterans (NDVs) and whether veteran CMI is associated with spouse CMI, and to describe the physical and psychological profile of spouses with CMI.

MATERIALS AND METHODS

To determine whether veteran CMI was associated with CMI in their spouses, we used retrospective data from the "National Health Survey of Gulf War Veterans and Their Families." Cross-sectional data were collected from spouses of veterans enrolled in the study, including those of 482 DVs and 532 NDVs who participated in an in-person examination between 1999 and 2001. In addition to a physical examination, this study evaluated health-related quality of life (Medical Outcomes Study Short-Form 36, SF-36), psychological symptoms, and post-traumatic stress disorder (PTSD) status, and measured a variety of common laboratory tests. Statistical analyses included Fisher's Exact Test (or Mantel-Haenszel χ² test for linear trend) as well as odds ratios (ODs) and 95% confidence intervals (CIs) for categorical data. For continuous outcomes, two-sample t-tests were used to compare mean responses among spouses of DV and NDV with and without CMI, and between spouses of DV and NDV with CMI only. Logistic or linear regression models were developed for multiple-covariate analysis to assess if any of the associations we found in the unadjusted analyses would change. The project was approved by the Hines Cooperative Studies Program Human Rights Committee, the Institutional Review Boards at each participating site, and the Brockton VAMC.

RESULTS

The prevalence of CMI in spouses was 19.5% (DV) and 17.3% (NDV) (odds ratio [OR]: 1.16; 95% confidence interval [CI]: 0.84, 1.59). Spouses were more likely to have CMI if their veteran partner had CMI (OR: 1.49; 95% CI: 1.01, 2.19) or PTSD (OR: 1.84; 95% CI: 1.01, 3.37). Deployment was not a predictor of CMI. Spouses with CMI reported poorer SF-36 physical and mental component scores; worse symptoms of depression, anxiety, and post-traumatic stress; and a higher percentage had probable PTSD, more nonroutine clinic visits, more hospitalization, more prescription medications, and more psychotropic medication use compared with spouses without CMI regardless of the deployment status of their veteran spouses.

CONCLUSION

Spouses of veterans with CMI report worse physical and mental functioning than spouses of veterans without CMI, regardless of the veteran's deployment status. Strengths of the study include that all participants were selected independently of veteran medical or psychiatric illness, and all underwent comprehensive health assessments. Weaknesses of the study include that data were not collected blindly, and that we made minor modifications of the Centers for Disease Control and Prevention diagnosis, such as defining fatigue and musculoskeletal pain more restrictively. The impact of veteran CMI on their spouse's health is likely to be significant in terms of medical cost and morbidity. Efforts to reduce the impact of CMI in the future should include identifying soldiers who are more vulnerable, such as those with prior GWI or PTSD.

A Novel Patient Engagement Platform Using Accessible Text Messages and Calls (Epharmix): Feasibility Study

Background

Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. One method to improve therapeutic adherence is to improve feedback loops in getting clinically acute events and issues to the relevant clinical providers as necessary (ranging from detecting hypoglycemic events for patients with diabetes to notifying the provider when patients are out of medications). Patients often don’t know which information should prompt a call to their physician and proactive checks by the clinics themselves can be very resource intensive. We hypothesized that a two-way SMS system combined with a platform web service for providers would enable both high patient engagement but also the ability to detect relevant clinical alerts.

Objective

The objectives of this study are to develop a feasible two-way automated SMS/phone call + web service platform for patient-provider communication, and then study the feasibility and acceptability of the Epharmix platform. First, we report utilization rates over the course of the first 18 months of operation including total identified clinically significant events, and second, review results of patient user-satisfaction surveys for interventions for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties.

Methods

To test this question, we developed a web service + SMS/phone infrastructure (“Epharmix”). Utilization results were measured based on the total number of text messages or calls sent and received, with percentage engagement defined as a patient responding to a text message at least once in a given week, including the number of clinically significant alerts generated. User satisfaction surveys were sent once per month over the 18 months to measure satisfaction with the system, frequency and degree of communication. Descriptive statistics were used to describe the above information.

Results

In total, 28,386 text messages and 24,017 calls were sent to 929 patients over 9 months. Patients responded to 80% to 90% of messages allowing the system to detect 1164 clinically significant events. Patients reported increased satisfaction and communication with their provider. Epharmix increased the number of patient-provider interactions to over 10 on average in any given month for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties.

Conclusions

Engaging high-risk patients remains a difficult process that may be improved through novel, digital health interventions. The Epharmix platform enables increased patient engagement with very low risk to improve clinical outcomes. We demonstrated that engagement among high-risk populations is possible when health care comes conveniently to where they are.

Assessing the Utility of a Novel SMS- and Phone-Based System for Blood Pressure Control in Hypertensive Patients: Feasibility Study

BACKGROUND

Although hypertension (HTN) is a major modifiable risk factor for arterial damage, blood pressure (BP) remains poorly controlled in the hypertensive population. Telemedicine is a promising adjunct intervention that may complement traditional therapies and improve adherence rates; however, current approaches have multiple barriers to entry, including the use of relatively expensive Bluetooth devices or the dependence on smart phone utilization, which tend to exclude low-income and more elderly populations.

OBJECTIVE

The aim of this study was to design and implement a new phone call- and short message service text messaging-based intervention, Epharmix's EpxHypertension, in a quality improvement project that demonstrates the feasibility of this system for BP control in a family medicine setting.

METHODS

We recruited 174 patients from a community clinic in St Louis from a database of patients diagnosed with HTN. An automated call or text messaging system was used to monitor patient-reported BPs. If determined to be elevated, physicians were notified by an email, text, or electronic medical record alert. Mean systolic BPs (SBPs) and diastolic BPs (DBPs) were compared at the beginning and end of 12 weeks.

RESULTS

After 12 weeks on the system, patients with a baseline SBP of 140 mm Hg or higher reduced SBP by 10.8 mm Hg (95% CI -14.5 to -7.2, P<.001) and DBP by 6.6 mm Hg (95% CI -9.9 to -3.4, P=.002), but no significant changes were observed in overall BPs and BPs in the group with baseline SBP less than 140 mm Hg.

CONCLUSIONS

EpxHypertension provides a viable means to control HTN in patients with high baseline BPs despite previous therapy. This community implementation study demonstrates the feasibility of implementing EpxHypertension across a primary care setting without the need for smartphones or Bluetooth-linked BP cuffs. Future studies should evaluate its effectiveness in a randomized control trial compared with standard of care.

Improving Glycemic Control With a Standardized Text-Message and Phone-Based Intervention: A Community Implementation

Background

Type II diabetes mellitus (T2DM) presents a major disease burden in the United States. Outpatient glycemic control among patients with T2DM remains difficult. Telemedicine shows great potential as an adjunct therapy to aid in glycemic control in real-world settings.

Objective

We aimed to explore the effectiveness of EpxDiabetes, a novel digital health intervention, in improving hemoglobin A1c (HbA1c) and fasting blood glucose (FBG) among patients with uncontrolled diabetes.

Methods

We recruited 396 patients from a community clinic in St. Louis, Missouri, from a database of patients diagnosed with T2DM and with a most recent HbA1c >7% as part of a quality improvement project. An automated call or text-messaging system was used to monitor patient-reported FBG. If determined to be elevated, care managers were notified by email, text, or electronic medical record alert. Participants self-reported their FBG data by replying to EpxDiabetes automated phone calls or text messages. Data were subsequently analyzed, triaged, and shared with providers to enable appropriate follow-up and care plan adjustments. Absolute HbA1c reduction, patient engagement, and absolute patient-reported FBG reduction were examined at approximately 6 months post implementation.

Results

EpxDiabetes had an average 95.6% patient response rate to messages at least once per month and an average 71.1% response rate to messages at least once per week. Subsequent HbA1c drop with EpxDiabetes use over 4 months was -1.15% (95% CI -1.58 to -0.71) for patients with HbA1c >8% at baseline compared to the change in HbA1c over 4 months prior to the implementation of EpxDiabetes of only -0.005 points (95% CI -0.28 to 0.27), P=.0018.

Conclusions

EpxDiabetes may help reduce HbA1c in patients with high HbA1c baselines (>8%). The intervention demonstrates high patient engagement sustainable for at least 6 months.

Use of a 90-Minute Admission Window and Front-Fill System to Reduce Work Compression on a General Medicine Inpatient Teaching Service

BACKGROUND

Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience and patient care.

OBJECTIVE

To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program.

METHODS

In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (front-fill).

RESULTS

Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (P < .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (P < .001). Reports of adequate time with patients increased from 16 to 36 (P < .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (P < .001). Reports of leaving on time after call days rose from 12 to 33 (P < .01), and overall satisfaction increased from 26 to 35 (P = .002). Results were similar when residents were resurveyed 6 months after the intervention.

CONCLUSIONS

Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.

Measurement and comparison of individual external doses of high-school students living in Japan, France, Poland and Belarus-the 'D-shuttle' project

Twelve high schools in Japan (of which six are in Fukushima Prefecture), four in France, eight in Poland and two in Belarus cooperated in the measurement and comparison of individual external doses in 2014. In total 216 high-school students and teachers participated in the study. Each participant wore an electronic personal dosimeter 'D-shuttle' for two weeks, and kept a journal of his/her whereabouts and activities. The distributions of annual external doses estimated for each region overlap with each other, demonstrating that the personal external individual doses in locations where residence is currently allowed in Fukushima Prefecture and in Belarus are well within the range of estimated annual doses due to the terrestrial background radiation level of other regions/countries.

Effect of Health Literacy on Decision-Making Preferences among Medically Underserved Patients

INTRODUCTION

Participation in the decision-making process and health literacy may both affect health outcomes; data on how these factors are related among diverse groups are limited. This study examined the relationship between health literacy and decision-making preferences in a medically underserved population.

METHODS

We analyzed a sample of 576 primary care patients. Multivariable logistic regression was used to examine the independent association of health literacy (measured by the Rapid Estimate of Adult Literacy in Medicine-Revised) and patients' decision-making preferences (physician directed or patient involved), controlling for age, race/ethnicity, and gender. We tested whether having a regular doctor modified this association.

RESULTS

Adequate health literacy (odds ratio [OR] = 1.7;P= 0.009) was significantly associated with preferring patient-involved decision making, controlling for age, race/ethnicity, and gender. Having a regular doctor did not modify this relationship. Males were significantly less likely to prefer patient-involved decision making (OR = 0.65;P= 0.024).

DISCUSSION

Findings suggest health literacy affects decision-making preferences in medically underserved patients. More research is needed on how factors, such as patient knowledge or confidence, may influence decision-making preferences, particularly for those with limited health literacy.

Relationships Between Health Literacy and Genomics-Related Knowledge, Self-Efficacy, Perceived Importance, and Communication in a Medically Underserved Population

The increasing importance of genomic information in clinical care heightens the need to examine how individuals understand, value, and communicate about this information. Based on a conceptual framework of genomics-related health literacy, we examined whether health literacy was related to knowledge, self-efficacy, and perceived importance of genetics and family health history (FHH) and communication about FHH in a medically underserved population. The analytic sample was composed of 624 patients at a primary care clinic in a large urban hospital. About half of the participants (47%) had limited health literacy; 55% had no education beyond high school, and 58% were Black. In multivariable models, limited health literacy was associated with lower genetic knowledge (β = -0.55, SE = 0.10, p < .0001), lower awareness of FHH (odds ratio [OR] = 0.50, 95% confidence interval [CI; 0.28, 0.90], p = .020), and greater perceived importance of genetic information (OR = 1.95, 95% CI [1.27, 3.00], p = .0022) but lower perceived importance of FHH information (OR = 0.47, 95% CI [0.26, 0.86], p = .013) and more frequent communication with a doctor about FHH (OR = 2.02, 95% CI [1.27, 3.23], p = .0032). The findings highlight the importance of considering domains of genomics-related health literacy (e.g., knowledge, oral literacy) in developing educational strategies for genomic information. Health literacy research is essential to avoid increasing disparities in information and health outcomes as genomic information reaches more patients.

[Recurrent laryngeal papillomatosis complicated by decompensated respiratory failure in two children]

Laryngeal papillomatosis is a rare, potentially severe cause of recurrent laryngeal dyspnea. It should be known as a cause of laryngeal dyspnea resistant to the usual treatments. We report on two pediatric cases of severe laryngeal papillomatosis with respiratory distress and failure. These observations illustrate the importance of early adequate treatment.

Racial Composition Over the Life Course: Examining Separate and Unequal Environments and the Risk for Heart Disease for African American Men

PURPOSE

Studies have demonstrated the effects of segregated social and physical environments on the development of chronic diseases for African Americans. Studies have not delineated the effects of segregated environments specifically on the health of African American men over their lifetime. This study examines the relationship between life course measures of racial composition of social environments and diagnosis of hypertension among African American men.

DESIGN

We analyzed cross-sectional data from a convenience sample of African American men seeking health care services in an outpatient primary care clinic serving a medically underserved patient population (N=118). Multivariable logistic regression analyses were used to examine associations between racial composition of multiple environments across the life course (eg, junior high school, high school, neighborhood growing up, current neighborhood, place of employment, place of worship) and hypertension diagnosis.

RESULTS

The majority (86%) of participants were not currently in the workforce (retired, unemployed, or disabled) and more than half (54%) reported an annual household income of <$9,999; median age was 53. Results suggest that African American men who grew up in mostly Black neighborhoods (OR=4.3; P=.008), and worked in mostly Black environments (OR=3.1; P=.041) were more likely to be diagnosed with hypertension than those who did not.

CONCLUSION

We found associations between mostly Black residential and workplace settings and hypertension diagnoses among African American men. Findings suggest exposure to segregated environments during childhood and later adulthood may impact hypertension risk among African American men over the life course.

Determination of phthalates and their by-products in tissues of roach (Rutilus rutilus) from the Orge river (France)

Seven phthalate by-products were investigated for the first time, in target tissues of roach from a contaminated river of the Ile-de-France district. All parent phthalates were bioaccumulated in liver and muscle and liver contents were correlated with river concentrations (p < 0.01). All metabolites were found in liver, plasma and bile. The mono-iso-butyl phthalate (MiBP; 1.6 μg g(-1) dw of liver), followed by mono-n-butyl phthalate (MnBP; 1.5 μg g(-1) dw of liver) were the most abundant ones. Among the three metabolites of di-ethylhexyl phthalate (DEHP), mono (2-ethylhexyl) phthalate (MEHP) predominated in bile (15.5 ng ml(-1)) and liver (0.237 μg g(-1) dw), whereas in plasma, it was mono (2-ethyl-5-hydroxyhexyl) phthalate - MEHHP (214 ng ml(-1)). In liver, MEHP/DEHP ratios ranged from 0.04 to 0.2. Among the oxidized metabolites, only mono (2-ethyl-5-oxohexyl) phthalate (MEOHP) was correlated (p < 0.05) with parent DEHP and appeared to be a more reliable marker of DEHP impact than the monoester.

Atypical failure after cochlear implantation in children

We report a case of intermittent dysfunction in a 10-years-old boy, implanted with MedEL(®) cochlear implant. Few weeks after the surgery the boy described short and intermittent episodes of implant dysfunction with rapid return to a normal function. No evidence for any electric or neural dysfunction was found. After few weeks, a clinical link was discovered to episodes of sneeze or nose blowing. Clinical and surgical implications are discussed.

Resting-state connectivity deficits associated with impaired inhibitory control in non-treatment-seeking adolescents with psychotic symptoms

OBJECTIVE

Psychotic symptoms are common in the population and index risk for a range of severe psychopathological outcomes. We wished to investigate functional connectivity in a community sample of adolescents who reported psychotic symptoms (the extended psychosis phenotype).

METHOD

This study investigated intrinsic functional connectivity (iFC) during resting-state functional magnetic resonance imaging (fMRI; rs-fMRI). Following screening in schools, 11 non-treatment seeking, youth with psychotic symptoms (aged 11-13) and 14 community controls participated in the study. Seed regions of interest comprised brain regions previously shown to exhibit aberrant activation during inhibitory control in adolescents with psychotic symptoms.

RESULTS

Relative to controls, adolescents with psychotic symptoms exhibited reduced iFC between regions supporting inhibitory control. Specifically, they showed weaker iFC between the right inferior frontal gyrus (IFG) and the cingulate, IFG and the striatum, anterior cingulate and claustrum, and precuneus and supramarginal gyrus. Conversely, the psychotic symptoms group exhibited stronger iFC between the superior frontal gyrus and claustrum and IFG and lingual gyrus.

CONCLUSION

The present findings are the first to reveal aberrant functional connectivity in resting-state networks in a community sample of adolescents with psychotic symptoms and suggest that disruption in integration between distributed neural networks (particularly between prefrontal, cingulate and striatal brain regions) may be a key neurobiological feature of the extended psychosis phenotype.

Occupational engagement among community dwelling older people: A time-geographic perspective†

How older people spend their time in different occupations could contribute to our understanding of everyday life in healthy ageing. This study adopted a time-geographic method and occupational perspective to explore the occupational engagement of community dwelling older people. The term occupational engagement encompasses what people do, where and with whom they spend their time and the perceived level of competence and meaningfulness of their time use. Nineteen volunteers born between 1932 and 1933, living alone in an urban area in northern Sweden and receiving no home care services, completed open time-geographic diaries for 5 days in May 2010. The diary data were analyzed using Daily Life software program. The study revealed the complexity and the diversity of the older people's occupational engagement and that most of their time was spent alone in their home. The older people reported they were very good at doing almost half of the occupations in which they engaged and that their occupations were primarily either very meaningful or meaningful. While some methodological limitations were identified, time-geographic studies of community dwelling older people living independently are considered to have potential to contribute to community and social planning for older people as they can provide interesting insights to older persons' time use and occupational needs.

[Genetic aspects of congenital sensorineural hearing loss]

Hearing loss is the most common sensory disability with an incidence of one over 1000 newborns. Hearing loss may be caused by environmental and genetic factors; inherited causes are assumed in two thirds of cases. There is a great clinical and genetic heterogenicity. All inheritance modes have been described. Mutations in the GJB2 gene, which encodes connexin 26, are mainly responsible for sensorineural deafness resulting in prelingual non syndromic autosomal recessive phenotypes DFNB1. The 35 delG mutation of this gene is very frequent (70% of the cases). Thus, 35 delG is, with the delta F508 mutation of the CFTR gene, the most frequent human pathogenic mutation known. Hearing loss might also be associated with other clinical features. Some of these syndromes, including hearing loss, have to be looked for systematically because of their frequency, of their possible clinical presentation as an isolated hearing loss and of the possibility of a medical treatment.