POS0667 CHARACTERIZING NON-RESPONSE TO METHOTREXATE MONOTHERAPY AMONG RHEUMATOID ARTHRITIS PATIENTS IN A LARGE REAL-WORLD LONGITUDINAL COHORT

Background

Methotrexate (MTX) monotherapy is the first choice among disease-modifying drugs (DMARDs) for most moderate-to-severe rheumatoid arthritis (RA) patients, consistent with treatment guidelines.1 However, response to, and tolerability of, MTX varies among patients.2 Understanding the proportion of patients with MTX non-response in a real-world setting and identifying its predictors could enable earlier access to alternative or additional medications and improve management of disease progression.

Objectives

The objectives of this study were, using data from a large, geographically representative US cohort of RA patients, to describe the pattern of non-response among patients initiating MTX monotherapy and to identify predictors of non-response to MTX.

Methods

The OM1 RA Registry (OM1, Inc; Boston, MA) follows more than 210,000 RA patients in the US managed by rheumatologists longitudinally with deep clinical data, including laboratory, patient-reported and disease activity information, and linked administrative claims starting from 2013. In this retrospective observational study, patients aged ≥ 18 years initiating MTX between 01 January 2014 and 01 August 2020 without previous bDMARD/tsDMARD utilization were identified. The first MTX date was the index date, with ≥1 Clinical Disease Activity Index (CDAI) measurement and ≥2 all-cause healthcare encounters required in the preceding 12 months (baseline). Patients initiating a bDMARD/tsDMARD within 30 days of the index date or with a history of other conditions where the same bDMARD/tsDMARDs are indicated were excluded. MTX non-response was defined as failing to attain remission or low disease activity (i.e., CDAI >10) within 4 to 8 months and/or the initiation of a bDMARD/tsDMARD within 8 months following the index date (with or without continuing MTX; non-response could include patients discontinuing MTX due to tolerability). Baseline characteristics were summarized with descriptive statistics. Multivariate logistic regression with age, gender, region, race, payor, year of index, the most recent CDAI and body mass index (BMI) measurements from the baseline, and Charlson comorbidity index (CCI) was used to investigate risk factors of non-response. P value was considered significant if <0.01.

Results

Among 6,648 eligible RA patients, 3,748 (56.4%) were classified as non-responders. Baseline charactesistics are summarized in Table 1. Being female (OR=1.3), increasing baseline CDAI (OR: Low activity=1.9, moderate activity=8.1, high activity=13.0) and higher BMI (OR=1.01) were significantly associated with non-response. Being older was found protective of non-response (OR=0.98). The C-statistic was 0.74.

Table 1.

Baseline Characteristics Overall and by Response Status

StatisticOverallRespondersNon-respondersAge61.6 (13.3)63.9 (13.0)59.8 (13.3)Female5,059 (76.1%)2,096 (72.3%)2,963 (79.1%)Region MIDWEST905 (13.6%)366 (12.6%)539 (14.4%) NORTHEAST1,115 (16.7%)520 (17.9%)595 (15.9%) SOUTH4,063 (61.1%)1,759 (60.7%)2,304 (61.5%) WEST565 (8.5%)255 (8.8%)310 (8.3%)Race BLACK597 (9.0%)243 (8.4%)354 (9.5%) WHITE4,305 (64.8%)1,935 (66.7%)2,370 (63.2%) OTHER166 (2.5%)73 (2.5%)93 (2.5%) UNKNOWN1,580 (23.8%)649 (22.4%)931 (24.8%)Payor COMMERCIAL3,768 (56.7%)1,516 (52.3%)2,252 (60.1%) MEDICARE2,590 (39.0%)1,273 (43.9%)1,317 (35.1%) MEDICAID290 (4.4%)111 (3.8%)179 (4.8%)CDAI15.6 (10.4)11.3 (9.5)18.9 (9.8)CCI1.4 (1.1)1.4 (1.1)1.4 (1.1)BMI30.4 (7.1)29.7 (6.8)30.9 (7.3)

Conclusion

We found that over half of patients qualified as MTX non-responders at approximately 6 months. Significant predictors of non-response were younger age, female gender, higher CDAI score and BMI. Maximizing improvement as quickly as possible and deploying more tailored escalation of care may be aided by identifying RA patients at higher risk of early MTX treatment failure.

References

[1]Smolen JS, et al. Annals of the Rheumatic Diseases 2020;79:685-699.

[2]Verstappen SM, et al. Int J Clin Rheumtol. 2012;7(5):559–567.

Disclosure of Interests

Zeynep Icten: None declared, Kathryn Starzyk: None declared, Mark Friedman: None declared, Joseph Menzin Grant/research support from: Grant support

Constraining the ^{30}P(p, γ)^{31}S Reaction Rate in ONe Novae via the Weak, Low-Energy, β-Delayed Proton Decay of ^{31}Cl

The ^{30}P(p,γ)^{31}S reaction plays an important role in understanding the nucleosynthesis of A≥30 nuclides in oxygen-neon novae. The Gaseous Detector with Germanium Tagging was used to measure ^{31}Cl β-delayed proton decay through the key J^{π}=3/2^{+}, 260-keV resonance. The intensity I_{βp}^{260}=8.3_{-0.9}^{+1.2}×10^{-6} represents the weakest β-delayed, charged-particle emission ever measured below 400 keV, resulting in a proton branching ratio of Γ_{p}/Γ=2.5_{-0.3}^{+0.4}×10^{-4}. By combining this measurement with shell-model calculations for Γ_{γ} and past work on other resonances, the total ^{30}P(p,γ)^{31}S rate has been determined with reduced uncertainty. The new rate has been used in hydrodynamic simulations to model the composition of nova ejecta, leading to a concrete prediction of ^{30}Si:^{28}Si excesses in presolar nova grains and the calibration of nuclear thermometers.

Measuring the 15O(α,γ)19Ne Reaction in Type I X-ray Bursts using the GADGET II TPC: Software

15O(α,γ)19Ne is regarded as one of the most important thermonuclear reactions in type I X-ray bursts. For studying the properties of the key resonance in this reaction using β decay, the existing Proton Detector component of the Gaseous Detector with Germanium Tagging (GADGET) assembly is being upgraded to operate as a time projection chamber (TPC) at FRIB. This upgrade includes the associated hardware as well as software and this paper mainly focusses on the software upgrade. The full detector set up is simulated using the ATTPCROOTv 2 data analysis framework for 20Mg and 241Am.

Measuring the 15O(α, γ)19Ne reaction in Type I X-ray bursts using the GADGET II TPC: Hardware

Sensitivity studies have shown that the 15O(α, γ)19Ne reaction is the most important reaction rate uncertainty affecting the shape of light curves from Type I X-ray bursts. This reaction is dominated by the 4.03 MeV resonance in 19Ne. Previous measurements by our group have shown that this state is populated in the decay sequence of 20Mg. A single 20Mg(βp α)15O event through the key 15O(α, γ)19Ne resonance yields a characteristic signature: the emission of a proton and alpha particle. To achieve the granularity necessary for the identification of this signature, we have upgraded the Proton Detector of the Gaseous Detector with Germanium Tagging (GADGET) into a time projection chamber to form the GADGET II detection system. GADGET II has been fully constructed, and is entering the testing phase.

Technological readiness and implementation of genomic-driven precision medicine for complex diseases

The fields of human genetics and genomics have generated considerable knowledge about the mechanistic basis of many diseases. Genomic approaches to diagnosis, prognostication, prevention and treatment - genomic-driven precision medicine (GDPM) - may help optimize medical practice. Here, we provide a comprehensive review of GDPM of complex diseases across major medical specialties. We focus on technological readiness: how rapidly a test can be implemented into health care. Although these areas of medicine are diverse, key similarities exist across almost all areas. Many medical areas have, within their standards of care, at least one GDPM test for a genetic variant of strong effect that aids the identification/diagnosis of a more homogeneous subset within a larger disease group or identifies a subset with different therapeutic requirements. However, for almost all complex diseases, the majority of patients do not carry established single-gene mutations with large effects. Thus, research is underway that seeks to determine the polygenic basis of many complex diseases. Nevertheless, most complex diseases are caused by the interplay of genetic, behavioural and environmental risk factors, which will likely necessitate models for prediction and diagnosis that incorporate genetic and non-genetic data.

Probabilistic divergence time estimation without branch lengths: dating the origins of dinosaurs, avian flight and crown birds

Branch lengths—measured in character changes—are an essential requirement of clock-based divergence estimation, regardless of whether the fossil calibrations used represent nodes or tips. However, a separate set of divergence time approaches are typically used to date palaeontological trees, which may lack such branch lengths. Among these methods, sophisticated probabilistic approaches have recently emerged, in contrast with simpler algorithms relying on minimum node ages. Here, using a novel phylogenetic hypothesis for Mesozoic dinosaurs, we apply two such approaches to estimate divergence times for: (i) Dinosauria, (ii) Avialae (the earliest birds) and (iii) Neornithes (crown birds). We find: (i) the plausibility of a Permian origin for dinosaurs to be dependent on whether Nyasasaurus is the oldest dinosaur, (ii) a Middle to Late Jurassic origin of avian flight regardless of whether Archaeopteryx or Aurornis is considered the first bird and (iii) a Late Cretaceous origin for Neornithes that is broadly congruent with other node- and tip-dating estimates. Demonstrating the feasibility of probabilistic time-scaling further opens up divergence estimation to the rich histories of extinct biodiversity in the fossil record, even in the absence of detailed character data.

Safety and feasibility of esophageal self- expandable metal stent placement without the aid of fluoroscopy

Self-expandable metal stents (SEMSs) are used for the management of certain esophageal conditions such as strictures, perforations, and fistulae. These can be placed using fluoroscopic control, endoscopic control, or a combination of both. We evaluated our institutional experience of placing a SEMS using only endoscopy without the aid of fluoroscopy to determine safety and feasibility using this technique. A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015. Placement of SEMS was accomplished under direct endoscopic visualization without the aid of fluoroscopy. Esophageal lesion was initially identified during endoscopy and a fully covered SEMS was passed over the guide wire and deployed under direct vision. Misplacement of the SEMS during the procedure that required replacement with another new SEMS was considered as a failed procedure. Other periprocedural complications caused by placement of SEMS were noted. A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years. The most common indication for SEMS placement was stricture in 248 (88%) procedures. Periprocedure SEMS misplacement occurred in 12 (4%) patients. However, only 8 (3%) patients needed to have a new SEMS placed during the same procedure. A total of 64 (23%) patients had migration of SEMS. There were no other periprocedure complications leading to adverse events. Self-expandable metal stent can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy.

Cost-Effectiveness of Migraine Prevention: The Case of Topiramate in the UK

The aim of this study was to assess the cost-effectiveness of topiramate vs. no preventive treatment in the UK. Model inputs included baseline migraine frequency, treatment discontinuation and response, preventive and acute medical cost per attack [2005 GBP (£)] and gain in health utility. Outcomes included monthly migraines averted, acute and preventive treatment costs and cost per quality-adjusted life year (QALY). Topiramate was associated with 1.8 fewer monthly migraines and a QALY gain of 0.0384. The incremental cost of topiramate vs. no preventive treatment was about £10 per migraine averted and £5700 per QALY. Results are sensitive to baseline monthly migraine frequency, triptan use rate and the gain in utility. Incorporating savings from reduced work loss (about £36 per month) suggests that topiramate would be cost saving compared with no preventive treatment. This analysis suggests that topiramate is a cost-effective treatment for migraine prevention compared with no preventive treatment.

Abstract P4-13-20: Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution

Background: Dual anti-HER2 blockade with trastuzumab and pertuzumab (HP) plus chemotherapy is an effective therapy (Rx) in the 1st-line setting for HER2-positive metastatic breast cancer (MBC). Our single arm phase II study included patients (pts) treated with HP plus paclitaxel in the 2nd-line setting with progression-free survival (PFS) benefit. Recently, we reported results from a retrospective study of pts treated at our institution, suggesting a longer PFS for those who received HP-based Rxs when compared to any other anti-HER2 based Rxs in the 2nd-line setting. To further assess the activity of this combination in later Rx lines, we conducted a retrospective analysis of pts with HER2-positive MBC who had progressive disease after 2nd-line and were treated with HP-based Rxs in the 3rd and later lines at MSKCC. Historically, the median (med) PFS in this setting with trastuzumab-based Rx is about 3-4 months.

Methods: Pts diagnosed with HER2-positive MBC and treated with HP-based Rxs at MSKCC between 1-1-2011 and 03-30-2015 and who progressed on 2nd-line Rx were identified through an institutional database. Primary endpoint was PFS in 3rd and later treatment lines.

Results: 70 pts who received any HP-based Rx in the 3rd or later lines of treatment were eligible. The med number of prior anti-HER2 Rx was 3. The baseline characteristics and Rxs are summarized in Table 1. The med PFS for the entire cohort was 5.7 months (95% CI, 4.8-6.5).

Conclusions: In this retrospective analysis involving heavly pretreated patients, HP-based Rx appears to be an active regimen and compares favorably to historical data. This supports the NCCN endorsement of HP-based Rx in later lines if HP has not been delivered previously.

Baseline Characteristics and treatments (n=70)Characteristic(n)(%)Age  Median56 Range27-83 Gender  Female70100.0Male00.0Race  Black1014.3White5477.1Other68.6Ethnicity  Non Hispanic6694.3Hispanic45.7ER/PR status  ER and PR negative2738.6ER and/or PR positive4361.4Type of disease  Non visceral1622.9Visceral5477.1Visceral CNS2130.0Anti-HER2 in early stage  Yes2941.4No4158.6Line of therapy  3rd line1927.14th line1521.45th line912.96th line912.97th line811.48th line and beyond1014.3HP-based regimens  Chemotherapy + HP5477.1Endocrine therapy + HP57.1HP alone912.9Other22.9

Citation Format: Argolo D, Friedman M, Smyth L, Iyengar N, Singh J, Patil S, Norton L, Baselga J, Hudis C, Dang C. Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-20.

Diagnostic performance of the PTSD checklist and the Vietnam Era Twin Registry PTSD scale

AIMS

Self-report questionnaires are frequently used in clinical and epidemiologic studies to assess post-traumatic stress disorder (PTSD). A number of studies have evaluated these scales relative to clinician administered structured interviews; however, there has been no formal evaluation of their performance relative to non-clinician administered epidemiologic assessments such as the Composite International Diagnostic Interview (CIDI). We examined the diagnostic performance of two self-report PTSD scales, the PTSD checklist (PCL) and the Vietnam Era Twin Registry (VET-R) PTSD scale, compared to the CIDI.

METHODS

Data were derived from a large epidemiologic follow-up study of PTSD in 5141 Vietnam Era Veterans. Measures included the PCL, VET-R PTSD scale and CIDI. For both the PCL and VET-R PTSD scale, ROC curves, areas under the curve (AUC), sensitivity, specificity, % correctly classified, likelihood ratios, predictive values and quality estimates were generated based on the CIDI PTSD diagnosis.

RESULTS

For the PCL and VET-R PTSD scale the AUCs were 89.0 and 87.7%, respectively. Optimal PCL cutpoints varied from the 31-33 range (when considering sensitivity and specificity) to the 36-56 range (when considering quality estimates). Similar variations were found for the VET-R PTSD, ranging from 31 (when considering sensitivity and specificity) to the 37-42 range (when considering quality estimates).

CONCLUSIONS

The PCL and VET-R PTSD scale performed similarly using a CIDI PTSD diagnosis as the criterion. There was a range of acceptable cutpoints, depending on the metric used, but most metrics suggested a lower PCL cutpoint than in previous studies in Veteran populations.

Synchrotron radiation Mössbauer spectra of a rotating absorber with implications for testing velocity and acceleration time dilation

Many Mössbauer spectroscopy (MS) experiments have used a rotating absorber in order to measure the second-order transverse Doppler (TD) shift, and to test the validity of the Einstein time dilation theory. From these experiments, one may also test the clock hypothesis (CH) and the time dilation caused by acceleration. In such experiments the absorption curves must be obtained, since it cannot be assumed that there is no broadening of the curve during the rotation. For technical reasons, it is very complicated to keep the balance of a fast rotating disk if there are moving parts on it. Thus, the Mössbauer source on a transducer should be outside the disk. Friedman and Nowik have already predicted that the X-ray beam finite size dramatically affects the MS absorption line and causes its broadening. We provide here explicit formulas to evaluate this broadening for a synchrotron Mössbauer source (SMS) beam. The broadening is linearly proportional to the rotation frequency and to the SMS beam width at the rotation axis. In addition, it is shown that the TD shift and the MS line broadening are affected by an additional factor assigned as the alignment shift which is proportional to the frequency of rotation and to the distance between the X-ray beam center and the rotation axis. This new shift helps to align the disk's axis of rotation to the X-ray beam's center. To minimize the broadening, one must focus the X-ray on the axis of the rotating disk and/or to add a slit positioned at the center, to block the rays distant from the rotation axis of the disk. Our experiment, using the (57)Fe SMS, currently available at the Nuclear Resonance beamline (ID18) at the ESRF, with a rotating stainless steel foil, confirmed our predictions. With a slit installed at the rotation axis (reducing the effective beam width from 15.6 µm to 5.4 µm), one can measure a statistically meaningful absorption spectrum up to 300 Hz, while, without a slit, such spectra could be obtained up to 100 Hz only. Thus, both the broadening and the alignment shift are very significant and must be taken into consideration in any rotating absorber experiment. Here a method is offered to measure accurately the TD shift and to test the CH.

Singular Value Decomposition of Optically-Mapped Cardiac Rotors and Fibrillatory Activity

Our progress of understanding how cellular and structural factors contribute to the arrhythmia is hampered in part because of controversies whether a fibrillating heart is driven by a single, several, or multiple number of sources, and whether they are focal or reentrant, and how to localize them. Here we demonstrate how a novel usage of the neutral singular value decomposition (SVD) method enables the extraction of the governing spatial and temporal modes of excitation from a rotor and fibrillatory waves. Those modes highlight patterns and regions of organization in the midst of the otherwise seemingly-randomly propagating excitation waves. We apply the method to experimental models of cardiac fibrillation in rabbit hearts. We show that the SVD analysis is able to enhance the classification of the heart electrical patterns into regions harboring drivers in the form of fast reentrant activity and other regions of by-standing activity. This enhancement is accomplished without any prior assumptions regarding the spatial, temporal or spectral properties of those drivers. The analysis corroborates that the dominant mode has the highest activation rate and further reveals a new feature: A transfer of modes from the driving to the passive regions resulting in a partial reaction of the passive region to the driving region.

Two waves of colonization straddling the K-Pg boundary formed the modern reef fish fauna

Living reef fishes are one of the most diverse vertebrate assemblages on Earth. Despite its prominence and ecological importance, the origins and assembly of the reef fish fauna is poorly described. A patchy fossil record suggests that the major colonization of reef habitats must have occurred in the Late Cretaceous and early Palaeogene, with the earliest known modern fossil coral reef fish assemblage dated to 50 Ma. Using a phylogenetic approach, we analysed the early evolutionary dynamics of modern reef fishes. We find that reef lineages successively colonized reef habitats throughout the Late Cretaceous and early Palaeogene. Two waves of invasion were accompanied by increasing morphological convergence: one in the Late Cretaceous from 90 to 72 Ma and the other immediately following the end-Cretaceous mass extinction. The surge in reef invasions after the Cretaceous–Palaeogene boundary continued for 10 Myr, after which the pace of transitions to reef habitats slowed. Combined, these patterns match a classic niche-filling scenario: early transitions to reefs were made rapidly by morphologically distinct lineages and were followed by a decrease in the rate of invasions and eventual saturation of morphospace. Major alterations in reef composition, distribution and abundance, along with shifts in climate and oceanic currents, occurred during the Late Cretaceous and early Palaeogene interval. A causal mechanism between these changes and concurrent episodes of reef invasion remains obscure, but what is clear is that the broad framework of the modern reef fish fauna was in place within 10 Myr of the end-Cretaceous extinction.

Levels of sirolimus in saliva and blood following mouthwash application

OBJECTIVES

Sirolimus (rapamycin) is a mammalian target of rapamycin (mTOR) inhibitor with antiproliferative activity. Its systemic administration is currently evaluated for the management of squamous cell carcinoma and various oral disorders. Topical oral application can enhance availability, efficacy and improve safety and compliance. Our objective was to evaluate the release profile and the safety of a sirolimus mouthwash.

SUBJECTS AND METHODS

A sirolimus mouthwash (0.05 mg ml(-1) ) was applied to ten healthy male volunteers. Saliva and blood samples were taken after rinsing. Mass spectrometry and chemiluminescent microparticle immunoassay were used to determine saliva and blood levels of sirolimus. A topical oral release profile measurement and safety evaluation were performed.

RESULTS

After rinsing with the mouthwash, a classic immediate release profile was noted in the oral cavity. Extremely high initial sirolimus levels rapidly declined over a 4-hour period. Systemic exposure was limited, with a maximum level significantly lower than therapeutic doses, and safety was confirmed.

CONCLUSIONS

A single rinse with sirolimus mouthwash leads to high transient levels of the drug in the saliva. Although levels were variable, a therapeutic concentration was achieved topically along with minimal systemic absorption. These results broaden the potential clinical use of oral topical rapalogs.

Risk for transmission of Naegleria fowleri from solid organ transplantation

Primary amebic meningoencephalitis (PAM) caused by the free-living ameba (FLA) Naegleria fowleri is a rare but rapidly fatal disease of the central nervous system (CNS) affecting predominantly young, previously healthy persons. No effective chemotherapeutic prophylaxis or treatment has been identified. Recently, three transplant-associated clusters of encephalitis caused by another FLA, Balamuthia mandrillaris, have occurred, prompting questions regarding the suitability of extra-CNS solid organ transplantation from donors with PAM. During 1995-2012, 21 transplant recipients of solid organs donated by five patients with fatal cases of PAM were reported in the United States. None of the recipients developed PAM, and several recipients tested negative for N. fowleri by serology. However, historical PAM case reports and animal experiments with N. fowleri, combined with new postmortem findings from four patients with PAM, suggest that extra-CNS dissemination of N. fowleri can occur and might pose a risk for disease transmission via transplantation. The risks of transplantation with an organ possibly harboring N. fowleri should be carefully weighed for each individual recipient against the potentially greater risk of delaying transplantation while waiting for another suitable organ. In this article, we present a case series and review existing data to inform such risk assessments.

High-power liquid-lithium jet target for neutron production

A compact liquid-lithium target (LiLiT) was built and tested with a high-power electron gun at the Soreq Nuclear Research Center. The lithium target, to be bombarded by the high-intensity proton beam of the Soreq Applied Research Accelerator Facility (SARAF), will constitute an intense source of neutrons produced by the (7)Li(p,n)(7)Be reaction for nuclear astrophysics research and as a pilot setup for accelerator-based Boron Neutron Capture Therapy. The liquid-lithium jet target acts both as neutron-producing target and beam dump by removing the beam thermal power (>5 kW, >1 MW/cm(3)) with fast transport. The target was designed based on a thermal model, accompanied by a detailed calculation of the (7)Li(p,n) neutron yield, energy distribution, and angular distribution. Liquid lithium is circulated through the target loop at ~200 °C and generates a stable 1.5 mm-thick film flowing at a velocity up to 7 m/s onto a concave supporting wall. Electron beam irradiation demonstrated that the liquid-lithium target can dissipate electron power areal densities of >4 kW/cm(2) and volume power density of ~2 MW/cm(3) at a lithium flow of ~4 m/s while maintaining stable temperature and vacuum conditions. The LiLiT setup is presently in online commissioning stage for high-intensity proton beam irradiation (1.91-2.5 MeV, 1-2 mA) at SARAF.

Time-periodic lattice of spiral pairs in excitable media

The feasibility of a spiral-type solution, periodic both in time and in space, of a reaction-diffusion equation (specifically the FitzHugh-Nagumo system) in an excitable medium is numerically demonstrated. The solution consists of arrays of interacting spiral pairs, which repeatedly create by partial annihilation a system of residual portions (RPs). The latter behaves as a source to the next generation of the spiral-pair array. If basic (highest) translational symmetry is not conserved, pointwise perturbations, above a certain threshold, are shown to be able to destroy the pattern after a certain transient time by changing its symmetry. If the basic translational symmetry is preserved, such perturbations do not cause destruction unless occurring at the nearest vicinity of the RP site. Singular value decomposition methods are used to analyze the structure of the pattern, revealing the importance of the spiral pairs and the RPs.

Failure to correct International Normalized Ratio and mortality among patients with warfarin-related major bleeding: an analysis of electronic health records

BACKGROUND

Delayed correction of blood clotting times as measured by the International Normalized Ratio (INR) is associated with adverse outcomes among certain patients with warfarin-related major bleeding. However, there are limited data on the association between INR correction and mortality.

OBJECTIVE

To assess factors associated with 30-day mortality and time to death in patients receiving fresh frozen plasma (FFP) for warfarin-associated major bleeding.

METHODS

A retrospective database analysis was undertaken with electronic health record data from a large integrated health system. Patients met the following criteria: major hemorrhage diagnosis; INR ≥ 2 on the day before or day of receipt of FFP; and prescription fill for warfarin within 90 days. INR correction (defined as INR ≤ 1.3) was evaluated at the last available test 1 day following the start of FFP administration. Kaplan-Meier curves and Cox proportional hazards models were constructed to assess mortality.

RESULTS

Four hundred and five patients met the selection criteria (mean age of 75 years, 54% male), and 67% remained uncorrected at 1 day following the start of FFP administration. Among all patients, 11% died within 30 days of hospital admission. An uncorrected INR was not associated with a higher risk of 30-day mortality for patients overall, but was statistically significant for the subgroup with intracranial hemorrhage (ICH) (adjusted odds ratio 2.55; 95% confidence interval 1.04-6.28).

CONCLUSIONS

Among the subgroup of major bleeding patients with warfarin-associated ICH, those not correcting to either INR ≤ 1.3 or INR ≤ 1.5 with the use of FFP have an increased rate of mortality at 30 days.

Antimicrobial activity of lemongrass oil against Salmonella enterica on organic leafy greens

AIMS

We investigated the antimicrobial effectiveness of lemongrass essential oil on organic leafy greens, romaine and iceberg lettuces and mature and baby spinach, inoculated with Salmonella Newport. The influences of exposure times and abuse temperatures on bacterial survival were also investigated.

METHODS AND RESULTS

Leaf samples were washed, inoculated with Salm. Newport (6-log CFUml(-1) ) and dried. Inoculated leaves were immersed in solutions containing 0·1, 0·3 or 0·5% lemongrass oil in phosphate-buffered saline for 1 or 2min and then individually incubated at 4 or 8°C. Samples were taken at day 0, 1 and 3 for the enumeration of survivors. Compared to the PBS control, romaine and iceberg lettuces, and mature and baby spinach samples showed between 0·6-1·5-log, 0·5-4·3-log, 0·5-2·5-log and 0·5-2·2-logCFUg(-1) reductions in Salm. Newport by day 3, respectively.

CONCLUSIONS

The antimicrobial activity of lemongrass oil against Salm. Newport was concentration and time dependent. The antimicrobial activity increased with exposure time; iceberg samples treated for 2min generally showed greater reductions (P<0·05) than those treated for 1min (c.1-log reduction difference for 0·3 and 0·5% treatments). Few samples showed a difference between refrigeration and abuse temperatures.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates the potential of lemongrass oil solutions to inactivate Salm. Newport on organic leafy greens.

Factors associated with failure to correct the international normalised ratio following fresh frozen plasma administration among patients treated for warfarin-related major bleeding. An analysis of electronic health records

This study assessed the frequency and factors associated with failure to correct international normalised ratio (INR) in patients administered fresh frozen plasma (FFP) for warfarin-related major bleeding. This retrospective database analysis used electronic health records from an integrated health system. Patients who received FFP between 01/01/2004 and 01/31/2010, and who met the following criteria were selected: major haemorrhage diagnosis the day before to the day after initial FFP administration; INR ≥2 on the day before or the day of FFP and another INR result available; warfarin prescription within 90 days. INR correction (defined as INR ≤1.3) was evaluated at the last available test up to one day following FFP. A total of 414 patients met selection criteria (mean age 75 years, 53% male, mean Charlson score 2.5). Patients presented with gastrointestinal bleeding (58%), intracranial haemorrhage (38%) and other bleed types (4%). The INR of 67% of patients remained uncorrected at the last available test up to one day following receipt of FFP. In logistic regression analysis, the INR of patients who were older, those with a Charlson score of 4 or greater, and those with non-ICH bleeds (odds ratio vs. intracranial bleeding 0.48; 95% confidence interval 0.31-0.76) were more likely to remain uncorrected within one day following FFP administration. In an alternative definition of correction, (INR ≤1.5), 39% of patients' INRs remained uncorrected. For a substantial proportion of patients, the INRs remain inadequately or uncorrected following FFP administration, with estimates varying depending on the INR threshold used.

[Are you afraid of open bite?]

Treatment of open bite malocclusion is a challenge for both the orthodontist and the patient. The key to successful treatment are careful evaluation, that leads to correct diagnosis and treatment plan, as well as meticulous cooperation on behalf of the patient. There are many treatment options starting with follow up and orofacial myofunctional therapy, and concluding with orthosurgical correction. The tendency to relapse and reopening the bite must be emphasized to the patient before initiation of the orthodontic treatment. It is highly recommended in indicated cases to include orofacial myofunctional therapy in combination with the orthodontic treatment. New modalities of treatment give great promise for the future, and enable us to intrude posterior teeth using skeletal anchorage. However, it is still unknown whether these new treatment modalities will give better stability for open bite correction.

Synchronized cluster formation in coupled laser networks

We experimentally investigate the phase dynamics of laser networks with homogenous time-delayed mutual coupling and establish the fundamental rules that govern their state of synchronization. We identified a specific substructure that imposes its synchronization state on the entire network and show that for any coupling configuration the network forms at most two synchronized clusters. Our results indicate that the synchronization state of the network is a nonlocal phenomenon and cannot be deduced by decomposing the network into smaller substructures, each with its individual synchronization state.

A novel subcutaneous controlled-release amoxicillin degradable implant for extended-interval administration in veterinary medicine

Dosage forms of antimicrobials play a critical role in facilitating the attainment of pharmacokinetic-pharmacodynamic (PK-PD) targets as well as adherence in both veterinary and human medicine. The purpose of this study was to develop and evaluate a controlled-release subcutaneous amoxicillin implant for single-dose therapy of large ruminants such as goats, sheep, and deer. The degradable implant, designed to attain PK-PD targets following single administration, was evaluated for amoxicillin release rate and time-concentration profile. In vitro release studies demonstrated constant-rate release of approximately 40% of amoxicillin content within 96 h. In an in vivo study in goats, serving as a model for target animals, a serum concentration of approximately 0.4 mg/L was achieved within 8 h of implant insertion and maintained for >6 days. In comparison, in control goats given a standard single intramuscular amoxicillin dose of 15 mg/kg, amoxicillin peaked at 1.2 mg/L after 1 h, rapidly dropping to below detection level at 8 h. These results suggest that the proposed implant offers a unique modality for animal caregivers to conveniently administer a full antimicrobial course following a single dose of an efficient PK-PD-optimized dosage form. Furthermore, modifications of implant composition may allow for tailoring of its characteristics to various PK, PD, microbiological, and clinical requirements.

Profiling protein expression and interactions: proximity ligation as a tool for personalized medicine

The ability to detect very low levels of expressed proteins has enormous potential for early diagnostics and intervention at curable stages of disease. An extended range of targets such as interacting or post-translationally modified proteins can further improve the potential for diagnostics and patient stratification, and for monitoring response to treatment. These are critical building blocks for personalized treatment strategies to manage disease. The past few decades have seen a remarkably improved understanding of the molecular basis of disease in general, and of tumour formation and progression in particular. This accumulated knowledge creates opportunities to develop drugs that specifically target molecules or molecular complexes critical for survival and expansion of tumour cells. However, tumours are highly variable between patients, necessitating the development of diagnostic tools to individualize treatment through parallel analysis of sets of biomarkers. The proximity ligation assay (PLA) can address many of the requirements for advanced molecular analysis. The method builds on the principle that recognition of target proteins by two, three or more antibodies can bring in proximity DNA strands attached to the antibodies. The DNA strands can then participate in ligation reactions, giving rise to molecules that are amplified for highly sensitive detection. PLA is particularly well suited for sensitive, specific and multiplexed analysis of protein expression, post-translational modifications and protein-protein interactions. The analysis of this extended range of biomarkers will prove critical for the development and implementation of personalized medicine.

RENAL INSUFFICIENCY FOLLOWING TRYPSIN INJECTION INTO THE RENAL ARTERIES

1. The injection of trypsin into both renal arteries of the dog was found to cause an acute necrosis of large sections of the kidney, an immediate excretory insufficiency, and a transient hypertension. 2. Dogs surviving the acute phase of the trypsin injection, developed a chronic renal excretory insufficiency with no hypertension, despite the severity and duration of the renal excretory insufficiency. 3. The application of a Goldblatt clamp to the renal artery of one of the two kidneys, previously injected with trypsin, led to a rise in blood pressure which returned at once to normal when the ischemic kidney was removed, even though the pre-existing renal excretory insufficiency was augmented. This experience demonstrated unequivocally that chronic renal excretory insufficiency and hypertension are not directly related. 4. The application of a Goldblatt clamp to the renal artery of one kidney and the simultaneous injection of trypsin into the other led to a hypertension. The later removal of the ischemic kidney led to a severe renal excretory insufficiency, at the same time the pre-existing hypertension disappeared. This indicated again that renal excretory insufficiency and renal ischemia produced different phenomena and that the former had no direct relation to hypertension.