The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

AB0537 PSORIATIC ARTHRITIS BURDEN, QUALITY OF LIFE AND FUNCTIONAL ABILITY IMPAIRMENTS IN PATIENTS INITIATED ON APREMILAST IN THE ROUTINE CARE IN GREECE: INTERIM RESULTS FROM THE MULTICENTER PROSPECTIVE STUDY “APROACH”

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with substantial psychosocial burden and health-related quality of life (HRQoL) and functional ability impairments.

Objectives:

To characterize the profile of patients with PsA initiating therapy with apremilast in routine care settings, in terms of the physician-assessed clinical disease burden and the patient-reported generic and disease-related HRQoL and functional disability.

Methods:

This is an ongoing 52-week multicenter, prospective study conducted in the Greek healthcare environment. Eligible patients are bio-naïve adults with active peripheral PsA, inadequate (within the first 12 months of treatment) response/intolerance to a prior conventional synthetic disease-modifying antirheumatic drug (csDMARD), and no prior use of tofacitinib, initiating apremilast as per the approved label. Data are being collected by physician assessments, as performed in routine clinical practice, and by patient-reported outcomes. 170 patients enrolled in the study; data at apremilast initiation (baseline) from the first 100 eligible consenting patients are presented in this interim analysis as per protocol.

Results:

99 evaluable patients were consecutively enrolled in 19 rheumatology departments between 15-Apr-2019 and 13-Jan-2020. At baseline (Table 1) [mean (SD) age: 53.8 (11.7) years], 43.4% of the patients had at least one (30.3% had ≥2) ongoing comorbidity other than PsA/PSO. The median [interquartile range (IQR)] PsA and psoriasis duration were 1.9 (1.0-3.5) and 7.5 (3.9-16.8) years, respectively. All subjects were on csDMARD while 24.2% received combination therapy, oral non-steroid anti-inflammatory drugs (32.3%), topical treatments (20.2%) and systemic steroids (11.1%). Based on the Clinical Disease Activity in PsA (cDAPSA) score, 58.6% of the patients had moderate, and 29.3% high disease activity. In the EuroQol (EQ) 5-Dimensions (5D) 5-Levels questionnaire, 93.9, 82.8, 82.8, 73.7, and 51.5% of the patients reported problems in ‘pain/discomfort’, ‘anxiety/depression’, ‘usual activities’, ‘mobility’, and ‘self-care’, respectively. The median (IQR) baseline UK-weighted EQ-5D index and EQ-Visual Analogue Scale scores were 0.55 (0.44-0.70) and 50.0 (40.0-70.0), respectively. The median (IQR) Health Assessment Questionnaire-Disability Index (HAQ-DI) and mean (SD) PsA Impact of Disease 12-item (PsAID12) scores were 1.0 (0.5-1.4) and 4.6 (2.0), respectively.

Conclusion:

More than 8 out of 10 bio-naïve patients initiated on apremilast in the routine clinical care in Greece have at least moderate disease activity, active psoriasis, and problems with pain/discomfort, anxiety/depression, and performance of usual activities at a median of 2 years post-diagnosis. HAQ-DI and PsAID12 scores indicate moderate impairment of physical functionality and PsA-related HRQoL. The findings underscore considerable disease burden early in the disease course.

Table 1.

Baseline characteristics

N%/Mean/MedianWomen, %57/9957.6Peripheral joint involvement only, %92/9992.9Polyarthritis (≥5 joints), %69/9969.7cDAPSA (range: 0-154), median (IQR)9922.0 (16.0-29.0)Number of SJC (0-66) / TJC (0-68), median (IQR)994 (2-8) / 6 (2-10)Active psoriasis (BSA>0%), %83/9983.8BSA score, median (IQR)77/835.0 (2.0-12.0)Nail involvement, %38/9639.6Enthesitis and/or dactylitis, %30/9531.6Dactylitis, %11/9511.6Finger and toe Dactylitis Severity Score (DSS) (range: 0-60), median (IQR)10/112.0 (1.0-6.0)Enthesitis, %22/9523.2 LEI score (range: 0-14), median (IQR)222.0 (1.0-2.0)Extra-articular manifestations (mainly fatigue), %10/9910.1Comorbidities in ≥15% of the patientsHypertension, Essential hypertension, %23/9923.2Dyslipidemia, hypercholesterolemia, (type V) hyperlipidemia, %15/9915.2Total PsAID12 score (range: 0-10), mean (SD)984.6 (2.0)Total HAQ-DI score (range: 0-3), median (IQR)991.0 (0.5-1.4)

Disclosure of Interests:

PELAGIA KATSIMPRI Speakers bureau: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Consultant of: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Dimitrios Vassilopoulos Speakers bureau: AbbVie, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, GenesisPharma, Νovartis, Pfizer, Roche, UCB, Janssen, MSD, Gkikas Katsifis Speakers bureau: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, Grant/research support from: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, GEORGIOS VOSVOTEKAS Speakers bureau: MSD, Consultant of: AbbVie, Novartis, Dimitrios Bogdanos Speakers bureau: Menarini, Novartis, Consultant of: Fresenius Kabi Hellas, Novartis, Grant/research support from: Aenorasis, Elpen, Genesis Pharma, GlaxoSmithKline, Boehringer Ingelheim, Lilly, Prodromos Sidiropoulos Grant/research support from: University of Crete Special Account for Research and pharma, Periklis Vounotrypidis Speakers bureau: Genesis Pharma, MSD, Novartis, Grant/research support from: Genesis Pharma, MSD, Novartis, Athanasios Georgountzos Grant/research support from: AbbVie, Genesis Pharma, Janssen, Mylan SAS, Pfizer, Roche, UCB, Andreas Bounas: None declared., Alexandros Garyfallos Speakers bureau: AbbVie, BGP, Roche, Consultant of: Genesis Pharma, UCB, Pfizer, Sousana Gazi: None declared., Panagiotis Georgiou Grant/research support from: Janssen-Cilag, Novartis, UCB, Evaggelia Kataxaki Speakers bureau: Novartis, Charalampos Papagoras Speakers bureau: Abbvie, Novartis, Genesis, Lilly, Biogen, Aenorasis, GSK, Pfizer, ANTONIA ELEZOGLOU: None declared., Stamatis-Nick Liossis: None declared., Athanasios Tzioufas Grant/research support from: AbbVie, Genesis Pharma, GSK, Horizon, Lilly, Novartis, Pfizer, Paraskevi Voulgari Speakers bureau: GlaxoSmithKline, Novartis, UCB, Consultant of: GlaxoSmithKline, Novartis, UCB, FOTEINI SATRA TZOUFRA Employee of: GENESIS PHARMA S.A., ZAFEIRIOS ANAGNOSTOPOULOS Employee of: GENESIS PHARMA S.A., NIKOLAOS ANTONAKOPOULOS Employee of: GENESIS PHARMA S.A., Petros Sfikakis Speakers bureau: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB.

Supervised machine learning for the prediction of infection on admission to hospital: a prospective observational cohort study

BACKGROUND

Infection diagnosis can be challenging, relying on clinical judgement and non-specific markers of infection. We evaluated a supervised machine learning (SML) algorithm for diagnosing bacterial infection using routinely available blood parameters on presentation to hospital.

METHODS

An SML algorithm was developed to classify cases into infection versus no infection using microbiology records and six available blood parameters (C-reactive protein, white cell count, bilirubin, creatinine, ALT and alkaline phosphatase) from 160203 individuals. A cohort of patients admitted to hospital over a 6 month period had their admission blood parameters prospectively inputted into the SML algorithm. They were prospectively followed up from admission to classify those who fulfilled clinical case criteria for a community-acquired bacterial infection within 72 h of admission using a pre-determined definition. Predictive ability was assessed using receiver operating characteristics (ROC) with cut-off values for optimal sensitivity and specificity explored.

RESULTS

One hundred and four individuals were included prospectively. The median (range) cohort age was 65 (21-98)  years. The majority were female (56/104; 54%). Thirty-six (35%) were diagnosed with infection in the first 72 h of admission. Overall, 44/104 (42%) individuals had microbiological investigations performed. Treatment was prescribed for 33/36 (92%) of infected individuals and 4/68 (6%) of those with no identifiable bacterial infection. Mean (SD) likelihood estimates for those with and without infection were significantly different. The infection group had a likelihood of 0.80 (0.09) and the non-infection group 0.50 (0.29) (P < 0.01; 95% CI: 0.20-0.40). ROC AUC was 0.84 (95% CI: 0.76-0.91).

CONCLUSIONS

An SML algorithm was able to diagnose infection in individuals presenting to hospital using routinely available blood parameters.

AB1201 INCREASING RATES OF INFLUENZA VACCINATION COVERAGE IN RHEUMATOID ARTHRITIS PATIENTS: DATA FROM A MULTICENTER, LONGITUDINAL COHORT STUDY OF 1,406 PATIENTS

Background:

Despite the increased incidence of influenza infection in rheumatoid arthritis (RA) patients, vaccination coverage has been shown to be suboptimal. Prospective data regarding the current rate and predictors of influenza vaccination adherence in RA patients are limited.

Objectives:

To calculate the current rate and predictors of influenza vaccination in a real-life, prospective, longitudinal RA cohort.

Methods:

Data regarding demographics, disease characteristics, treatments and co-morbidities from a multi-center, longitudinal cohort of Greek RA patients were collected at baseline and ~ 3 years later. Disease and patient characteristics were compared between patients with at least one influenza vaccine administration and non-vaccinated ones, during the 3 year follow-up period.

Results:

From a cohort of 1,569 RA patients, 1,406 with available vaccination data at baseline and 3 years later (mean interval: 2.9 years) were included; (women: 80.4%, mean age: 61.8 years, mean disease duration: 9.7 years, RF and/or anti-CCP positive: 50.4%, mean DAS-28 = 3.33, mean HAQ: 0.44, bDMARD use: 44.8%). At baseline, 54.2% of patients reported influenza vaccination in the past (31.8% during the previous season), while during the 3 year follow-up period, 81% had ≥1 influenza vaccinations (p=<0.001). Patients who received ≥1 influenza vaccine were older (63.5 vs. 54.7 years, p<0.001), were more likely to be seropositive (59.2% vs. 45.2%, p<0.001), had higher HAQ (0.46 vs. 0.36, p=0.02) and BMI (27.7 vs. 26.9, p=0.02) at baseline, more likely to be treated with bDMARDs (46.8% vs. 36.4%, p<0.001) and more likely to have chronic lung disease (9.7% vs. 5.3%, p=0.02), dyslipidemia (36.4% vs. 24.2%, p<0.001), hypertension (46.1% vs. 29.2%, p<0.001) and to report vaccination against influenza the previous season before baseline evaluation (34.9% vs. 18.2%, p<0.001). By multivariate analysis, history of influenza vaccination during the last season before baseline (OR=1.87, CI: 1.27-2.74, p=0.001), bDMARD treatment (OR=1.51, CI: 1.07-2.13, p=0.018) and age (OR=1.05, CI: 1.04-1.06, p<0.001) were independent predictors of influenza vaccination.

Conclusion:

In this ongoing, longitudinal, prospective, real-life RA cohort study, a significant increase in the influenza vaccination coverage was noted (from 53% to 81%). Influenza vaccination was independently associated with recent history of influenza vaccination, older age, and bDMARD treatment.

Acknowledgments:

Supported by grants from the Greek Rheumatology Society and Professional Association of Rheumatologists.

Disclosure of Interests:

Konstantinos Thomas: None declared, Argyro Lazarini: None declared, Evripidis Kaltsonoudis: None declared, Alexandros Drosos: None declared, ARGYRO REPA: None declared, Prodromos Sidiropoulos: None declared, Kalliopi Fragkiadaki: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Panagiota Tsatsani: None declared, Sousana Gazi: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas: None declared, Evangelia Argyriou: None declared, Kyriaki Boki: None declared, Gerasimos Evangelatos: None declared, Alexios Iliopoulos: None declared, Konstantina Karagianni: None declared, Lazaros Sakkas: None declared, Konstantinos Melissaropoulos: None declared, Panagiotis Georgiou: None declared, Eleftheria Grika: None declared, PANAYIOTIS VLACHOYIANNOPOULOS: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Constantinos Georganas: None declared, Periklis Vounotrypidis: None declared, Konstantinos Ntelis: None declared, Maria Areti: None declared, George D Kitas: None declared, Dimitrios Vassilopoulos: None declared

Machine learning for clinical decision support in infectious diseases: a narrative review of current applications

BACKGROUND

Machine learning (ML) is a growing field in medicine. This narrative review describes the current body of literature on ML for clinical decision support in infectious diseases (ID).

OBJECTIVES

We aim to inform clinicians about the use of ML for diagnosis, classification, outcome prediction and antimicrobial management in ID.

SOURCES

References for this review were identified through searches of MEDLINE/PubMed, EMBASE, Google Scholar, biorXiv, ACM Digital Library, arXiV and IEEE Xplore Digital Library up to July 2019.

CONTENT

We found 60 unique ML-clinical decision support systems (ML-CDSS) aiming to assist ID clinicians. Overall, 37 (62%) focused on bacterial infections, 10 (17%) on viral infections, nine (15%) on tuberculosis and four (7%) on any kind of infection. Among them, 20 (33%) addressed the diagnosis of infection, 18 (30%) the prediction, early detection or stratification of sepsis, 13 (22%) the prediction of treatment response, four (7%) the prediction of antibiotic resistance, three (5%) the choice of antibiotic regimen and two (3%) the choice of a combination antiretroviral therapy. The ML-CDSS were developed for intensive care units (n = 24, 40%), ID consultation (n = 15, 25%), medical or surgical wards (n = 13, 20%), emergency department (n = 4, 7%), primary care (n = 3, 5%) and antimicrobial stewardship (n = 1, 2%). Fifty-three ML-CDSS (88%) were developed using data from high-income countries and seven (12%) with data from low- and middle-income countries (LMIC). The evaluation of ML-CDSS was limited to measures of performance (e.g. sensitivity, specificity) for 57 ML-CDSS (95%) and included data in clinical practice for three (5%).

IMPLICATIONS

Considering comprehensive patient data from socioeconomically diverse healthcare settings, including primary care and LMICs, may improve the ability of ML-CDSS to suggest decisions adapted to various clinical contexts. Currents gaps identified in the evaluation of ML-CDSS must also be addressed in order to know the potential impact of such tools for clinicians and patients.

Delivering precision antimicrobial therapy through closed-loop control systems

Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.

Animal models to improve our understanding and treatment of suicidal behavior

Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.

A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?

OBJECTIVES

Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems.

METHOD

PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation.

RESULTS

Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor.

CONCLUSION

Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.

Is robotic ventral mesh rectopexy better than laparoscopy in the treatment of rectal prolapse and obstructed defecation? A meta-analysis

Ventral mesh rectopexy is an approach in the treatment of internal and external rectal prolapse and rectocele. Our aim was to assess whether robotic surgery confers any significant advantages over laparoscopy, and the associated complication rate. Two reviewers performed a literature search using MEDLINE and PubMed databases for studies comparing robotic versus laparoscopic surgery. Five prospective, non-randomised studies were identified and included. A total of 244 patients (101 robotic and 143 laparoscopic) were included in the analysis. Operative time was shorter with laparoscopic surgery, mean weighted difference 27.94 [confidence interval (CI) 19.30-36.57; p < 0.00001]. The conversion rate was not significantly different between groups. There was a trend towards a reduction in length of inpatient stay and early post-operative complications in the robotic group; however, these did not reach statistical significance. Recurrence rates were similar between groups (odds ratio 0.91, CI 0.32-2.63; p = 0.87). Functional results were comparable between groups. Early studies show that robotic ventral rectopexy is a safe option compared to the laparoscopic approach, with overall comparable results. There appeared to be a trend towards a reduction in length of inpatient stay and post-operative complications. These perceived benefits may offset the longer operative times and outlay costs. Larger randomised controlled trials are needed to further evaluate clinical value and cost-effectiveness.

Real-life efficacy and safety of omalizumab in Portuguese patients with persistent uncontrolled asthma

INTRODUCTION

The real life effectiveness, safety and the use of omalizumab for Portuguese patients with uncontrolled persistent allergic asthma are not sufficiently well known. The objective of this report was to make an evaluation, in a post-marketing, non-interventional, observational registry, of the Portuguese population included in the eXpeRience study.

METHODS

The methods used in this report are the same as the global eXpeRience ones, applied to a Portuguese sub-population. Patients with uncontrolled allergic asthma who had started omalizumab within the previous 15 weeks were enrolled and received omalizumab add-on therapy for 24 months. The physicians' global evaluation of treatment effectiveness (GETE), asthma symptoms and control (ACT score), quality of life (mini-AQLQ score), exacerbations, and serious adverse events (SAE) were reported.

RESULTS

Of the 943 patients recruited in the eXpeRience registry, 62 patients were from Portugal. 62.1% of them were observed to be responders with good/excellent GETE assessment at Week 16. Clinically meaningful improvements in asthma control (ACT score) and quality of life (mini-AQLQ score) were observed with omalizumab therapy at Months 12 (mean change: +7.7 [n=35]; +2.1 [n=20], respectively) and 24 (mean change: +7.0 [n=26]; +2.7 [n=13], respectively). Asthma symptoms and rescue medication usage were reduced to ≤1 day/week at Month 24 from a baseline of ≥3.5 days/week. The proportion of patients with no clinically significant exacerbations increased from 6.5% during pre-treatment (n=62) to 50% at Month 12 (n=54) and 60% at Month 24 (n=45).

CONCLUSION

The findings from the Portugal subpopulation of eXpeRience registry confirm that omalizumab add-on therapy is efficacious and well tolerated in the management of uncontrolled persistent allergic asthma. Another pertinent issue is the fact that the Portuguese subpopulation response is similar to the international population average of the study.

The eXpeRience registry: the 'real-world' effectiveness of omalizumab in allergic asthma

Omalizumab has demonstrated therapeutic benefits in controlled clinical trials. Evaluation of outcomes in real-world clinical practice is needed to provide a complete understanding of the benefits of omalizumab treatment. eXpeRience was a 2-year, international, single-arm, open-label, observational registry that evaluated real-world effectiveness, safety and use of omalizumab therapy in 943 patients with uncontrolled persistent allergic asthma. Effectiveness variables (physician's Global Evaluation of Treatment Effectiveness [GETE], and change from baseline in exacerbation rate, symptoms, rescue medication use, and oral corticosteroid [OCS] use) were evaluated at pre-specified time-points. Safety data were also recorded. By physician's GETE, 69.9% of patients were responders to omalizumab after 16 (±1) weeks. The proportion of patients with no clinically significant exacerbations increased from 6.8% during the 12-month pre-treatment period to 54.1% and 67.3% at Months 12 and 24, respectively. Symptoms and rescue medication use at Month 24 were reduced by >50% from baseline. Maintenance OCS use was lower at Month 24 (14.2%) compared with Month 12 (16.1%) and baseline (28.6%). Overall, omalizumab had an acceptable safety profile. The results from eXpeRience indicate that omalizumab was associated with improvements in outcomes in patients with uncontrolled persistent allergic asthma; these improvements were consistent with the results of clinical trials.

The tumour biology of synchronous and metachronous colorectal liver metastases: a systematic review

Forty to fifty percent of colorectal cancer (CRC) patients develop colorectal liver metastases (CLM) that are either synchronous or metachronous in presentation. Clarifying whether there is a biological difference between the two groups of liver metastases or their primaries could have important clinical implications. A systematic review was performed using the following resources: MEDLINE from PubMed (1950 to present), Embase, Cochrane and the Web of Knowledge. Thirty-one articles met the inclusion criteria. The review demonstrated that the majority of studies found differences in molecular marker expression between colorectal liver metastases and their respective primaries in both the synchronous and metachronous groups. Studies investigating genetic aberrations demonstrated that the majority of changes in the primary tumour were 'maintained' in the colorectal liver metastases. A limited number of studies compared the primary tumours of the synchronous and metachronous groups and generally demonstrated no differences in marker expression. Although there were conflicting results, the colorectal liver metastases in the synchronous and metachronous groups demonstrated some differences in keeping with a more aggressive tumour subtype in the synchronous group. This review suggests that biological differences may exist between the liver metastases of the synchronous and metachronous groups. Whether there are biological differences between the primaries of the synchronous and metachronous groups remains undetermined due to the limited number of studies available. Future research is required to determine whether differences exist between the two groups and should include comparisons of the primary tumours.

Expression of ets family genes in hematopoietic-cells

We have examined the expression of the ets family of transcription factors in different types of hematopoietic cells. Our results demonstrate that several members of the ets gene family are expressed differentially in hematopoietic cells. During phorbol ester induced differentiation of HL60 cells, ETS2, PEA3, as well as GABPalpha and GABPbeta mRNAs are coordinately induced. During the activation of T-cells, ETS2 proteins are induced; however, the expression of the ETS1 and ERGB gene products are reduced. These results demonstrate that the regulation of ets family of genes is complex and depends on cell type. This observation leads to the conclusion that the regulation of ets target genes, will be dependent, in part, upon the type of ets genes expressed in each particular cell type.

A silicon pancreatic Beta cell for diabetes

The paper will consider how silicon devices such as ion-sensitive field effect transistors can be used to model metabolic functions in biology. In a first example, a biologically inspired silicon beta cell is presented to serve as the main building block of an artificial pancreas. This is to be used for real-time glucose sensing and insulin release for diabetics. This system presents the first silicon implementation of a metabolic cell capable of exhibiting variable bursting behavior upon glucose stimulation. Based on the Hodgkin and Huxley formalism, this approach achieves dynamics similar to that of biological beta cells by using devices biased in the subthreshold regime. In addition to mimicking the physiological behavior of the beta cell, the circuit achieves good power efficiency, measured to be 4.5 muW.

Reconstructive surgery for kidney transplant recipients

Many decades have passed since the first kidney transplantation, which is now the most common organ transplant performed worldwide. Despite the impressive advances, some patients may develop posttransplant complications that require proper management and treatment. The plastic and reconstructive surgeon, among others, may be called on to help resolve a number of reconstructive problems present in the immunosuppressed kidney recipients. This study presents our experience with 41 kidney recipients who needed plastic surgical treatment. Patients were placed into one of three study groups according to the type of posttransplant surgical condition. Group 1 included 17 patients with posttraumatic wound healing problems; group 2, 17 patients with skin tumors; and group 3, 7 patients with other posttransplant surgical complications. Only two of these patients had early posttransplant wound dehiscence; the remaining patients suffered late complications. In conclusion, the kidney recipient can successfully undergo minor or major reconstructive procedures. The possibility of surgical problems arising during the early posttransplant period presents increased complication rates, possibly due to high immunosuppressive drug levels.

Autoantibodies against aggrecan in systemic rheumatic diseases

OBJECTIVE

This study was undertaken to investigate the presence of autoantibodies against the main cartilage proteoglycan, aggrecan, in systemic rheumatic disease sera, and to identify substructure(s) responsible for the autoimmune response.

METHODS

Sera were obtained from 86 patients with various systemic rheumatic diseases, 14 with osteoarthritis (OA), 18 with cancer and 40 healthy individuals. The presence of autoantibodies against aggrecan was examined by a solid phase assay and by Western blotting, using proteoglycan aggregates treated with proteolytic enzymes. The positive bands were subjected to nanohigh performance liquid chromatography (nanoHPLC)-MS, in order to identify the aggrecan substructures involved in the autoimmune response.

RESULTS

Autoantibodies against aggrecan were identified in all systemic rheumatic disease sera at a high titre, almost three times that observed in healthy controls. OA and cancer sera produced a reaction equal to that of the healthy. Western blotting analysis of aggrecan proteolytic fragments revealed the presence of a triple band, reacting with the patients' sera, of about 37 kDa, which also reacted with a polyclonal antibody against hyaluronan-binding region. NanoHPLC-MS analysis suggested that this band belonged to the G2 domain of aggrecan.

CONCLUSION

At least a part of the autoimmune reaction to aggrecan, displayed by the systemic disease sera, involves the G2 domain. The significant difference observed between these sera and those from other diseases, especially cancer, may suggest a possible discriminatory role of anti-aggrecan antibodies. This may help in the differential diagnosis in complicated clinical cases. However, for this to be confirmed, studies in larger cohorts of patients should be performed.

Asymptomatic gastrocnemius muscle biopsy: an extremely sensitive and specific test in the pathologic confirmation of sarcoidosis presenting with hilar adenopathy

OBJECTIVE

To evaluate asymptomatic gastrocnemius muscle biopsy as a tool in the histologic confirmation of the diagnosis of sarcoidosis.

METHODS

Twenty-two patients admitted over a 2-year period to our department with bilateral hilar adenopathy and a variety of symptoms compatible with sarcoidosis were studied prospectively. Besides a complete history and physical, serum angiotensin converting enzyme (SACE) determination, pulmonary function, slit lamp eye examination, PPD skin test, gallium 67 scan and gastrocnemius muscle biopsy were performed.

RESULTS

The biopsy revealed non-caseating granuloma in all patients, confirming the diagnosis of sarcoidosis. No other patient in our department received this diagnosis over the 2-year period of the study. The procedure was well tolerated by all patients and almost zero morbidity was noted. Erythema nodosum was present in 68.2% of the patients, PPD was negative in all of them, SACE was elevated in 59.1% and pulmonary function was normal in the majority.

CONCLUSION

The impressive sensitivity of asymptomatic gastrocnemius muscle biopsy, its safety and ease of performance, along with the extreme rarity of muscle involvement by other granulomatous diseases included in the differential diagnosis, may render it the procedure of choice for the histologic confirmation of sarcoidosis presenting with hilar adenopathy.

Bronchiectasis in systemic sclerosis. A study using high resolution computed tomography

OBJECTIVE

To detect noninvasively the presence of bronchiectasis in patients with systemic sclerosis (SSc), through the use of high resolution chest computed tomography (HRCT).

METHODS

Twenty two patients with SSc, of whom 13 with diffuse and 9 with limited disease, besides a complete history, physical and routine laboratory and immunologic profile, were evaluated by pulmonary function testing and HRCT. The chi square test with Yates' correction, the Fisher's exact test, the Fisher's test (F test) and the "t" test were used for statistical analysis of the results.

RESULTS

Eleven patients (50.0%) had decreased carbon monoxide diffusing lung capacity (DLCO) and, out of these, four had restrictive lung disease, based on a combined decrease of forced vital capacity (FVC) and total lung capacity (TLC). Another two patients exhibited this pattern without DLCO impairment. HRCT revealed a ground glass picture in 15 patients (68.2%), fibrosis in 9 (40.9%) (of which 5 with ground glass as well), and cylindrical bronchiectasis in 13 (59.1%). Bronchiectasis was more common in diffuse than in limited SSc, and the difference approached but did not reach the level of statistical significance. On the other hand, it was not correlated with either decreased DLCO, presence of ground glass and fibrosis, or with patients' age and disease duration.

CONCLUSION

Although the number of patients included in our study is relatively small, our data, for the first time in the literature, indicate a significant association between scleroderma and bronchiectasis. Bronchiectasis should be included in the list of pulmonary manifestations of SSc, and SSc in the list of conditions causing bronchiectasis.

Upper eyelid island orbicularis oculi myocutaneous flap for periorbital reconstruction

PURPOSE

To describe the upper eyelid island orbicularis oculi myocutaneous flap, medially or laterally based, for reconstruction of periorbital defects.

METHODS

During the past three years we have used the island orbicularis oculi myocutaneous flap in 62 patients with tumors of the periorbital area, with the following indications: (a) anterior lamellar defects of the medial aspect of the upper eyelid, when the peripheral arcade is intact; (b) up to 2/3 anterior lamellar lower eyelid defects; (c) inner and outer canthus defects; and (d) defects of the peripalpebral area (the lateral half of the eyebrow, bridge of the nose and suprazygomatic areas).

RESULTS

The flap proved to be flexible, safe, relatively simple, and provided good functional and aesthetic results. Complications were minimal.

CONCLUSIONS

The upper eyelid island orbicularis oculi myocutaneous flap may be a useful tool for periorbital reconstruction.

Upper eyelid orbicularis oculi flap with tarsoconjunctival island for reconstruction of full-thickness lower lid defects

The reconstruction of full-thickness defects of the lower eyelid after tumor resection is a challenging operation. The great number of techniques for these defects shows that none of them is the operation of choice. The method of reconstruction will be chosen according to the extent of the defect, the missing components of the eyelid structure, the age of the patient, and the quantity and the quality of the surrounding tissues. In this article, we propose, under specific indications, the use of a pedicled myocutaneous orbicularis oculi flap with a tarsoconjunctival island from the upper eyelid to reconstruct full-thickness lower lid defects. The more choices in a surgeon's armamentarium, the more easily the difficult problems of periorbital surgical oncology will be resolved.

Island mucochrondrocutaneous flap for reconstruction of total loss of the lower eyelid

The methods usually employed for reconstruction of total lower eyelid loss include (1) tarsoconjunctival flaps from the upper eyelid and skin-graft cover and (2) chondromucosal grafts and local skin-flap cover. We report a technique for coverage of these defects with an island flap involving the full thickness of the ipsilateral nasal wall based on the dorsal (external) nasal vessels, terminal branches of the ophthalmic vessels. The advantages of this method are (1) the main components of the eyelid (skin, tarsus, conjunctiva) are reconstructed in a single short operation, even under local anesthesia, (2) there is one donor area that can be closed primarily without significant deformity, (3) the upper lid remains intact, and ectropion is improbable, and (4) the procedure involves a short hospitalization. As disadvantages we might mention bulkiness of the new eyelid and difficult dissection of the (subcutaneous) pedicle.

Effect of pranlukast, an oral leukotriene receptor antagonist, on leukotriene D4 (LTD4) challenge in normal volunteers

BACKGROUND

There is increasing evidence to show that leukotrienes are important mediators in asthma. Leukotriene receptor antagonists protect against antigen and exercise challenges in patients with chronic asthma. A study was undertaken to investigate the activity of the leukotriene receptor antagonist pranlukast (SB 205312, ONO-1078) in blocking bronchoconstriction induced by leukotriene D4 (LTD4) inhalation. The selectivity of pranlukast was evaluated using histamine challenge.

METHODS

Pranlukast, 450 mg twice daily, was given to eight healthy non-smoking men for five days in a randomised, double blind, placebo controlled, crossover study. The specific airways conductance (sGaw) was measured before and after bronchial provocation with inhaled LTD4 at 3.5 hours after the first dose and at 3.5 and 9.5 hours after the last dose of pranlukast on the morning of day 5. The concentration of LTD4 required to produce a fall in sGaw of 35% (PC35) was calculated. Subjects also underwent a histamine challenge 3.5 hours after a single dose of pranlukast, 450 mg, or placebo.

RESULTS

A single dose of pranlukast produced a 10.6 fold increase in PC35sGaw (95% confidence interval (CI) 4.4 to 25.5; p < 0.001) for LTD4 at 3.5 hours after dosing compared with placebo. Three and a half hours after the morning dose of pranlukast on day 5 the PC35sGaw for LTD4 was increased 25.9 fold (95% CI 10.8 to 62.2; p < 0.001) and was still increased sevenfold (95% CI 2.9 to 16.7; p < 0.001) relative to placebo 9.5 hours after administration of the morning dose. No significant differences were noted for the PC35sGaw to histamine for pranlukast compared with placebo.

CONCLUSIONS

This study shows that pranlukast is a potent and selective LTD4 receptor antagonist in humans which blocks LTD4 challenge after initial and repeated administration when given twice daily for five days.

A double blind, placebo-controlled study to assess the effect of famciclovir on virus replication in patients with chronic hepatitis B virus infection

This is the first double-blind controlled study of famciclovir, an oral antiviral agent, as potential therapy for chronic hepatitis B virus (HBV) carries. A fall of more than 90% in HBV DNA levels was noted in six of 11 evaluable patients treated with a 10 day course of oral famciclovir. Further studies with more prolonged therapy are ongoing.

Expression of ets family of genes in systemic lupus erythematosus and Sjogren's syndrome

We have examined the expression of three members of the ets family of genes, ETS1, ETS2 and ERGB/Fli-1, in lymphocytes from patients with systemic lupus erythematosus and in two murine autoimmune model systems. The ERGB/Fli-1 gene is expressed at a higher level in lymphocytes from autoimmune disease patients than healthy individuals. In addition, we found that the ERGB/Fli-1 gene expression is higher in splenic T-cells from lupus prone mice and in infiltrating lymphocytes in the salivary glands of HTLV-I tax transgenic mice. Taken together, these results suggest that the elevated expression of the ERGB/Fli-1 gene in lymphocytes may be a prelude to the development of autoimmune diseases.