IMscin001 Part 2: a randomised phase III, open-label, multicentre study examining the pharmacokinetics, efficacy, immunogenicity, and safety of atezolizumab subcutaneous versus intravenous administration in previously treated locally advanced or metastatic non-small-cell lung cancer and pharmacokinetics comparison with other approved indications

BACKGROUND

Atezolizumab intravenous (IV) is approved for the treatment of various solid tumours. To improve treatment convenience and health care efficiencies, a coformulation of atezolizumab and recombinant human hyaluronidase PH20 was developed for subcutaneous (SC) use. Part 2 of IMscin001 (NCT03735121) was a randomised phase III, open-label, multicentre, noninferiority study comparing the drug exposure of atezolizumab SC with atezolizumab IV.

PATIENTS AND METHODS

Eligible patients with locally advanced/metastatic non-small-cell lung cancer were randomised 2 : 1 to receive atezolizumab SC (1875 mg; n = 247) or IV (1200 mg; n = 124) every 3 weeks. The co-primary endpoints were cycle 1 observed trough serum concentration (Ctrough) and model-predicted area under the curve from days 0 to 21 (AUC0-21 d). The secondary endpoints were steady-state exposure, efficacy, safety, and immunogenicity. Exposure following atezolizumab SC was then compared with historical atezolizumab IV values across approved indications.

RESULTS

The study met both of its co-primary endpoints: cycle 1 observed Ctrough {SC: 89 μg/ml [coefficient of variation (CV): 43%] versus IV: 85 μg/ml (CV: 33%); geometric mean ratio (GMR), 1.05 [90% confidence interval (CI) 0.88-1.24]} and model-predicted AUC0-21 d [SC: 2907 μg d/ml (CV: 32%) versus IV: 3328 μg d/ml (CV: 20%); GMR, 0.87 (90% CI 0.83-0.92)]. Progression-free survival [hazard ratio 1.08 (95% CI 0.82-1.41)], objective response rate (SC: 12% versus IV: 10%), and incidence of anti-atezolizumab antibodies (SC: 19.5% versus IV: 13.9%) were similar between arms. No new safety concerns were identified. Ctrough and AUC0-21 d for atezolizumab SC were consistent with the other approved atezolizumab IV indications.

CONCLUSIONS

Compared with IV, atezolizumab SC demonstrated noninferior drug exposure at cycle 1. Efficacy, safety, and immunogenicity were similar between arms and consistent with the known profile for atezolizumab IV. Similar drug exposure and clinical outcomes following SC and IV administration support the use of atezolizumab SC as an alternative to atezolizumab IV.

Study protocol for FUTURES: Testing a web-based reproductive health education program for adolescent and young adult males with sickle cell disease

Individuals with sickle cell disease are increasingly surviving into adulthood, many of whom have interest in future biological parenthood. Reproductive health knowledge is low among adolescent and young adult males and their caregivers. Their understanding of these topics is needed to optimize their reproductive health outcomes. As such, through collaboration with a community advisory board (adolescents and young adults with sickle cell disease and mothers of adolescent and young adult males with sickle cell disease) and digital design team, we developed a web-based sickle cell disease-focused reproductive health program entitled FUTURES to address these knowledge gaps. For phase I of this two phase feasibility and acceptability study, adolescent and young adult males and their caregivers will complete a pre- and post-program reproductive health knowledge and attitudes questionnaire to assess change in knowledge. In phase II, after learning about fertility testing as part of the FUTURES curriculum, adolescent and young adult male participants are given the option to pursue testing. The two-phase study aims to: 1) develop and test the feasibility, acceptability, and efficacy of a reproductive health web-based educational program at increasing reproductive health knowledge in male adolescent and young adult males with sickle cell disease and their caregivers, and 2) assess feasibility of fertility testing. The long-term goal is to improve reproductive and psychosocial outcomes among adolescent and young adult males with sickle cell disease.

Personal belief on elastic tape and tape tension affect perceived performance, but not muscle activity and endurance

BACKGROUND

Previous studies reported inconsistent outcomes on elastic taping for three potential reasons: 1) poor control of placebo effect; 2) no consensus regarding the optimal tape tension; and 3) lack of investigation on muscle endurance, as the proposed tape recoiling force may not promote peak force generation but exert a consistently low force and improve submaximal contraction.

PURPOSE

This study compared the effects of elastic tape and its tension on muscle activity and endurance in people with extremely positive and negative personal belief on elastic tape.

METHODS

Using a validated instrument, we identified 20 participants with extremely positive personal belief on elastic tape (+ belief), and 20 with extremely negative personal belief (- belief). They performed wrist isometric endurance tests under three taping conditions (i.e. no tape, 50%, and 100% tension). We measured isometric wrist extensor muscle endurance, electromyography muscle activity, and self-perceived performance for each condition.

RESULTS

The differences between the two groups in isometric muscle endurance (p = .85) and muscle activity (p = .53) were not statistically significant, regardless of tape conditions. However, participants with + belief reported better perceived performance than those with - belief (p < .001, partial eta squared = 0.70). Specifically, 100% tape tension yielded stronger self-perceived performance than 50% tension (Cohen's d = 0.91) and no tape (Cohen's d = 1.86). On the other hand, participants with - belief perceived similar performance across tape tensions (p = .55).

CONCLUSION

Elastic tape does not modulate muscle activity and enhance muscle endurance. People with a strong positive personal belief on elastic tape may perceive a better performance with a greater tape tension.

Sperm DNA methylome abnormalities occur both pre- and post-treatment in men with Hodgkin disease and testicular cancer

BACKGROUND

Combination chemotherapy has contributed to increased survival from Hodgkin disease (HD) and testicular cancer (TC). However, questions concerning the quality of spermatozoa after treatment have arisen. While studies have shown evidence of DNA damage and aneuploidy in spermatozoa years following anticancer treatment, the sperm epigenome has received little attention. Our objectives here were to determine the impact of HD and TC, as well as their treatments, on sperm DNA methylation. Semen samples were collected from community controls (CC) and from men undergoing treatment for HD or TC, both before initiation of chemotherapy and at multiple times post-treatment. Sperm DNA methylation was assessed using genome-wide and locus-specific approaches.

RESULTS

Imprinted gene methylation was not affected in the sperm of HD or TC men, before or after treatment. Prior to treatment, using Illumina HumanMethylation450 BeadChip (450 K) arrays, a subset of 500 probes was able to distinguish sperm samples from TC, HD and CC subjects; differences between groups persisted post-treatment. Comparing altered sperm methylation between HD or TC patients versus CC men, twice as many sites were affected in TC versus HD men; for both groups, the most affected CpGs were hypomethylated. For TC patients, the promoter region of GDF2 contained the largest region of differential methylation. To assess alterations in DNA methylation over time/post-chemotherapy, serial samples from individual patients were compared. With restriction landmark genome scanning and 450 K array analyses, some patients who underwent chemotherapy showed increased alterations in DNA methylation, up to 2 to 3 years post-treatment, when compared to the CC cohort. Similarly, a higher-resolution human sperm-specific assay that includes assessment of environmentally sensitive regions, or "dynamic sites," also demonstrated persistently altered sperm DNA methylation in cancer patients post-treatment and suggested preferential susceptibility of "dynamic" CpG sites.

CONCLUSIONS

Distinct sperm DNA methylation signatures were present pre-treatment in men with HD and TC and may help explain increases in birth defects reported in recent clinical studies. Epigenetic defects in spermatozoa of some cancer survivors were evident even up to 2 years post-treatment. Abnormalities in the sperm epigenome both pre- and post-chemotherapy may contribute to detrimental effects on future reproductive health.

Targeting the tubulin C-terminal tail by charged small molecules

The disordered tubulin C-terminal tail (CTT), which possesses a higher degree of heterogeneity, is the target for the interaction of many proteins and cellular components. Compared to the seven well-described binding sites of microtubule-targeting agents (MTAs) that localize on the globular tubulin core, tubulin CTT is far less explored. Therefore, tubulin CTT can be regarded as a novel site for the development of MTAs with distinct biochemical and cell biological properties. Here, we designed and synthesized linear and cyclic peptides containing multiple arginines (RRR), which are complementary to multiple acidic residues in tubulin CTT. Some of them showed moderate induction and promotion of tubulin polymerization. The most potent macrocyclic compound 1f was found to bind to tubulin CTT and thus exert its bioactivity. Such RRR containing compounds represent a starting point for the discovery of tubulin CTT-targeting agents with therapeutic potential.

Exposure of men living in the greater Montreal area to organophosphate esters: Association with hormonal balance and semen quality

Exposure to organophosphate esters (OPEs) is extensive, yet few studies have investigated their association with hormone levels or semen quality. Here, we studied the association between urinary concentrations of OPEs and their metabolites with hormone levels and semen parameters in men (n = 117) predominantly in the 20-29 years age range who were recruited from the greater Montreal area between 2009 and 2012. Urine, serum, and semen samples were analyzed for OPEs, hormones, and semen quality, respectively. Bis(2-ethylhexyl) phosphate (BEHP), bis(2,4-di-tert-butylphenyl) hydrogen phosphate (B2,4DtBPP), tris(2-chloroisopropyl) phosphate (TCIPP), diphenyl phosphate (DPHP), bis (2-butoxyethyl) phosphate (BBOEP) and di-cresyl phosphate (DCPs) were detected in urine at a frequency ≥ 95%. The highest geometric mean concentration was observed for DPHP (18.54 ng/mL) and the second highest was B2,4DtBPP (6.23 ng/mL). Associations between a doubling in analyte concentrations in urine and hormone levels and semen quality parameters were estimated using multivariable linear regression. B2,4DtBPP levels were positively associated with total T3 (β = 0.09; 95% CI: 0.01, 0.17). DPHP was inversely associated with estradiol (β = -2.56; 95% CI: -5.00, -0.17), and TCIPP was inversely associated with testosterone (β = -0.78; 95% CI: -1.40, -0.17). Concentrations of BCIPP were inversely associated with sperm concentrations (β = -7.76; 95% CI: -14.40, -0.61), progressive motility (β = - 4.98; 95% CI: -8.71, -1.09), and the sperm motility index (β = -9.72; 95% CI: -17.71, -0.96). In contrast, urinary DPHP concentrations were positively associated with the sperm motility (β = 4.37; 95% CI: 0.76, 8.12) and fertility indices (β = 6.64; 95% CI: 1.96, 11.53). Thus, OPE detection rates were high and exposure to several OPEs was associated with altered hormone levels and semen parameters. The possibility that OPEs affect male reproduction warrants further investigation.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Electroconvulsive Therapy for Neuropsychiatric Symptoms due to Major Neurocognitive Disorder: A Prospective, Observational Study

OBJECTIVES

Neuropsychiatric symptoms (NPSs) in those with major neurocognitive disorder (MNCD) include the responsive behaviors of agitation and aggression. Electroconvulsive therapy (ECT) has shown some effectiveness based on retrospective studies and one open label prospective study. We hypothesized that ECT will reduce NPSs between baseline and after treatment in those with medication-refractory behaviors.

METHOD/DESIGN

This Canadian prospective multicenter study included MNCD patients admitted to geriatric psychiatry units for the management of refractory NPSs. All treatment-refractory participants suffered from advanced MNCD. We conducted the Neuropsychiatric Inventory-Clinician version and the Pittsburgh Agitation Scale at baseline, and during and after the ECT course. A bitemporal or bifrontal ECT series based on dose titration to 1.5 to 2.5 times seizure threshold was administered.

RESULTS

Data were collected for 33 patients with a mean age of 73 and categorized with severe MNCD using the Functional Assessment Staging of Alzheimer's Disease scale (stages 6 and 7). The data showed a drop in mean Neuropsychiatric Inventory-Clinician version from 58.36 to 24.58 (P < 0.0001). Mean Neuropsychiatric Inventory agitation subscale dropped from 7.12 to 3.09 (P = 0.007). Mean Neuropsychiatric Inventory aggression subscale dropped from 6.94 to 0.97 (P < 0.0001). There was a concomitant significant decline in Pittsburgh Agitation Scale scores. No participants dropped out because of intolerance of ECT. One participant died from pneumonia, which did not appear related to ECT.

CONCLUSIONS

In this naturalistic study, ECT was found to be a safe and effective treatment for certain NPSs in people with MNCD. This can translate into improving quality of life.

Evaluation of a Mobile Health App Offering Fertility Information to Male Patients With Cancer: Usability Study

Background

Cancer and its treatment can adversely affect male fertility. Although sperm banking is an effective fertility preservation method, there is an unmet need for information and support surrounding these issues.

Objective

This usability study evaluates a mobile health app providing male patients with cancer with credible information about the impact of cancer and its treatment on fertility and fertility preservation.

Methods

Participants were recruited by a market research firm. Eligibility criteria were men who were 18-45 years of age, identified as male, diagnosed with new or recurring cancer within 1 year, not in fertility treatment, able to read and write in English or French, and had internet access. App usage was tracked for 2 weeks. After app use, participants provided qualitative feedback about their experiences using the app as well as quantitative data regarding their sperm banking decisions, perceived change in fertility knowledge, evaluation of the app’s information on the Information Assessment Method, and the app’s quality on the user version of the Mobile App Rating Scale.

Results

The sample included 40 men aged 27-45 years. Approximately 68% (27/40) indicated that no one had previously spoken to them about the impact of cancer on fertility, and 85% (34/40) had not received information on fertility preservation. Approximately 83% (33/40) found the app’s information relevant, and 85% (34/40) said that it increased their fertility knowledge. Approximately 23% (9/40) made a decision about sperm banking after using the app. Participants rated the app’s quality highly, with mean scores (out of 5) of 4.14 for information, 4.06 for functionality, 3.84 for aesthetics, and 3.63 for engagement.

Conclusions

The app proved to be useful for male patients with cancer, suggesting that mobile health resources could be beneficial to incorporate into clinical care to enable shared decision-making about fertility.

The Use of Anticonvulsant Adjuncts to Treat Alcohol Withdrawal Syndrome in Older Adults

Background  We evaluated the prescribing practices of anticonvulsant (AC) adjuncts to benzodiazepines in managing Alcohol Withdrawal Syndrome (AWS). We also examined the prescription of relapse prevention agents for Alcohol Use Disorder (AUD), and adverse events related to AWS treatment.  Methods  Records were reviewed retrospectively pertaining to medically ill adults aged 60 and above with AWS and admitted to a medicine or hospitalist unit of a Canadian centre between June 2013 and June 2018. Duration and dosing of benzodiazepine, dosing and type of AC and AUD agent, and adverse events were collected. A multivariable regression model was employed.  Results  83 encounters were included in the study and 28 were prescribed an AC. The amount and duration of benzodiazepine administered were not statistically different between the benzodiazepine only and the AC adjunct groups, once severe AWS complications were accounted for. Five new prescriptions of traditional AUD agents were provided on discharge. No AC-associated adverse events occurred.  Conclusions  AC adjuncts for AWS did not decrease the amount of benzodiazepine administered nor shorten the duration of treatment. Their routine use is not supported by our findings. Our study highlights a missed opportunity for AUD agents to be prescribed during hospitalization. 

“Who needs an app? Fertility patients’ use of a novel mobile health app”

Objective

The number of couples experiencing infertility treatment has increased, as has the number of women and men experiencing infertility treatment-related stress and anxiety. Therefore, there is a need to provide information and support to both men and women facing fertility concerns. To achieve this goal, we designed a mhealth app, Infotility, that provided men and women with tailored medical, psychosocial, lifestyle, and legal information.

Methods

This study specifically examined how fertility factors (e.g. time in infertility treatment, parity), socio-demographic characteristics (e.g. gender, education, immigrant status), and mental health characteristics (e.g. stress, depression, anxiety, fertility-related quality of life) were related to male and female fertility patients’ patterns of use of the Infotility app.

Results

Overall, the lifestyle section of the app was the most highly used section by both men and women. In addition, women without children and highly educated women were more likely to use Infotility. No demographic, mental health or fertility characteristics were significantly associated with app use for men.

Conclusion

This study shows the feasibility of a mhealth app to address the psychosocial and informational needs of fertility patients.

Risky Business: Increasing Fertility Knowledge of Men in the General Public Using the Mobile Health Application Infotility XY

Male infertility presents a public health concern. As most men wish to become fathers, it is important to increase men’s awareness of infertility risk factors. We developed a mobile health application (mHealth app), Infotility XY, to promote men’s reproductive health. This study evaluates whether use of the app led to increased knowledge of infertility risk factors, and whether knowledge change was associated with participants’ sociodemographic characteristics and/or app usage. Participants were recruited between August and October 2020. Eligibility criteria included: identified as male; 18–45 years old; childless; no infertility history; able to read and write in English/French; had internet access. We assessed participants’ fertility knowledge before and after app use. App usage data were captured during the 2-week intervention period. Our sample included 49 men aged 18–45. Seventy-eight percent of participants had not previously sought fertility information. Participants viewed on average 75% of the app’s articles, and 96% of participants said the app increased their fertility knowledge. Before app use, 55% of men said they were aware of infertility risk factors, compared to 96% after app use. Men correctly identified more risk factors after app use compared to before, t(48) = 8.28, p < .001. Participants’ sociodemographic characteristics and amount of app usage were not associated with knowledge change. This study provides evidence of the feasibility of an mHealth app to improve men’s awareness of infertility risk factors. Given the positive relationship between male reproductive health and overall health, increased awareness of infertility risk factors may lead to men’s improved overall health.

P–383 Cytogenetic analysis of products of conception from miscarriages following natural conception and IVF pregnancy: a comparative study

Study question

Do cytogenetic results from products of conception from miscarriages differ from patients conceiving by natural conception versus IVF? Summary answer: Cytogenetic results were similar, with no statistical difference from miscarriages following natural conception and assisted conception.

What is known already

Cytogenetic sampling of products of conception (POC) following recurrent miscarriages (RM) are recommended to rule out parental chromosomal rearrangements. The RCOG recommends cytogenetic testing in cases of recurrent miscarriages (3 consecutive miscarriages). However some units routinely request cytogenetic analysis following a single miscarriage following an IVF pregnancy. There is no evidence to support the routine sampling of POCs following assisted conception. Study design, size, duration: Retrospective cohort study of 117 cytogenetic samples, followed up by the outcome of parental karyotyping if applicable. Patients were categorised based on mode of conception into natural conception (NC) with recurrent miscarriages (≥3) or one miscarriage following IVF. Data collected between 2018–2020. Primary Outcome measure: Presence and type of cytogenetic abnormality; individual parental targeted G-band karyotyping result. Participants/materials, setting, methods: A total of 117 cytogenetic results were reviewed, of which 35 were unsuitable for analysis due to contamination (Total n = 79: NC = 60, IVF = 19). Main results and the role of chance: Cytogenetic analysis showed abnormal results in 59% of miscarriages following natural conception and 53% of miscarriages from IVF pregnancy (p = 0.46).

Abnormal cytogenetic results were mainly sporadic. Trisomy 16 was the commonest abnormality in both groups. Others included Trisomy 15, 22, 21, 8, 13, 5, 9, 10, 14, 18, single X (Turner’s), all occurring in the same frequency in both groups. As expected 35 out of 45 abnormal cytogenetic results occurred with a maternal age greater than 35 years.

One couple from the NC group were referred to a geneticist for a Trisomy 9 imbalance. All other parental karyotyping results were normal.

Limitations, reasons for caution

This study contains a small sample size, and would benefit from further data collection to account for a percentage of samples being inadequate for analysis. Wider implications of the findings: Cytogenetic results were similar from miscarriages following natural conception and assisted conception. IVF does not increase the risk of miscarriage from abnormal embryonic karyotype. Routine cytogenetic testing following one miscarriage in patients undergoing IVF is not cost effective.

Trial registration number

Not applicable

Abstract 1005: The bispecific antibody zanidatamab's (ZW25's) unique mechanisms of action and durable anti-tumor activity in HER2-expressing cancers

HER2-directed therapies have improved clinical outcomes for many patients with HER2-positive breast and gastric cancer. Despite these successes, there remains a need to develop improved HER2-targeted therapies for these and other HER2-expressing tumors, particularly in the setting of recurrent or metastatic disease. Zanidatamab (ZW25) is a humanized, bispecific, immunoglobulin (Ig) G1-like antibody directed against the juxtamembrane extracellular domain (ECD4) and the dimerization domain (ECD2) of human epidermal growth factor receptor 2 (HER2), the same domains targeted by trastuzumab (T) and pertuzumab (P), respectively. Data from the ongoing phase 1 study (NCT02892123) demonstrate that zanidatamab is well tolerated and has single agent activity in patients with advanced HER2-expressing cancers that have progressed after standard of care (SOC) therapies, including HER2-targeted agents such as T, P, and trastuzumab emtansine.1,2 We have previously shown that the unique design and bispecific binding of zanidatamab results in multiple mechanisms of action including increased antibody binding density, potent effector function, improved receptor internalization and HER2 downregulation relative to T.3 To better understand the mechanism by which zanidatamab differentiates itself from T, P and T+P, we recently expanded our mechanistic evaluations including cell surface HER2 aggregation, complement-dependant cytotoxicity (CDC) and inhibition of both tumor cell growth and intracellular signaling. Single molecule-sensitive direct stochastic optical reconstruction microscopy (dSTORM) was used to map HER2 receptor distribution and quantitate the size, density, and frequency of receptor clusters induced by antibody binding. In vitro assessments were performed in a panel of HER2-expressing cell lines using standard assays including CDC with human complement serum and inhibition of both tumor cell growth and intracellular signaling. Using dSTORM, we observed that zanidatamab binding resulted in enhanced HER2 aggregation and distinct HER2 capping on the tumor cell surface compared to T, P or T+P. Evaluation of CDC activity in HER2-overexpressing tumor cells demonstrated that zanidatamab, but not T, P or T+P, elicited CDC suggesting that the enhanced HER2 aggregation and capping on the tumor cell surface provides high avidity docking sites to which C1 binds and is activated. Zanidatamab showed further differentiation in the inhibition of both tumor growth and intracellular signaling of HER2-overexpressing cells compared to T, P and T+P. Zanidatamab has novel cell surface binding and additional mechanisms of action compared to T, P and T+P. Zanidatamab is actively being evaluated in clinical trials in multiple HER2-expressing solid tumors, including a registration-enabling clinical trial in HER2 gene amplified biliary tract cancer (NCT04466891).

Citation Format: Nina E. Weisser, Grant Wickman, Libin Abraham, Jason O'Toole, Bryant Harbourne, Joy Guedia, Chi Wing Cheng, Peter Chan, Duncan Browman, Michael R. Gold, Neil Josephson, Surjit Dixit, Gerry Rowse. The bispecific antibody zanidatamab's (ZW25's) unique mechanisms of action and durable anti-tumor activity in HER2-expressing cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1005.

Molecular response of a sub-antarctic population of the blue mussel (Mytilus edulis platensis) to a moderate thermal stress

The Kerguelen Islands (49°26'S, 69°50'E) represent a unique environment due to their geographical isolation, which protects them from anthropogenic pollution. The ability of the endemic mussel, part of the Mytilus complex, to cope with moderate heat stress was explored using omic tools. Transcripts involved in six major metabolic functions were selected and the qRT-PCR data indicated mainly changes in aerobic and anaerobic energy metabolism and stress response. Proteomic comparisons revealed a typical stress response pattern with cytoskeleton modifications and elements suggesting increased energy metabolism. Results also suggest conservation of protein homeostasis by the long-lasting presence of HSP while a general decrease in transcription is observed. The overall findings are consistent with an adaptive response to moderate stresses in mussels in good physiological condition, i.e. living in a low-impact site, and with the literature concerning this model species. Therefore, local blue mussels could be advantageously integrated into biomonitoring strategies, especially in the context of Global Change.

Surgery Performed by Supervised Trainees Does not Affect Outcome in First Metatarsophalangeal Joint (MTPJ) Arthrodesis

First metatarsophalangeal joint (MTPJ) arthrodesis is an index procedure for orthopedic trainees in the United Kingdom. There is an absence of evidence as to the outcome of surgery when performed by supervised trainees. The aim of this study is to compare the incidence of fusion, complication rate and radiographic outcomes in first MTPJ arthrodesis performed by supervised orthopedic trainees with consultants. This is a retrospective cohort study of 117 patients undergoing first MTPJ arthrodesis from August 2015 to December 2017 in our institute for hallux valgus (HV) deformity with first MPTJ arthrosis or for hallux rigidus. Patients were followed to a minimum of 1-year postsurgery and were given an open appointment thereafter. In the hallux rigidus group, there was no significant difference between the complication rate (p = .477), incidence of fusion (p = .663), postoperatively HVA (p = .763), and postoperative intermetatarsal angle (p = .539) between trainees and consultants. There was a significant difference in mean tourniquet time (p = .563) between trainees and consultants. In the hallux valgus group, there was no significant difference in the complication rate (p = .519), incidence of fusion (p = .786), tourniquet time (p = .075), postoperative HVA (p = .423), and postoperative intermetatarsal angle (p = .143) between the trainees and consultants. This is the first MTPJ fusion series that demonstrates good results can be achieved by supervised trainees performing the procedure. This would suggest that first MTPJ arthrodesis remains an opportunity for trainees to continue learning to perform under supervision whilst ensuring no change in outcome for the patient.

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BACKGROUND

Pilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.

METHODS

Ovid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.

RESULTS

Of the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.

CONCLUSIONS

This review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment

BACKGROUND

Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD.

METHODS

This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement.

RESULTS

Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance.

CONCLUSIONS

TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.

Clinical and laboratory impact of concomitant syphilis infection during acute HIV

INTRODUCTION

Cognitive impairment has been reported in people living with HIV-1 (PLWH) with prior syphilis, while PLWH who present with incident syphilis have reduced blood CD4 T-lymphocyte and elevated HIV-1 RNA levels. However, the clinical, virological and neurocognitive effects of syphilis during acute HIV-1 (AHI) remain unknown.

METHODS

Pre-antiretroviral therapy laboratory outcomes and neurocognitive performance in a four-test battery in the SEARCH10/RV254 AHI cohort were compared according to syphilis status, determined by serum Treponema pallidum haemagglutination (TPHA), Venereal Disease Research Laboratory (VDRL) and syphilis treatment history. Impaired cognitive performance was defined as having z-scores ≤ -1 in at least two tests or ≤ -2 in at least one test.

RESULTS

Out of 595 AHI participants (97% male, median age of 26 years and estimated duration of HIV-1 infection of 19 days), 119 (20%) had history of syphilis (TPHA-positive), of whom 51 (9%) had untreated syphilis (TPHA-positive/VDRL-positive/without prior treatment). Compared with those without syphilis (TPHA-negative), individuals with untreated syphilis had higher CD8 T-lymphocyte levels but not higher plasma HIV-1 RNA or lower CD4 T-lymphocyte levels. Taking into account estimated duration of HIV-1 infection (P < 0.001), and later Fiebig stages (III-V) (P < 0.001), those with untreated syphilis had higher CD8 T-lymphocyte levels (P = 0.049). Individuals with any syphilis (TPHA-positive), but not untreated syphilis, had higher odds of impaired cognitive performance than those without (P = 0.002).

CONCLUSIONS

During AHI, individuals with any history of syphilis (TPHA-positive) had poorer cognitive performance than those without syphilis. However, syphilis was not associated with worsened HIV disease measures as described in chronic infection.

Apolipoprotein E Polymorphism and Frailty: Apolipoprotein ε4 Allele Is Associated with Fatigue but Not Frailty Syndrome in a Community-Dwelling Older Population Cohort

OBJECTIVE

Frailty is known to be influenced by genetics, however, little evidence on the association of Apolipoprotein E (ApoE) genotype and frailty exists which we aim to investigate.

DESIGN

This study is a cross-sectional analysis from a prospective longitudinal study cohort.

SETTING AND PARTICIPANTS

Community-dwelling individuals aged 55 years and older from Beijing region in China.

MEASUREMENTS

A total of 3,569 older adults with a mean age of 75.06(±6.79) years were included. We investigated the association between ApoE polymorphism and frailty syndrome using the frailty index (FI) and frailty phenotype (including association with individual components of the frailty phenotype). Logistic regressions were performed to investigate the relation between ApoE variants and frailty.

RESULTS

There was no significant association between ApoE variants and frailty as assessed by the FI. In the age and sex-adjusted model, compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost 1.5 times higher odds of being frail as assessed by the frailty phenotype. However, the significance was lost on the model with adjustment for cognitive impairment. Compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost two times higher odds of fatigue. ApoE e4 heterozygotes had higher odds of fatigue compared to ApoE e4 non-carriers. No significant association was found between ApoE variants and other components of frailty phenotype.

CONCLUSIONS

Our findings do not support an association between ApoE genotype and frailty irrespective of the frailty assessment tools. Fatigue in older adults is the only component of frailty phenotype influenced by ApoE genotype.

Intrinsic Capacity as a Determinant of Physical Resilience in Older Adults

The traditional disease-oriented model of healthcare is inadequate to address the needs of the older population. Greater attention should be given to strategies that promote healthy aging. Recently proposed constructs of intrinsic capacity (IC) and physical resilience (PR) hold great potential to reshape geriatric medicine and aging research. These constructs accentuate the positive health attributes of older people in contrast to the popular frailty construct that is centered on functional deficits. IC was introduced by the World Health Organization (WHO) as a composite of all the physical and mental capacities. WHO has emphasized enhancement of IC throughout the life course so as to maintain functional ability in old age. PR, recently highlighted by the National Institute on Aging, is the ability to successfully cope with stressors. High levels of resilience can result in desirable clinical and functional outcomes after stressors. Therefore, it is important to understand the underlying physiology of PR and the risk factors contributing to diminished PR. The main goal of this article is to explore the potential relationship between IC and PR. Based on a classical theory of aging, we postulate that IC is a determinant of PR and is also a high-level integrative measure of physiologic reserve which is the fundamental factor underlying one's ability to withstand stressors. A major implication of our postulates is that even though IC is only one of the many determinants of PR, it could serve as an important intervenable target for enhancing resilience in older adults.

Frailty in China: From Research to Practice

Although geriatric research in general has increased in recent years, there is no effective treatment for frailty. Among older adults, those with frailty have an increased risk of falls, disability, and death. The population of older adults has increased rapidly in China, and resulting in an increased demand for medical care services for older adults, including those with frailty. However, much of the research on frailty has been conducted in Europe and the United States, and European and American standards for frailty are not always applicable to Chinese individuals. Clinicians and researchers in China have shown increasing interest in frailty in recent years. Here, we reviewed the current state of frailty research in China.

High-resolution analyses of human sperm dynamic methylome reveal thousands of novel age-related epigenetic alterations

Background

Children of aged fathers are at a higher risk of developing mental disorders. Alterations in sperm DNA methylation have been implicated as a potential cause. However, age-dependent modifications of the germ cells’ epigenome remain poorly understood. Our objective was to assess the DNA methylation profile of human spermatozoa during aging.

Results

We used a high throughput, customized methylC-capture sequencing (MCC-seq) approach to characterize the dynamic DNA methylation in spermatozoa from 94 fertile and infertile men, who were categorized as young, 48 men between 18–38 years or old 46 men between 46–71 years. We identified more than 150,000 age-related CpG sites that are significantly differentially methylated among 2.65 million CpG sites covered. We conducted machine learning using our dataset to predict the methylation age of subjects; the age prediction accuracy based on our assay provided a more accurate prediction than that using the 450 K chip approach. In addition, we found that there are more hypermethylated (62%) than hypomethylated (38%) CpG sites in sperm of aged men, corresponding to 798 of total differential methylated regions (DMRs), of which 483 are hypermethylated regions (HyperDMR), and 315 hypomethylated regions (HypoDMR). Moreover, the distribution of age-related hyper- and hypomethylated CpGs in sperm is not random; the CpG sites that were hypermethylated with advanced age were frequently located in the distal region to genes, whereas hypomethylated sites were near to gene transcription start sites (TSS). We identified a high density of age-associated CpG changes in chromosomes 4 and 16, particularly HyperDMRs with localized clusters, the chr4 DMR cluster overlaps PGC1α locus, a protein involved in metabolic aging and the chr16 DMR cluster overlaps RBFOX1 locus, a gene implicated in neurodevelopmental disease. Gene ontology analysis revealed that the most affected genes by age were associated with development, neuron projection, differentiation and recognition, and behaviour, suggesting a potential link to the higher risk of neurodevelopmental disorders in children of aged fathers.

Conclusion

We identified thousands of age-related and sperm-specific epigenetic alterations. These findings provide novel insight in understanding human sperm DNA methylation dynamics during paternal aging, and the subsequently affected genes potentially related to diseases in offspring.

The Cytoplasmic Droplets of Rat Epididymal Spermatozoa Show Diminution of Glycosyl Transferases During Spermatozoa Epididymal Maturation

The cytoplasmic droplet of the epididymal spermatozoon is a small localized outpouching of cytoplasm of the tail and is of unknown significance. Electron microscopy revealed flattened saccular elements of almost exclusive membranous components. In this study, a simple, reproducible method for the isolation of saccular elements from the caput and the cauda of rat epididymal spermatozoa is presented. Using exogenous glycosylation assays and immunocytochemistry for light and electron microscopy, we confirm the presence of three Golgi markers in the saccular elements of rat cytoplasmic droplets, namely, a-2,6-sialyltransferase, b- 1,4-galactosyltransferase and TGN-38 (trans-Golgi network protein). The variation in galactosyltransferase activity of isolated saccular elements in response to in vitro trypsinization was similar to that observed in the rat liver Golgi apparatus. Electrophoresis and immunoblotting analyses revealed polypeptide modifications in the saccular elements during spermatozoa epididymal transit. In addition, a significant decline in the content of galactosyltransferase and sialyltransferase occurred in the saccular elements during spermatozoa transit from the caput to the cauda epididymides. The content of TGN-38, however, did not show any significant change, suggesting that the modification of the content of the saccular elements is selective. Considering the glycosylating ability of the saccular elements and that the diminution of glycosyltransferase activities in cytoplasmic droplets coincides with the maturation of spermatozoa during epididymal transit, we suggest a potential role for the saccular elements of cytoplasmic droplets in the maturation of spermatozoa during their transit through the epididymis.

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

Background

Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both.

Methods

Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for &gt;20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival.

Results

Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P&lt;0.001) than post-resuscitation survival (rho=0.90, P&lt;0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P&lt;0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P&lt;0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11).

Conclusion

Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NHLBI

A Randomized Sham-controlled Trial of 1-Hz and 10-Hz Repetitive Transcranial Magnetic Stimulation (rTMS) of the Right Dorsolateral Prefrontal Cortex in Civilian Post-traumatic Stress Disorder: Un essai randomisé contrôlé simulé de stimulation magnétique transcrânienne repetitive (SMTr) de 1 Hz et 10 Hz du cortex préfrontal dorsolatéral droit dans le trouble de stress post-traumatique chez des civils

OBJECTIVE

Despite effective psychological and pharmacological treatments, there is a large unmet burden of illness in post-traumatic stress disorder (PTSD). Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive intervention and a putative treatment strategy for PTSD. The evidence base to date suggests that rTMS targeting the dorsolateral prefrontal cortex (DLPFC), in particular the right DLPFC, leads to improvements in PTSD symptoms. However, optimal stimulation parameters have yet to be determined. In this study, we examine the efficacy of high- and low-frequency rTMS of the right DLPFC using a randomized, double-blind, sham-controlled design in civilian PTSD.

METHODS

We conducted a 2-week single-site randomized sham-controlled trial of rTMS targeting the right DLPFC. We recruited civilians aged 19 to 70 with PTSD and randomized subjects with allocation concealment to daily 1-Hz rTMS, 10-Hz rTMS, or sham rTMS. The primary outcome was improvement in Clinician Administered PTSD Scale-IV (CAPS-IV). Secondary outcomes included change in depressive and anxiety symptoms.

RESULTS

We recruited 31 civilians with PTSD. One 1-Hz-treated patient developed transient suicidal ideation. Analyses revealed significant improvement in CAPS-IV symptoms in the 1-Hz group relative to sham (Hedges' g = -1.07) but not in the 10-Hz group. This was not attributable to changes in anxious or depressive symptomatology. Ten-Hz stimulation appeared to improve depressive symptoms compared to sham.

CONCLUSION

Low-frequency rTMS is efficacious in the treatment of civilian PTSD. Our data suggest that high-frequency rTMS of the right DLPFC is worthy of additional investigation for the treatment of depressive symptoms comorbid with PTSD.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Predictors of infertility-related concerns in a Canadian survey of men and women seeking fertility treatment

OBJECTIVE

To examine if and how factors associated with infertility-related concerns and opportunity to discuss concerns differ between male and female fertility patients.

METHODS

A cross-sectional survey of 313 female and 254 male patients recruited from Canadian fertility clinics. An online survey asked about sociodemographic characteristics, psychological distress, the severity of psychosocial concerns on a scale of 0 (not concerned) to 5 (very concerned) related to fertility treatment, and their opportunity and desire to discuss concerns with healthcare providers (HCPs).

RESULTS

For women, higher stress, educational attainment and being childless were associated with higher concern (F(6, 287) = 14.73, p < .001). For men, higher stress, being religious and longer treatment duration were associated with higher concern (F(8, 222) = 9.87, p < .001). No significant difference existed between men's and women's average concern scores (t(558) = -1.62, p = .11) or opportunity to discuss concerns (t(149) = 0.28, p = .78).

CONCLUSION

Our results indicate an unmet need and desire for support among subgroups of patients who were concerned about psychosocial issues related to infertility, but did not have the opportunity to discuss these issues with HCPs.

PRACTICE IMPLICATIONS

There is a need to tailor resources to address the concerns of male and female fertility patients from diverse sociodemographic backgrounds and with different fertility histories.

Correlations of phthalate metabolites in urine samples from fertile and infertile men: Free-form concentration vs. conjugated-form concentration

In previous studies, the total content of urinary phthalate metabolites was commonly used to evaluate human exposure to phthalates. However, phthalate metabolites are mainly present in urine in two forms, conjugated and free. These metabolite forms in urine are more relevant to the biotransformation pathways of the phthalates in humans. Therefore, the concentration of these forms is more relevant to exposure related health outcomes than total content. In this study, instead of measuring total content, the free- and conjugated-form concentrations of phthalate metabolites in the urine of fertile and infertile men were measured. The main metabolites in urine of both groups are monoethyl phthalate (MEP) and the di-(2-ethylhexyl) phthalate (DEHP) metabolites. The geometric means of their both conjugated- and free-forms in the infertile group were higher than in the fertile group, specifically, 24.3 and 43.4 μg/g creatinine vs 8.5 and 28.9 μg/g creatinine, respectively, for MEP, and 50.0 and 9.1 μg/g creatinine vs 39.1 and 8.4 μg/g creatinine, respectively for total DEHP metabolites. We investigated the correlations of free- and conjugated-form phthalate metabolite concentrations between the infertile and fertile group as well as among different phthalate metabolites. The results showed that there was a statistically significant difference between the infertile and fertile group for monobenzyl phthalate (MBzP) in both free-form and conjugated-form. However, there was only a statistically significant difference between the two groups for conjugated-form MEP and MEHP, and no statistically significant difference between the two groups for free-form MEP and MEHP. The results of the Pearson correlation test revealed that the correlations between DEHP metabolites and the correlations between mid-sized phthalate metabolites (mono-n-butyl phthalate (MnBP), mono-isobutyl phthalate (MiBP) and mono-benzyl phthalate (MBzP)) were stronger than between these two clusters of metabolites. This study is the first attempt to examine possible effects of conjugated-form concentrations of phthalate metabolites on human fertility. The results of this study suggest that conjugated-form and free-form concentrations of urinary phthalate metabolites may be appropriate biomarkers for assessing human exposure to phthalates and association with health outcomes.

Report from the First Clinical Trials on Alzheimer's Disease (CTAD) Asia-China 2018 : Bringing together Global Leaders

Population of older adults in Asia, and particularly in China is increasing rapidly. Older population are at increased risk of Alzheimer's disease (AD) and other dementias. Soon, the Chinese population with AD will represent almost half of the world's AD population. There is a desperate need of disease modifying therapies to delay or slow the progression of AD, to tackle this emerging healthcare emergency. In this context, the first CTAD Asia-China conference was held in China to bring together Western and Asian leaders in AD. This meeting focused largely on how to develop successful trials in China, utilizing past experiences from the West.