Hospital-wide healthcare-associated carbapenemase-producing Enterobacterales outbreak: risks of electric floor scrubbers in catering facilities and kitchens

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) are associated with poor clinical outcomes and can spread rapidly in healthcare settings. Environmental reservoirs are increasingly recognized as playing an important part in some nosocomial outbreaks.

AIM

To describe the investigation and control of a CPE outbreak, lasting several years, across two separate hospital sites within one organization.

METHODS

Investigation of multiple ward-level CPE cross-transmissions with a number of sporadic cases. Environmental sampling of ward environments, catering facilities and electric floor scrubbers was undertaken.

FINDINGS

Eleven patients over a 19-month period were identified as carrying healthcare-associated New Delhi metallo-beta-lactamase (NDM)-producing Enterobacter cloacae, and a further patient carried NDM Escherichia coli. E. cloacae isolates were indistinguishable on pulsed-field gel electrophoresis typing, supporting acquisition with a single point source. Environmental sampling found contamination of the electric floor scrubbers used for cleaning the hospital catering facilities and in the associated toilets. Standard outbreak response measures achieved control of ward outbreaks. Sporadic cases and hospital-wide cross-transmission were controlled after interventions on the central food-handling unit and by decommissioning affected floor scrubbers. Electric floor scrubbers were found to have the potential to disperse Gram-negative bacteria into the surrounding environment under experimental conditions.

CONCLUSION

This outbreak report demonstrates that catering facilities and kitchens can be involved in widespread healthcare outbreaks of enteric organisms. This is also the first report of the potential role of electric floor scrubbers in causing significant environmental contamination with CPE which may indicate a role in nosocomial transmission.

Real-World Analysis of Treatment Patterns and Platinum-Based Treatment Eligibility of Patients With Metastatic Urothelial Cancer in 5 European Countries

INTRODUCTION

The global treatment landscape for metastatic urothelial cancer (mUC) is evolving, with the recent approval of several new therapeutics. To enable informed treatment decisions, a need exists to understand both treatment patterns and how physicians determine platinum-based treatment eligibility status. This study investigated physicians' current approaches to first-line (1L) chemotherapy, treatment patterns, and assessment of platinum-based treatment eligibility of patients with mUC in real-world clinical practice.

PATIENTS AND METHODS

Data were derived from the Adelphi mUC Disease Specific Programme™, a large, independent, multinational, cross-sectional survey of physicians and their consulting patients with mUC presenting in a real-world clinical setting, conducted in France, Germany, Italy, Spain, and the United Kingdom between November 2020 and April 2021. Physicians completed record forms for their next 8 consecutively consulting patients (≤3 1L, ≤2 second-line, and ≤3 third-line) with a physician-confirmed diagnosis of mUC, reporting data on demographics, clinical characteristics, eligibility for platinum-based chemotherapy, and treatments received.

RESULTS

Overall, 232 physicians provided data for 1922 patients. Renal function impairment (72%), Eastern Cooperative Oncology Group performance status (59%), and age (38%) were the most commonly reported criteria physicians used to determine eligibility for platinum-based chemotherapy. At 1L, 82% of patients received platinum-based chemotherapy (cisplatin, 51%; carboplatin, 31%) and 10% received immune checkpoint inhibitor (ICI) therapy. At second-line, 12% received platinum-based chemotherapy, 63% ICI therapy, and 21% non-platinum-based chemotherapy. At third-line, 4% received platinum-based chemotherapy, 41% best supportive care only, and 36% other non-platinum-based chemotherapy.

CONCLUSIONS

The results of this real-world study indicate that in accordance with European guidelines, the majority of patients with mUC received standard-of-care 1L platinum-based chemotherapy and use of ICIs was limited. Future research should assess how physicians' perceptions toward determining platinum eligibility status evolve with newer guideline recommendations and the introduction of new therapy options for mUC.

Real-World Treatment Trends Among Patients with Metastatic Castration-Sensitive Prostate Cancer: Results from an International Study

BACKGROUND

Continuous androgen deprivation therapy ± first-generation non-steroidal antiandrogen was previously the standard-of-care for patients with metastatic castration-sensitive prostate cancer (mCSPC). Treatment intensification with novel hormonal therapy (NHT) or taxane chemotherapy is now approved and guideline-recommended for these patients.

METHODS

Physician-reported data on adult patients with mCSPC from the Adelphi Prostate Cancer Disease Specific Programme were analyzed descriptively. We evaluated real-world treatment trends for patients with mCSPC in 5 European countries (United Kingdom, France, Germany, Spain, and Italy) and the United States (US), looking at differences between patients initiating treatment in 2016-2018 and in 2019-2020. We also investigated treatment trends by ethnicity and insurance status in the US.

RESULTS

This study found that most patients with mCSPC do not receive treatment intensification. However, greater use of treatment intensification with NHT and taxane chemotherapy was observed in 2019-2020 than in 2016-2018 across 5 European countries. In the US, greater use of treatment intensification with NHT in 2019-2020 than in 2016-2018 was observed for all ethnicity groups and those with Medicare and commercial insurance status.

CONCLUSIONS

As the number of patients with mCSPC who receive treatment intensification increases, more patients who progress to metastatic castration-resistant prostate cancer (mCRPC) will have been exposed to intensified treatments. Treatment options for patients with mCSPC and mCRPC overlap, suggesting that an unmet need will emerge for new therapies. Further studies are needed to understand optimal treatment sequencing in mCSPC and mCRPC.

Real-World Treatment Patterns Among Patients With Metastatic Castration-Resistant Prostate Cancer: Results From an International Study

BACKGROUND

There is limited real-world evidence on how increasing use of treatment intensification in metastatic castration-sensitive prostate cancer (mCSPC) has influenced treatment decisions in metastatic castration-resistant prostate cancer (mCRPC). The study objective was to evaluate the impact of novel hormonal therapy (NHT) and docetaxel use in mCSPC on first-line treatment patterns among patients with mCRPC in 5 European countries and the United States (US).

METHODS

Physician-reported data on patients with mCRPC from the Adelphi Prostate Cancer Disease Specific Program were descriptively analyzed.

RESULTS

A total of 215 physicians provided data on 722 patients with mCRPC. Across 5 European countries and the US, 65% and 75% of patients, respectively, received NHT, and 28% and 9% of patients, respectively, received taxane chemotherapy as first-line mCRPC treatment. In Europe, patients who had received NHT in mCSPC (n = 76) mostly received taxane chemotherapy in mCRPC (55%). Patients who had received taxane chemotherapy, or who did not receive taxane chemotherapy or NHT in mCSPC (n = 98 and 434, respectively) mostly received NHT in mCRPC (62% and 73%, respectively). In the US, patients who had received NHT, taxane chemotherapy, or neither in mCSPC (n = 32, 12, and 72, respectively) mostly received NHT in mCRPC (53%, 83%, and 83%, respectively). Two patients in Europe were rechallenged with the same NHT.

CONCLUSIONS

These findings suggest that physicians consider mCSPC treatment history when making first-line treatment decisions in mCRPC. Further studies are needed to better understand optimal treatment sequencing, especially as new treatments emerge.

Real-world homologous recombination repair (HRR) mutation testing patterns in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) in the United States (US)

99

Background: A subset of pts with metastatic prostate cancer have HRR mutations. These can be either germline or somatic mutations. Previous studies have established a prognostic and predictive role of HRR mutations and there are ongoing trials (e.g., TALAPRO-3, AMPLITUDE) exploring combination strategies of poly-ADP ribose polymerase inhibitors (PARPi) with novel hormonal therapies (NHT). Therefore, it is relevant to establish baseline HRR testing rates in the real-world setting. This study assessed real-world (rw) HRR testing patterns in pts with mCSPC in the US and described characteristics of tested vs untested pts. Methods: Data were drawn from the Adelphi Prostate Cancer Disease Specific Programme; a point-in-time questionnaire administered to oncologists and urologists in the US between January-August 2020. Physicians abstracted medical records for the next 4-9 pts receiving active drug treatment for mCSPC. Study variables included pt demographics, clinical factors, physician characteristics, and testing status for at least 1 of 12 HRR genes of interest ( ATM, ATR, BRCA1, BRCA2, CDK12, CHEK2, FANCA, MLH1, MRE11A, NBN, PALB2, RAD51C). Pt demographics and clinical characteristics were compared between groups using t-tests for continuous and chi-squared or Fisher’s exact test for categorical variables. A multiple logistic regression model was used to assess factors associated with odds of HRR testing. Results: A total of 71 physicians reported on 204 pts with mCSPC. The median age was 68.8. 57/204 (28%) pts were tested for HRR mutations using germline or tumor testing. Pts who were not HRR tested were older compared to HRR tested pts (69.6 vs 66.8, P = 0.038). More pts currently receiving care by an oncologist had a HRR mutation test vs. pts currently receiving care by a urologist [50/156 (32%) vs 7/48 (15%), P =0.02]. According to the multiple logistic regression model, having a known family history of prostate cancer [OR = 3.9 (95% CI: 1.1 – 13.6); P = 0.04], and having visceral metastases at mCSPC diagnosis [OR=4.9 (95% CI: 2.0 – 12.1); P = 0.001] were associated with a significantly higher odds of receiving a HRR mutation test. Conclusions: In this rw US study of adult patients with mCSPC, most patients did not receive HRR testing. Disparities in HRR mutation testing were observed, suggesting that clinical characteristics may influence decisions to test for HRR mutations. Focused efforts to increase HRR mutation testing should be implemented.

Real world (rw) homologous recombination repair (HRR) gene mutation testing trends in patients (pts) with metastatic castrate-resistant prostate cancer (mCRPC) in the United States (US)

98

Background: Previous research suggests that HRR mutations may have prognostic value in mCRPC. Additionally, HRR mutations are therapeutically relevant and can inform treatment decisions. Limited information is available on HRR mutation testing rates in the US. This study assessed rw HRR testing patterns in pts with mCRPC in the US and described characteristics associated with HRR testing. Methods: Retrospective data from pts with mCRPC initiating first line (1L) treatment between 2014 – 2021 was obtained from the nationwide Flatiron Health electronic health record-derived de-identified database. Pt demographic and clinical characteristics were summarized descriptively across subgroups by HRR gene testing status (tested vs not tested). A multivariable logistic regression model was used to assess factors associated with receiving HRR testing, and included covariates for demographic, clinical, and treatment characteristics. Results: A total of n=8,166 pts with mCRPC receiving 1L treatment were identified. The mean age of the cohort was 72.9 (standard deviation (SD) 8.1) years. Overall, 2,122/8,166 (26%) were known to have received HRR mutation testing. Pts who did not receive HRR testing were older compared to HRR tested pts (mean age 73.7 (SD 8.5) vs 70.6 (SD 7.5) years). A higher proportion of HRR tested were receiving treatments from an academic medical center vs community practice (14.5% vs. 7.7%). Multivariable logistic regression indicated age > 65 (vs < 65 years), Black race (vs White), being treated in the community (vs academic), and having de novo metastatic disease (vs recurrent) were associated with a statistically significant lower odds of HRR mutation testing. In contrast, a higher socioeconomic status and being diagnosed with mCRPC after 2018 were associated with a statistically significant increased odds of HRR mutation testing. Conclusions: In this rw study, a minority of US pts with mCRPC received HRR mutation testing. Disparities in HRR mutation testing exist, and focused efforts to increase HRR testing should be developed, especially among Black pts, pts with lower socioeconomic status, pts treated in the community setting, and pts > 65 years of age. [Table: see text]

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

Treatment trends among men with metastatic castration sensitive prostate cancer (mCSPC): Results from the US component of an international study

66

Background: Novel hormonal therapies (NHTs) and taxane-based chemotherapy (CT) were initially approved for the treatment of metastatic castration resistant prostate cancer (mCRPC) and are now approved for use in mCSPC. Little is known about the recent uptake of these treatments in mCSPC. This study evaluated mCSPC treatment trends from 2016 to 2020 in the US. Methods: Participating physicians collected information from medical charts for the next consecutive 8 men with advanced prostate cancer (4 men with mCSPC, and 4 men with mCRPC) during January-August 2020. A subset of men with current mCRPC had historical mCSPC treatment information available. Treatments were categorized into 4 mutually exclusive categories: (1) androgen deprivation therapy (ADT) ± first-generation anti-androgen (1st gen AA); treatment intensification with (2) NHT, (3) taxane CT ± NHT, and (4) other treatments (e.g., radium-223, sipuleucel-T, non-taxane CT). To account for the availability of new mCSPC treatments, treatment patterns across all lines of mCSPC therapy were described for men initiating treatment in 2016-2018 and 2019-2020. Results: 239 men with mCSPC were included (146 with mCSPC at data collection; 93 with mCRPC at data collection and who had historical information on mCSPC treatments). Mean age was 69 years; 69% had bone metastases and 30% had visceral metastases. Most patients were managed by oncologists (75%), while 48% were treated at academic/cancer centers. From 2016-2018 to 2019-2020, mCSPC treatment intensification with NHT increased while treatment intensification with taxane CT or other therapies declined. (Table) Conclusions: In this real-world study of adult men with mCSPC, increased use of NHT was observed over time indicating that more men will have been exposed to NHT when they progress to mCRPC. This suggests an unmet need for novel therapies in mCRPC. Funding: Pfizer. [Table: see text]

Criteria used to determine platinum eligibility and first-line (1L) treatment (tx) patterns among platinum-eligible (PE) and -ineligible (PI) patients (pts) with metastatic urothelial cancer (mUC) in France, Germany, Spain, Italy, and the United Kingdom (Eu5)

457

Background: European Society for Medical Oncology (ESMO) guidelines recommend tx for mUC based on cisplatin and platinum eligibility. To date, most real-world analyses have not included physician-confirmed eligibility status. This study collected mUC patient data in Eu5 and summarized the criteria used in the real-world setting to determine PE and 1L tx prescribed based on PE. Methods: Data were drawn from the Adelphi mUC Disease-Specific Programme, a real-world point-in-time study conducted from November 2020 to April 2021. Oncologists and urologists were enrolled in the study and recruited the next 8 eligible pts who came for a consultation. Demographic, clinical characteristics, platinum eligibility, and tx patterns were collected. Results: Physicians provided data on 1,868 mUC pts who were receiving or had completed 1L tx and had a known PE status as determined by a physician prior to 1L tx. Renal function contributed to physicians’ platinum eligibility decisions for 72% of pts; ECOG score and age were used in 59% and 38% of pts, respectively. The mean (SD) age was 69.1 (7.88) years and 73% were men. At initial mUC diagnosis (dx), 25% were PD-L1–positive, 17% were PD-L1–negative, and 58% had either unknown PD-L1 status or were not tested. 87% of pts were PE (55% were eligible for cisplatin and carboplatin; 31% were cisplatin ineligible), and 13% were PI. PE pts who were eligible for cisplatin and carboplatin were younger than cisplatin ineligible and PI pts (66.6, 71.9 and 73.1 years, respectively). The percentage of pts with ECOG 0 or 1 at dx was 92%, 79%, and 67% for cisplatin and carboplatin eligible, cisplatin ineligible, and PI pts respectively. Conclusions: Only a small proportion of pts were classified as PI. The majority of PE pts received guideline-recommended tx with platinum-based regimens in the 1L. Overall, there was limited use of immune checkpoint inhibitor tx in the 1L, with use observed primarily among PI pts. Some guideline deviations were observed, including pts deemed PI who still received platinum-based chemotherapy. Recently, ESMO guidelines were updated to include avelumab for 1L maintenance tx in PE pts. Future studies should evaluate concordance with updated guideline recommendations in PE pts and rationale for guideline deviations.[Table: see text]

Use of perioperative treatment (tx) among patients (pts) undergoing radical resection (RR) for muscle-invasive urothelial cancer (MIUC) in France, Germany, Italy, Spain, the United Kingdom, the United States, Canada, China, and Japan

467

Background: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by RR is the standard of care in cisplatin-eligible pts with MIUC. Adjuvant chemotherapy (AC) with cisplatin-based tx may be offered to those not given NAC. The unmet need this survey tried to evaluate is the post-RR burden of disease, quality of life (QoL) and perioperative tx patterns among MIUC pts. Methods: Real-world descriptive data were drawn from Adelphi’s MIUC Disease-Specific Programme: A point-in-time survey conducted with clinical/medical oncologists/urologists and their pts in 9 countries between January and June 2021. Physicians completed a survey on their pts’ clinical characteristics and tx patterns, while pts voluntarily completed a series of patient-reported outcome measures. Results: Of 2178 pts (data provided by 320 physicians), 30% received NAC only, 26% received AC only, 38% received no NAC or AC tx, and 6% received both. 1744 pts had initial tumour in the bladder; 35% received NAC only, 24% AC only, 35% no NAC or AC tx, and 6% received both. Of 387 pts with upper-tract urothelial carcinoma (UTUC), 51% received no NAC/AC tx, 35% received AC only, and 12% NAC only. More pts with T3 disease received no NAC/AC tx (36%) or NAC (35%) than AC (24%). Of 734 pts with nodal disease, 36% received NAC only. Of all pts, 60% experienced symptoms at data abstraction: 50% in pts who received NAC only, 71% in pts who received AC only and 82% in pts of those who received both. Pts reported similar EQ-5D-5L utility index scores (mean = 0.86; range: 0.84 [AC only] to 0.89 [NAC only]). Overall, feeling pain (40%) and stress (39%) were the EQ-5D domains with the worst scores. Pts who received AC only reported nominally lower EQ-5D visual analogue scale scores (71.11) compared with pts who received no NAC/AC (73.17) or pts who received NAC only (75.05). EORTC QLQ-C30 Global Health Status scores were 60.0 in pts who received AC only, 64.1 in pts who received NAC only or no NAC/AC, and 66.7 for pts who received both NAC and AC. Conclusions: Nearly 40% of pts remain untreated in either NAC or AC setting in 9 countries. A higher proportion of pts with UTUC go untreated. AC was more frequently used in UTUC vs BC pts; and in pts with Tis. NAC was implemented more frequently in pts T3 disease and in those with N+ disease. Pts who received AC appear to have nominally worse QOL and more symptoms, further demonstrating the need for efficacious adjuvant tx that does not decrease post-RR QoL.[Table: see text]

Treatment (tx) patterns among men with metastatic castration resistant prostate cancer (mCRPC) in the United States (US)

52

Background: Novel hormonal therapies (NHTs) and docetaxel were initially approved for the tx of men with mCRPC. Over time, these agents moved earlier in the disease continuum and are now also used in metastatic castration sensitive prostate cancer (mCSPC). Little is known about first-line (1L) mCRPC tx patterns for men with prior taxane-based chemotherapy (CT) or NHT exposure. This study evaluated the impact of taxane CT or NHT use in mCSPC on recent 1L tx patterns among men with mCRPC in the US. Methods: Participating physicians collected information from medical charts for the next consecutive 4 adult men with mCRPC during January-August 2020. A subset of men had prior mCSPC tx information available. 1L mCRPC txs were described overall and stratified by previous tx with taxane CT or NHT during mCSPC. No statistical comparisons were performed. Results: 116 adult men with mCRPC and known mCSPC tx history were included. Mean age was 70 years; 15% had known family history of prostate cancer; 70% had bone metastases and 33% had visceral metastases at data collection. Overall, 10% (12/116) of men had been previously treated with taxane CT and 28% (32/116) were treated with NHT during mCSPC. 1L mCRPC tx was initiated on average 35 days after mCRPC diagnosis. NHT was the most common 1L mCRPC tx regardless of prior taxane CT or NHT use. Men pre-treated with taxane CT were more likely to initiate mCRPC tx with NHT than taxane naïve men. NHT pre-treated men were less likely to initiate 1L mCRPC tx with NHT and more likely to initiate tx with docetaxel than NHT naïve men. 53% of men with prior NHT tx were rechallenged with NHTs in 1L mCRPC. (Table). Conclusions: Findings from this US real-world study among men with mCRPC suggest physicians most commonly initiate 1L mCRPC life-prolonging tx with NHT regardless of prior taxane CT or NHT exposure. Additional studies with larger sample sizes are needed to confirm these findings and better understand optimal tx sequencing, especially as new tx options become available.[Table: see text]

Deep Exclusive Electroproduction of π^{0} at High Q^{2} in the Quark Valence Regime

We report measurements of the exclusive neutral pion electroproduction cross section off protons at large values of x_{B} (0.36, 0.48, and 0.60) and Q^{2} (3.1 to 8.4  GeV^{2}) obtained from Jefferson Lab Hall A experiment E12-06-014. The corresponding structure functions dσ_{T}/dt+εdσ_{L}/dt, dσ_{TT}/dt, dσ_{LT}/dt, and dσ_{LT^{'}}/dt are extracted as a function of the proton momentum transfer t-t_{min}. The results suggest the amplitude for transversely polarized virtual photons continues to dominate the cross section throughout this kinematic range. The data are well described by calculations based on transversity generalized parton distributions coupled to a helicity flip distribution amplitude of the pion, thus providing a unique way to probe the structure of the nucleon.

An international collaborative study to compare different von Willebrand factor glycoprotein Ib binding activity assays: the COMPASS-VWF study

Essentials New VWF activity assays are increasingly used but information on their comparability is limited. This is an ISTH SSC-organized study (expert labs, 5 countries) to compare all available assays. VWF activity by six assays correlated well with each other. The new assays show improved characteristics - minor differences are noted. SUMMARY: Background Several new assays have become available to measure von Willebrand factor (VWF) activity. The new assays appear to have improved performance characteristics compared with the old reference standard, ristocetin cofactor activity (VWF:RCo), but information is limited about how they compare with VWF:RCo and each other. Methods The von Willebrand factor Subcommittee of the International Society for Thrombosis and Haemostasis (ISTH) Scientific and Standardization Committee (SSC) designed a collaborative study involving expert laboratories from several countries to compare available tests with each other and with VWF:RCo. Eight laboratories from five countries were provided with blinded samples from normal healthy individuals and well-characterized clinical cases. Laboratories measured VWF activity using all tests available to them; data from six laboratories, not affected by thawing during transportation, are included in this study. Results All tests correlated well with VWF:RCo activity (r-values ranged from 0.963 to 0.989). Slightly steeper regression lines for VWF:Ab and VWF:GPIbM were clinically insignificant. The new assays showed improved performance characteristics. Of the commercially available assays, the VWF:GPIbR using the AcuStar system was the most sensitive and could reliably detect VWF activity below 1 IU dL-1 . The lower limit of the measuring interval for the VWF:GPIbM and the VWF:GPIbR assays was in the 3-4 and 3-6 IU dL-1 range, respectively. Inter-laboratory variation was also improved for most new assays. Conclusion All VWF activity assays correlated well with each other and the VWF:RCo assay. The slight differences in characteristics found in the COMPASS-VWF study will assist the VWF community in interpreting and comparing activity results.

The management of tibial fracture non-union using the Taylor Spatial Frame

We reviewed 40 complex tibial non-unions treated with Taylor Spatial Frames. 39 healed successfully. Using the ASAMI scoring, we obtained 33 excellent, 5 good, 1 fair and 1 poor bone results. The functional results were excellent in 29 patients, good in 8, fair in two and poor in one. Mean patient satisfaction score was 95%. All but one patient would have the same treatment again. 28 of the 36 patients in work when injured, returned to work at the time of their final review. Four patients had an adverse event requiring significant intervention. Average treatment cost was approximately £26,000/patient.

Frailty and Health-Related Quality of Life in End Stage Renal Disease Patients of All Ages

BACKGROUND: Frailty is associated with worse health-related quality of life (HRQOL) in older adults and worse clinical outcomes in adults of all ages with end stage renal disease (ESRD). It is unclear whether frail adults of all ages with ESRD are more likely to experience worse HRQOL. OBJECTIVE: The goal of this study was to identify factors associated with worsening HRQOL in this population. DESIGN, SETTING AND MEASUREMENTS: We studied 233 adults of all ages with ESRD enrolled (11/2009-11/2013) in a longitudinal cohort study. Frailty status was measured at enrollment and HRQOL was reported (Excellent, Very Good, Good, Fair or Poor) at the initial assessment and follow-up (median follow-up 9.4 months). We studied factors associated with Fair/Poor HRQOL at follow-up using logistic regression and factors associated with HRQOL change using multinomial regression. All models were adjusted for age, sex, race, education, BMI, diabetes status, history of a previous transplant, type of dialysis and time between assessments. RESULTS: Fair/Poor HRQOL was reported by 28% at initial assessment and 33% at follow-up. 47.2% of participants had stable HRQOL, 22.8% better HRQOL, and 30.0% worse HRQOL at follow-up (P<0.001). In adjusted models, only frailty was associated with Fair/Poor HRQOL at follow-up (OR: 2.79, 95% CI: 1.32-5.90) and worsening HRQOL at follow-up (RR: 2.91, 95%CI: 1.08-7.80). CONCLUSIONS: Frail adults of all ages with ESRD are more likely to experience fair/poor HRQOL and worsening HRQOL over time. Frailty represents a state of decreased physiologic reserve that impacts not only clinical outcomes but also the patient-centered outcome of HRQOL.

Longitudinal target-spin asymmetries for deeply virtual compton scattering

A measurement of the electroproduction of photons off protons in the deeply inelastic regime was performed at Jefferson Lab using a nearly 6 GeV electron beam, a longitudinally polarized proton target, and the CEBAF Large Acceptance Spectrometer. Target-spin asymmetries for ep→e^{'}p^{'}γ events, which arise from the interference of the deeply virtual Compton scattering and the Bethe-Heitler processes, were extracted over the widest kinematics in Q^{2}, x_{B}, t, and ϕ, for 166 four-dimensional bins. In the framework of generalized parton distributions, at leading twist the t dependence of these asymmetries provides insight into the spatial distribution of the axial charge of the proton, which appears to be concentrated in its center. These results also bring important and necessary constraints for the existing parametrizations of chiral-even generalized parton distributions.

Compton scattering for spectroscopic detection of ultra-fast, high flux, broad energy range X-rays

Compton side-scattering has been used to simultaneously downshift the energy of keV to MeV energy range photons while attenuating their flux to enable single-shot, spectrally resolved, measurements of high flux X-ray sources to be undertaken. To demonstrate the technique a 1 mm thick pixelated cadmium telluride detector has been used to measure spectra of Compton side-scattered radiation from a Cobalt-60 laboratory source and a high flux, high peak brilliance X-ray source of betatron radiation from a laser-plasma wakefield accelerator.

Third Åland islands conference on von Willebrand disease, 26-28 September 2012: meeting report

The first meeting of international specialists in the field of von Willebrand disease (VWD) was held in the Åland islands in 1998 where Erik von Willebrand had first observed a bleeding disorder in some members of a family from Föglö and a summary of the meeting was published in 1999. The second meeting was held in 2010 and a report of the meeting was published in 2012. Topics covered included progress in understanding of VWD over the last 50 years; multimers; classification of VWD; pharmacokinetics and laboratory assays; genetics; treating the paediatric patient; prophylaxis; geriatrics; gene therapy and treatment guidelines. This third meeting held over 3 days covered the structure and function of von Willebrand factor (VWF); type 1 VWD, the most common form of the disease; a lifespan of pharmacokinetics in VWD; detecting inhibitors in VWD patients; and special challenges in understanding and treating the female VWD patient.

von Willebrand's disease: a report from a meeting in the Åland islands

von Willebrand's disease (VWD) is probably the most common bleeding disorder, with some studies indicating that up to 1% of the population may have the condition. Over recent years interest in VWD has fallen compared to that of haemophilia, partly the result of focus on blood-borne diseases such as HIV and hepatitis. Now the time has come to revisit VWD, and in view of this some 60 international physicians with clinical and scientific interest in VWD met over 4 days in 2010 in the Åland islands to discuss state-of-the-art issues in the disease. The Åland islands are where Erik von Willebrand had first observed a bleeding disorder in a number of members of a family from Föglö, and 2010 was also the 140th anniversary of his birth. This report summarizes the main papers presented at the symposium; topics ranged from genetics and biochemistry through to classification of VWD, pharmacokinetics and laboratory assays used in the diagnosis of the disease, inhibitors, treatment guidelines in different age groups including the elderly who often have comorbid conditions that present challenges, and prophylaxis. Other topics included managing surgeries in patients with VWD and the role of FVIII in VWF replacement, a controversial subject.

Quantitative detection of promoter hypermethylation as a biomarker of acute kidney injury during transplantation

Aberrant promoter hypermethylation, also known as epigenetics, is thought to be a promising biomarker approach to diagnose malignancies. Kidney repair after injury is a recapitulation of normal morphogenesis, with similarities to malignant transformation. We hypothesized that changes in urine epigenetics could be a biomarker approach during early kidney transplant injury and repair. We examined urine DNA for aberrant methylation of two gene promoters (DAPK and CALCA) by quantitative methylation-specific polymerase chain reaction from 13 deceased and 10 living donor kidney transplant recipients on postoperative day 2 and 65 healthy controls. Results were compared with clinical outcomes and to results of the kidney biopsy. Transplant recipients were significantly more likely to have aberrant hypermethylation of the CALCA gene promoter in urine than healthy controls (100% vs 31%; P < .0001). There was increased CALCA hypermethylation in the urine of deceased versus living donor transplants (21.60 +/- 12.5 vs 12.19 +/- 4.7; P = .04). Furthermore, there was a trend toward increased aberrant hypermethylation of urine CALCA in patients with biopsy-proven acute tubular necrosis versus acute rejection and slow or prompt graft function (mean: 20.40 +/- 6.9, 13.87 +/- 6.49, 17.17 +/- 13.4; P = .67). However, there was no difference of CALCA hypermethylation in urine of patients with delayed graft function versus those with slow or prompt graft function (16.9 +/- 6.2 vs 18.5 +/- 13.7, respectively; P = .5). There was no aberrant hypermethylation of DAPK in the urine of transplant patients. Urine epigenetics is a promising biomarker approach for acute ischemic injury in transplantation that merits future study.

Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully.

Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately £30 000 per patient.

We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.

Thalidomide increases thrombin generation in multiple myeloma patients

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Background: Numerous reports have demonstrated that the clinical use of thalidomide (THAL) carries a risk for deep venous thrombosis. Only limited investigations into the causative mechanisms for this complication have been conducted. Thrombin generation is a global measurement of hyper or hypocoagulability that has not been used to examine the hypercoagulable state caused by THAL. The aim of this study was to determine if THAL affects thrombin generation in patients with multiple myeloma (MM). Methods: MM patients on and off THAL were recruited. Patients were considered to be “on THAL” if they had been taking the medication for at least three months and “off THAL” if they had not been taking the medication for at least three months. Coagulation tubes of blood containing 3.2% sodium citrate were drawn from each patient. Platelet poor plasma was prepared from these specimens using standard technique. The samples were snap frozen at -70 C and stored until analysis. Thrombin generation was measured using the Calibrated Automated Thrombogram as described by Hemker(Pathophysiol Haemo Thromb 2003;33:4–15) using a microplate fluorometer, the Fluoroskan Ascent from Thermo Electron and the Thrombinoscope software package. The endogenous thrombin potential or ETP (area under the thrombin generation curve) and peak thrombin generation (the maximum release of thrombin per unit of time) were the variables of interest for this study. Results: Twenty seven patients were recruited. Five were excluded from analysis because they were on warfarin or enoxaparin. The normal ETP in females is 1803 ± 241 nM*min and in males is 1745 ± 259 nM *min. Normal peak thrombin generation in females is 318.5 ± 52.9 nM and in males is 293.4 ± 48.5 nM. The t-test was used to compare subjects to normal values.Peak thrombin generation was significantly increased in the 9 subjects taking THAL, 374 ± 10.6 nM (p<0.001) and in the 13 subjects not taking THAL, 352 ± 14.7 nM (p=0.009) when compared to normal values. The ETP was not significantly increased 1818 ± 10.7 nM*min (p=0.69) in subjects not taking THAL. However, ETP was increased in subjects taking THAL, 1939± 90 nM*min and showed a trend toward statistical significance (p=0.10). Conclusions: Thalidomide therapy increases thrombin generation significantly in patients with MM.

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Influence of tumor type, disease status, and patient age on self-reported interest regarding participation in cancer clinical trials

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Background: There is limited data available regarding the reasons cancer patients decide to enter clinical trials. Methods: To explore this issue, aggregate responses to the question, “Are you interested in learning about clinical trials for your condition?” obtained from > 115,000 cancer patients (or their families) who entered data into one of several proprietary decision-support programs embedded within approximately 100 cancer-related Internet sites, were analyzed. Results: The proportion of patients (or their families) who expressed interest in learning of the availability of clinical trials ranged from as low as 21% (endometrial and cervix cancer patients > 80 years old; n=178) to as high as 85% (recurrent ovarian cancer patients, aged 51–60; n=842). Patients > 80 years old, regardless of sex, tumor type, or disease status, were substantially less likely to desire such information. Patients with self-declared more “serious conditions” (e.g., metastatic breast cancer [71%; n=5,444], recurrent prostate cancer [70%; n=4,121]), and those with cancers widely known to have a poor prognosis (e.g., non-small cell lung cancer [75%; n=23,298]), were more likely to request data on trials, than those with an overall more “favorable” prognosis (e.g., newly diagnosed prostate cancer [46%; n=21,348]). There were no observed differences in interest between men and women with similar conditions. Conclusion: In this large data base, major differences in self-expressed interest regarding availability of clinical trails were observed. Particularly notable were the reduced interest among the very elderly, and the increased interest by patients with the most serious cancer-related conditions.

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