Donor call simulation: A novel medical education tool to evaluate trainees' clinical decision-making in transplant infectious disease

BACKGROUND

Evaluating organ suitability for transplantation based on infection risk is a core competency in transplant infectious disease (TID). It is unclear if trainees have opportunities to practice during training. We created a simulation curriculum to develop and evaluate this skill among infectious disease (ID) trainees.

METHODS

We created six simulation questions about organ suitability for transplant based on infection risk. During trainees' TID rotations, faculty texted or paged the simulation cases posing as the transplant coordinator. Trainees had 15 min to ask questions before deciding the suitability of the organ and explained their clinical reasoning in a survey. Trainees completed a post-simulation survey to evaluate its effectiveness.

RESULTS

ID trainees, including residents and fellows on rotation, from seven centers participated. Eighty-seven percent (13/15) of trainees felt the simulation was effective in teaching them this concept, and 80% (12/15) felt prepared for clinical practice. The proportion of correct responses was generally high among the six different cases (43%-100%); correct responses increased for some cases in the post-activity survey. Of the 100 clinical reasoning decisions made during the activity, 19% were discordant, where the trainee correctly identified suitable organs for incorrect reasons.

CONCLUSION

Our simulation was effective in teaching when to accept or reject an organ for transplant and was a valuable educational tool. By evaluating clinical reasoning for decisions our simulation provides educators with nuanced insight and allows for targeted coaching. This study demonstrates a critical need for further educational tools in TID.

Clinical Outcome of Cefiderocol for Infections with Carbapenem-Resistant Organisms

Cefiderocol is a novel cephalosporin recently approved by the FDA to aid clinicians in the fight against multidrug-resistant (including carbapenem-resistant) gram-negative organisms. The primary objective of this study is to evaluate the 14- and 28-day mortality associated with cefiderocol. We performed a retrospective chart review of all adult patients admitted at Stony Brook University Hospital between October 2020 and December 2021 and received cefiderocol for at least 3 days. Patients were excluded if they received more than one course of cefiderocol therapy or remained hospitalized at the time of this study. A total of 22 patients met the inclusion criteria. The all-cause mortality on day 28 for all patients was 13.6%, whereas this rate for patients with BSI was 0%, with cUTI was 0% and with LRTI was 16.7%. The all-cause mortality on day 28 for patients who received the dual antibiotics (in conjunction with cefiderocol) was 0%, compared to 25% for patients who only received cefiderocol (p = 0.25). We noted treatment failure in two patients (9.1%). Our findings suggest that cefiderocol could possibly be associated with lower all-cause mortality than previously thought. In our study, we did not find any significant difference between cefiderocol's use in combination with another antibacterial agent and its use as a monotherapy.

1298. Donor Call Simulation: A Novel Medical Education Tool to Evaluate Trainees’ Clinical Decision-Making in Transplant Infectious Disease

Background

Simulation is a useful education tool for high-stakes clinical skills and decision-making. Recommending whether to accept or reject an organ for transplantation based on infection risk is a critical core competency in Transplant Infectious Disease (ID), however there are no published data that learners have opportunities to practice this during training. We created a novel simulation to expose learners to this real-life clinical scenario and evaluated their clinical decision-making in these situations.

Methods

We created 6 simulations with common ID consult questions about whether to accept or reject an organ for transplant based on infection risk (Table 1). During learners’ Transplant ID rotations, faculty periodically texted or paged them with the simulation cases as though they were the transplant coordinator. Learners had 15 minutes to ask follow up questions before deciding to accept or reject the organ and explain their decision-making process in a survey. Learners completed a survey 1 month after the simulation experience to evaluate its effectiveness.

Results

Between October 2021 and April 2022, 16 learners from 7 medical centers participated in the simulation (Table 2) and 94% (15/16) completed the follow up survey. Eighty-seven percent (13/15) of ID learners reported that the simulation was effective in teaching them when to accept or reject organs and 80% (12/15) felt more prepared to make these decisions in practice. Most learners correctly identified acceptable organs for transplant during the simulations (Figure 1). Of the 100 clinical reasoning decisions made during the activity, 19% were discordant, where the learner correctly decided to accept or decline the organ but with incorrect or incomplete reasoning for this decision (Figure 2).

Conclusion

ID learners perceived our transplant ID simulation as an effective educational tool to learn when to accept or reject an organ for transplant. By evaluating the clinical reasoning behind these decisions our simulation provides ID educators with nuanced insight into their learners' thought process and allows for targeted coaching to correct deficits in reasoning.

Disclosures

Rebecca Kumar, MD, Gilead: Grant/Research Support|Regeneron: Grant/Research Support Jonathan Hand, MD, GlaxoSmithKline: Grant/Research Support|Janssen: Grant/Research Support|Pfizer: Grant/Research Support Roderick Go, DO, Aptose Biosciences: Stocks/Bonds|Bristol Meyers Squibb: Stocks/Bonds|Cytodyn Inc.: Stocks/Bonds|Scynexis: Grant/Research Support Erica J. Stohs, MD, MPH, bioMerieux: Grant/Research Support.

640. A Retrospective Assessment of the Effects of Cefiderocol in Patients with Multidrug-resistant Gram-negative Bacterial Infections

Background

Cefiderocol has emerged recently as a new tool for combating multidrug-resistant bacterial infections; however, concerns about its efficacy has approved its FDA approval for the use in person with limited or no treatment options. The aim of our study is to assess the outcomes of patients treated with cefiderocol for such infections.

Methods

Retrospective cohort study which includes all adult patients who received cefiderocol for at least three days from 1 October 2020 to 31 December 2021 at Stony Brook University Hospital. Patients who received multiple courses of cefiderocol during the same hospitalization or are still hospitalized were excluded.

Results

22 patients received cefiderocol and met the inclusion criteria. Average age, Charlson comorbidity index, and length of stay were 63.6 year, 5.4, and 53 days respectively.

6 patients had respiratory tract infections, 3 had bacteremia, 2 had complicated UTI, and 11 had infections in other sites. Bacteria isolates included Pseudomonas aeruginosa (14), Acinetobacter baumannii complex (8), and Stenotrophomonas maltophilia (1).

The 14-day and 28-day all-cause mortality for all patients was 4.5% and 13.6%, respectively. The 14-day and 28-day all-cause mortality for patients with respiratory tract infections was 16.7% and 16.7%, bloodstream infections was 0% and 0%, complicated UTI was 0% and 0% and with infections at other sites was 0% and 15.4%, respectively. These rates are lower compared to CREDIBLE-CR study.

The 28-day all-cause mortality in double gram-negative coverage group (including cefiderocol) was 0% versus 25% in the cefiderocol monotherapy group (p=0.25). The 28-day all-cause mortality in patient group with Pseudomonas aeruginosa was 14.3% vs. with Acinetobacter baumannii complex was 12.5%. Out of 18 isolates, 13 (72.2%) were susceptible to cefidericol, 1 (5.5%) was intermediate, and 4 (22.2%) were resistant. No carbapenemases were detected in any of the 11 tested clinical isolates of Pseudomonas aeruginosa. Treatment failure, defined as requiring change of antibiotic, was 9.1%.

Conclusion

The 14-day and 28-day all-cause mortality for all patients treated with cefiderocol are possibly lower than once thought to be. No significant differences were noted when cefidericol was used as monotherapy versus in combination.

Disclosures

Roderick Go, DO, Aptose Biosciences: Stocks/Bonds|Bristol Meyers Squibb: Stocks/Bonds|Cytodyn Inc.: Stocks/Bonds|Scynexis: Grant/Research Support.

1106. A Retrospective Assessment of the Effects of Baricitinib and Tocilizumab on COVID-19 Patients requiring High Flow Oxygen

Background

SARS-CoV-2 has been a leading cause of mortality worldwide for over two years. It continues to be a group effort to discover treatment to prevent further deterioration during the disease course. Positive outcomes have been observed in select patients with immune modulator therapy. Although large randomized controlled trials have investigated the use of immunomodulators in COVID-19 therapy, few have compared the differences in safety profiles and clinical outcomes between the different drugs. We studied the differences in outcomes in hospitalized patients with COVID-19 pneumonia treated with baricitinib versus tocilizumab.

Methods

Adult patients admitted to Stony Brook University Hospital between April 2020 and April 2021 with high flow oxygen requirements due to severe COVID-19 pneumonia were retrospectively analyzed. The primary endpoint was the time to reduction of highest oxygen requirement 14 days after immune modulator therapy was administered or hospital discharge, whichever came first. Secondary endpoints include length of hospital stay (LOS), 28-day mortality, and serious adverse events.

Results

132 patients with COVID-19 pneumonia were treated with immune modulators. One patient was excluded from primary and secondary analysis due to having received both tocilizumab and baricitinib. All patients received steroids and remdesivir. 73 received baricitinib and 58 received tocilizumab. Oxygen requirements at the initiation of either baricitnib or tocilizumab had a mean of 5.84±0.6 and 5.9±0.7, respectively using the WHO ordinal scale. The mean time to oxygen down titration in the baricitinib group was similar (5.7±2.6 and 6.07±2.7 days). In continuous variable analysis, patients who received baricitinib had a longer duration of fever (6.0 days vs 3.6 days, p=0.04) and lower serum ferritin (909.9 ng/ml vs. 1331.8 ng/ml, p=0.09). LOS was not similar between the groups (mean 24.4 vs. 25.8, p=0.89). Hospital mortality was not statistically significant between the two groups (32.9% vs. 27.6%, p=0.514).

Conclusion

This study suggests similar outcomes for oxygen requirements, hospital length of stay, and mortality between baricitinib and tocilizumab when given in conjunction with remdesivir and steroids for severe COVID-19 pneumonia.

Disclosures

Kathy Tin, D.O., Merck: Stocks/Bonds|Novavax: Stocks/Bonds|Pfizer: Stocks/Bonds Roderick Go, DO, Aptose Biosciences: Stocks/Bonds|Bristol Meyers Squibb: Stocks/Bonds|Cytodyn Inc.: Stocks/Bonds|Scynexis: Grant/Research Support.

A Quality Assurance Initiative on Improving Cefazolin Peri-operative Redose Compliance

Background

Compliance with perioperative antibiotic prophylaxis is crucial for preventing surgical site infection. Anesthesiologists can play a significant role in reducing surgical site infections by following clinical practice guidelines for antibiotic prophylaxis and redosing during surgery. A quality assurance initiative was implemented at a tertiary hospital with the goal of improving cefazolin perioperative antibiotic compliance.

Methods

A multifaceted intervention was initiated to address low compliance with cefazolin redosing. Multifaceted interventions included the development of a perioperative antibiotic guide for anesthesia providers, automated reminders in anesthesia electronic medical records, grand rounds education, survey and email communications, and regular feedback reports to the anesthesia department.

Results

Rates of redose compliance were examined in three time periods: pre-intervention, intervention, and post-intervention. Cefazolin redosing compliance was 58% in the pre-intervention period and 90% in the post-intervention period. There was a significant positive change in the trend of compliance during the intervention period, indicating that the odds of compliance increased by 13% per month in the intervention period compared to the pre-intervention period (odds ratio = 1.13, p<0.001). Redose compliance improvements were sustained a year after the post intervention period (average 91%). Surgical site infection rates for colon, coronary artery bypass graft and hip surgeries did not show any significant trend during these time periods.

Conclusion

Multifaceted interventions led to significant and sustained improvements in cefazolin redosing compliance in the main operating room of a tertiary hospital.

POS1377 LUNG INVOLVEMENT IN VEXAS SYNDROME

Background

Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently identified disorder caused by somatic mutations in the UBA1 gene of myeloid cells. Various manifestations of pulmonary involvement have been reported, but a detailed description of lung involvement and radiologic findings is lacking.

Objectives

To describe lung involvement in VEXAS syndrome.

Methods

A retrospective cohort study was conducted of all patients identified at the Mayo Clinic with VEXAS syndrome since October 2020. Clinical records and chest high resolution computed tomography (HRCT) scans were reviewed.

Results

Our cohort comprised 22 white men with a median age of 69 years (IQR 62-74, range 57-84). Hematologic disorders including multiple myeloma, myelodysplastic syndrome and pancytopenia were present in 10 patients (45%), rheumatologic diseases including granulomatosis with polyangiitis, IgG4-related disease, polyarteritis nodosa, relapsing polychondritis, and rheumatoid arthritis were found in 10 patients (45%), and 4 patients had dermatologic presentations including Sweet syndrome, Schnitzer-like syndrome or drug rash with eosinophilia skin syndrome (DRESS). VEXAS syndrome-related features included fever (18, 82%), skin lesions (20, 91%), lung infiltrates (12, 55%), chondritis (10, 45%), venous thromboembolism (12, 55%), macrocytic anemia (21, 96%), and bone marrow vacuoles (21, 96%). Other manifestations observed were arthritis, scleritis, hoarseness and hearing loss. Median erythrocyte sedimentation rate (ESR) was 69 mm/1st hour (IQR 34.3-118.8) and median C-reactive protein (CRP) of 55.5 mg/dL (IQR 11.4-98.8). The somatic mutations affecting methionine-41 (p.Met41) in UBA1 gene were: 11 (50%) p.Met41Thr, 7 (32%) p.Met41Val, 2 (9%) p.Met41Leu, and 2 (9%) in the splice site. All patients received glucocorticoids (GC) (median duration of treatment was 2.6 years); 21 (96%) received conventional immunosuppressive agents (methotrexate, azathioprine, mycophenolate, leflunomide, cyclosporin, hydroxychloroquine, tofacitinib, ruxolitinib) and 9 (41%) received biologic agents (rituximab, tocilizumab, infliximab, etanercept, adalimumab, golimumab, abatacept). Respiratory symptoms included dyspnea and cough present in 21 (95%) and 12 (55%), respectively, and were documented prior to VEXAS diagnosis. Most of the patients were non-smokers (14, 64%) and obstructive sleep apnea (OSA) was present in 11 patients (50%). Seven patients (32%) used non-invasive ventilation, 6 used C-PAP, and 1 used Bi-PAP. Bronchoalveolar lavage (BAL) was available in 4 patients, and the findings were compatible with neutrophilic alveolitis in 3. Two patients had lung biopsies (2 transbronchial and 1 surgical) that showed ATTR amyloidosis and organizing pneumonia with lymphoid interstitial pneumonia, respectively. Pulmonary function tests were available in 9 (41%) patients and showed normal results in 5; 3 patients had isolated reduction in DLCO and 1 with mild restriction. On chest HRCT, 16 patients (73%) had parenchymal changes including ground-glass opacities in 9, septal thickening in 4, and nodules in 3; pleural effusions were present in 3 patients, air-trapping in 3 patients and tracheomalacia in 1 patient. Follow-up chest HRCT was available for 8 patients (36%), the ground-glass opacities resolved in 5 patients, 3 patients manifested new or increased ground-glass opacities, and 1 patient had increased interlobular septal thickening. After 1 year of follow-up, 4 patients (17%) had died; 3 due to pneumonia (2 COVID-19,1 bacterial) and 1 due to heart failure. VEXAS flares occurred in 18 patients (82%), the maximum number of relapses was 7, and they were mainly managed with GC and with changes in the immunosuppressive regimen.

Conclusion

Pulmonary involvement was documented by chest HRCT in most patients with VEXAS syndrome. Respiratory symptoms occurred in over one half of patients and about 20% had PFT abnormalities. The pulmonary manifestations of VEXAS are nonspecific and characterized predominantly by inflammatory parenchymal involvement.

Disclosure of Interests

None declared

554. Clinical Impact of Monoclonal Antibody Therapy with SARS-CoV-2 Infection

Background

The novel coronavirus SARS-CoV2 is the causative agent for COVID-19 responsible for the ongoing global pandemic. The spike protein on its surface binds to the angiotensin-converting enzyme 2 receptor helps to enter human cells. Neutralizing antibodies to this protein can be protective and helpful in alleviating symptoms. Monoclonal antibodies (mAb) have been utilized in the U.S. under an emergency use authorization by the FDA, including bamlanivimab (BAM) and casirivimab-imdevimab (CAR/IMD). We report our experience of using COVID mAb.

Methods

We conducted a retrospective chart review of patients that received CAR/IMD or BAM between December 1st, 2020, and May 15th, 2021. Medical records were reviewed to determine demographic and clinical information as well as tolerability and effectiveness of mAb.

Results

463 patients with mild to moderate symptoms of SARS-CoV2 received mAb: 355(176 Men) BAM, 108(53 Men) CAR/IMD. The median BMI was 31 (17.4 to 62.5), 85% Caucasian, 4% Asian, 3% African American, 4% Hispanic, 4% others. The average duration of symptoms was 3.4 days and included cough (74%), malaise (71%), Headache (28%), dyspnea (28%), rhinorrhea (25%), fever (20%), diarrhea (18%), and anosmia (14%). Risk factors included hypertension (65%), diabetes mellitus (32%), coronary artery disease (22%), asthma (16%), COPD (9%), CHF (9%), CKD (8%), active malignancy (6%), and immunocompromised state (7%). Those who received BAM were older (p=0.000) and have underlying dementia and congestive heart failure (p=0.025 and 0.034, respectively). 27 patients (2 CAR/IMG, 25 BAM) got admitted to the hospital due to worsening of their respiratory status and were treated for COVID-19. 4 patients in the BAM group and 0 in the CAR/IMD group died. 2 patients developed a mild allergic reaction to CAR/IMD, no other side effects were reported in both groups. 37 patients (19 CAR/IMD, 18 BAM) received mRNA COVID vaccine prior. Overall mortality rate was 0.8%. There was no significant difference between BAM and CAR/IMR in terms of hospitalization (p= 0.104) or mortality (p=0.268).

Conclusion

Treatment with BAM versus CAR/IMR was well tolerated and resulted in similar outcomes in terms of hospitalization or mortality.

Disclosures

All Authors: No reported disclosures

563. Tocilizumab in the Treatment of Critical COVID-19 Pneumonia

Background

The anti-interleukin-6 receptor monoclonal antibody tocilizumab has been proposed as a treatment for COVID-19 pneumonia although the efficacy remains unknown.

Methods

Patients with COVID-19 confirmed by nasal swab PCR for SARS-CoV-2 who were admitted to Stony Brook University Hospital in Suffolk County, New York between March 10^th and April 2^nd and received tocilizumab while undergoing mechanical ventilation in any intensive care unit were retrospectively analyzed from data available in the electronic medical record. Baseline characteristics and clinical outcomes were compared to mechanically ventilated patients admitted during the same time period who received standard hospital protocol.

Results

Forty-five patients received tocilizumab compared to seventy controls. Mean dose of tocilizumab given was 4.8mg/kg and mean time to receipt from initial intubation was 2.5 days. Baseline demographic characteristics, inflammatory markers, treatment with corticosteroids, and SOFA scores were similar between the two cohorts (Table 1). Patients who received tocilizumab had significantly lower Charlson co-morbidity index (2.0 versus 3.0, p = 0.01) and higher temperature (38.7 C versus 38.2 C, p = 0.004) than controls. There was no significant association between receipt of tocilizumab and the rate of extubation within fourteen days (44.4 percent versus 34.2 percent; OR = 1.53, 95% C.I. 0.71 – 3.30), discharge from hospital (51.1 percent versus 40.0 percent; OR = 1.568, 95% C.I. 0.737 – 3.337), or mortality (31.1 percent versus 41.4 percent; OR = 0.639, 95% C.I. 0.290 – 1.4407) (Table 2). Patients who were administered tocilizumab within two days of intubation had increased likelihood of extubation within fourteen days compared to those who were treated later (OR = 3.50, 95% C.I. 1.01 – 12.18). There was no observed increased risk of secondary infection in patients given tocilizumab (28.9 versus 25.7, OR = 1.1736, 95% C.I. = 0.507 – 2.714).

Table 1: Patient Demographics and Baseline Characteristics

Table 2: Primary Outcomes

Conclusion

Tocilizumab was not associated with a significant improvement in rate of extubation, hospital discharge, or reduction in mortality in this retrospective cohort study of mechanically ventilated patients with COVID-19 pneumonia. Further studies are needed to determine whether earlier treatment may result in improved outcomes.

Disclosures

All Authors: No reported disclosures

Tocilizumab in the treatment of critical COVID-19 pneumonia: A retrospective cohort study of mechanically ventilated patients

Objectives

The purpose of this study is to evaluate clinical outcomes in patients with critical COVID-19 pneumonia requiring invasive mechanical ventilation who were treated with tocilizumab

Design

Single-center retrospective cohort study

Setting

Stony Brook University Hospital, a 600-bed academic tertiary medical center in Suffolk County, New York

Participants

Consecutive patients with COVID-19 confirmed by nasopharyngeal polymerase chain reaction (PCR) who were admitted to Stony Brook University Hospital between March 10 and April 2 2020 and required mechanical ventilation in any intensive care unit during their hospitalization

Exposure

Treatment with tocilizumab while intubated

Main Outcome

Overall mortality 30 days from the date of intubation

Results

Forty-five patients received tocilizumab compared to seventy controls. Baseline demographic characteristics, inflammatory markers, treatment with corticosteroids, and sequential organ failure assessment (SOFA) scores were similar between the two cohorts. Patients who received tocilizumab had significantly lower Charlson co-morbidity index (2.0 vs 3.0,P = 0.01) than controls. There was a trend towards younger mean age in the tocilizumab exposed group (56.2 vs 60.6; P = 0.09). In logistic regression analysis there was no reduction in mortality associated with receipt of tocilizumab (odds ratio (OR) 1.04; 95% CI, 0.27–3.75). There was no observed increased risk of secondary infection in patients given tocilizumab (28.9 vs 25.7; OR 1.17; 95% CI, 0.51–2.71).

Conclusion

When controlling for age, severity of illness, and co-morbidities, tocilizumab was not associated with reduction in mortality in this retrospective cohort study of mechanically ventilated patients with COVID-19 pneumonia. Further studies are needed to determine the role of tocilizumab in the treatment of COVID-19.

229. The Role of Antimicrobial Stewardship Program on Appropriate Use, Dose, and Duration of Vancomycin Treatment

Background

Methods

Results

Conclusion

Disclosures

Evolving changes in disease biomarkers and risk of early progression in smoldering multiple myeloma

We studied 190 patients with smoldering multiple myeloma (SMM) at our institution between 1973 and 2014. Evolving change in monoclonal protein level (eMP) was defined as ⩾10% increase in serum monoclonal protein (M) and/or immunoglobulin (Ig) (M/Ig) within the first 6 months of diagnosis (only if M-protein ⩾3 g/dl) and/or ⩾25% increase in M/Ig within the first 12 months, with a minimum required increase of 0.5 g/dl in M-protein and/or 500 mg/dl in Ig. Evolving change in hemoglobin (eHb) was defined as ⩾0.5 g/dl decrease within 12 months of diagnosis. A total of 134 patients (70.5%) progressed to MM over a median follow-up of 10.4 years. On multivariable analysis adjusting for factors known to predict for progression to MM, bone marrow plasma cells ⩾20% (odds ratio (OR)=3.37 (1.30-8.77), P=0.013), eMP (OR=8.20 (3.19-21.05), P<0.001) and eHb (OR=5.86 (2.12-16.21), P=0.001) were independent predictors of progression within 2 years of SMM diagnosis. A risk model comprising these variables was constructed, with median time to progression of 12.3, 5.1, 2.0 and 1.0 years among patients with 0-3 risk factors respectively. The 2-year progression risk was 81.5% in individuals who demonstrated both eMP and eHb, and 90.5% in those with all three risk factors.

A new anthraquinone from Morinda citrifolia roots

An investigation of Morinda citrifolia roots afforded a new anthraquinone, 2-ethoxy-1-hydroxyanthraquinone (1), along with five other known anthraquinones: 1-hydroxy-2-methylanthraquinone (2), damnacanthal (3), nordamnacanthal (4), 2-formyl-1-hydroxyanthraquinone (5) and morindone-6-methyl-ether (6). This is the first report on the isolation of morindone-6-methyl-ether (6) from this plant. The structures of these compounds were elucidated based on spectroscopic analyses such as NMR, MS and IR. Biological evaluation of five pure compounds and all the extracts against the larvae of Aedes aegypti indicated 1-hydroxy-2-methylanthraquinone (2) and damnacanthal (3) were the extracts to exhibit promising larvicidal activities.

Cancer in the oldest old population in the United States: Current statistics and projections

9553

Background: The oldest old, defined as people age ≥ 85 years, in the U.S. is projected to double from 4.3 million in 2000 to 9.6 million in 2030. Since cancer is the number one cause of death, it is critical to assess the current and projected cancer burden in this population. Methods: We obtained data from the Surveillance, Epidemiology and End Results (SEER) program. We included patients who had a previous cancer before age 85, but excluded benign tumors, myeloproliferative, and myelodysplastic neoplasms. Incidence was reported per 100,000 person years and age-adjusted to the 2000 U.S. standard population. For current statistics, we included years 2001–2005. Trend analyses were based on 1973–2005 data. Results: The oldest old represents 7.2% of annual new cancers cases diagnosed and 10.5% of cancer deaths in the U.S. The 10 leading cancers by incidence (both sexes and decreasing order) are colorectal (388.9), lung (287.7), breast (250), prostate (211.5), urinary bladder (162.5), non-Hodgkin lymphoma (110.9), leukemia (85.1), melanoma (65), renal (46.4), and uterine (40.2). The incidences of melanoma, non-Hodgkin lymphoma, renal, and lung cancers are increasing, while those of leukemia, prostate, breast, and colorectal cancers are decreasing. The top 5 causes of cancer deaths are lung and bronchus (21%), colorectal (15%), pancreatic (7.1%), prostate (5.9%), and breast cancers (5.3%). Cancer specific survival (CSS) has been increasing continuously since 1973 for melanoma, non-Hodgkin lymphoma, breast, colorectal, prostate, and urinary bladder cancers but decreasing in recent years for colorectal, breast, prostate, and uterine cancers. CSS for leukemia, lung, renal, and uterine cancers showed no change over time. If the current incidence trends for each cancer continue in a linear fashion, it is projected, using 1973–2005 data, that in 2030, the oldest old will represent 8.8% of annual new cancers cases diagnosed and 13.6% of cancer deaths. Conclusions: Cancer incidence and mortality trends in the oldest old differ from the general population. Because the oldest old are likely to have multiple co-morbid conditions, there is a need to find better ways to diagnose and treat cancers in this unique segment of the population.

No significant financial relationships to disclose.

Compliance to National Comprehensive Cancer Network guidelines in patients with newly diagnosed small cell lung cancer at a community cancer center

17064

Background: The National Comprehensive Cancer Network (NCCN) provides yearly updated guidelines for the management of patients diagnosed with small cell lung cancer (SCLC). Compliance to clinical guidelines may improve patient care and outcome, but this may vary among institutions. In this study, we determined the compliance of our community cancer center to the NCCN guidelines in patients with SCLC. Methods: We identified patients with newly diagnosed SCLC in 2004 and 2005 using our cancer registry database. Using the NCCN guideline for the corresponding years, we determined the compliance rate for the following phases of cancer care: initial evaluation (pathology review, imaging, smoking cessation counseling, mediastinal staging for T1-T2 limited disease), and treatment (chemotherapy, radiation). Results: There were 39 new patients with SCLC, 14 (35.9%) of which had limited stage disease. The overall compliance rates for initial evaluation and treatment were 33.3%, and 92.3%, respectively. A total of 32 deviations were identified: 21 (65.6%) for neglecting smoking cessation counseling, 7 (21.9%) for not performing recommended imaging, 3 (9.4%) for not giving recommended chemotherapy and/or radiation and 1 (3.1%) for not reviewing outside pathology. In all of the imaging and treatment deviations, there were medically appropriate reasons for doing so: 7 patients with limited disease had PET/CT scan instead of CT/bone scan (PET/CT scan now incorporated into the 2006 guidelines); 2 patients with limited disease did not receive concurrent chemoradiotherapy due to poor performance status and co-morbidity; 1 patient with extensive disease refused chemotherapy. Conclusion: Our compliance with NCCN guidelines for SCLC was poor for initial evaluation, but better for treatment. The primary reasons for this outcome were the lack of a perceived benefit in smoking cessation counseling and the use of PET/CT scanning as the initial imaging modality of choice.

No significant financial relationships to disclose.

Unequal treatment access and malaria risk in a community-based intervention program in the Philippines

This study assesses the influence of several malaria risk factors and volunteer health worker (VHW) accessibility on parasite prevalence and treatment-seeking in a remote area of Mindanao, the Philippines. An anti-malaria program in the area seeks to devolve malaria diagnosis and treatment to the VHWs. Firstly, the relationship between malaria and demographic factors, bednet use, and access to treatment was investigated. Secondly, adults from villages with and without resident VHWs were questioned on historical and proposed treatment-seeking for fever and the capacity of the communities to support more health workers was assessed. Parasite prevalence was significantly higher among patients living in villages lacking a resident VHW (adjusted OR=3.88, p=0.02), where proposed delays in consulting VHWs and the official health service, and the use of alternative medicine, were also significantly higher. Kinship or social closeness to VHWs appears to play a role in accessibility. The educational and economic requirements demanded of VHWs impede potential expansion of the program to non-serviced villages. If the effectiveness and equity of community-based treatment strategies is to be increased, increased flexibility allowing use of local, less-educated, drug dispensers needs to be considered.

Diagnosis of malaria in a remote area of the Philippines: comparison of techniques and their acceptance by health workers and the community

OBJECTIVE

To compare the efficacies of remote symptom-based diagnosis of malaria, rapid diagnostic tests and microscopy in an area of low endemicity in the Philippines.

METHODS

In Trial I, 350 symptomatic patients were tested within their villages using malaria Plasmodium falciparum (Pf)/Plasmodium vivax (Pv) immunochromatographic tests (ICT tests) and blood films stored and read under local conditions. The slides were later restained and read. In Trial II, unsupervised volunteer barangay health workers prepared ICT tests and slides after brief training. These slides were read at rural health units. Twenty-seven barangay health workers and 72 community members were later questioned about the three diagnostic strategies.

FINDINGS

A history of fever alone was sensitive (95.4%) but poorly specific (16.5%) for predicting parasitaemia. The inclusion of other symptoms reduced the sensitivity to below 85%, while specificity remained low. The axillary temperature was poorly predictive. ICT tests achieved high sensitivity (97.9%) but many cases indicated as positive by ICT tests were negative by microscopy. Further analysis of these cases in Trial I indicated that ICT tests were detecting low-level parasitaemias missed by microscopy, and that local microscopy had poor accuracy. ICT tests were well accepted and accurately performed by barangay health workers.

CONCLUSION

These tests meet a strong desire in the community for blood-based diagnosis and may increase the compliance and treatment-seeking behaviour of patients.

No evidence for genetic association or linkage of the cathepsin D (CTSD) exon 2 polymorphism and Alzheimer disease

Two recent case-control studies have suggested a strong association of a missense polymorphism in exon 2 of the cathepsin D gene (CTSD) and Alzheimer disease (AD). However, these findings were not confirmed in another independent study. We analyzed this polymorphism in two large and independent AD study populations and did not detect an association between CTSD and AD. The first sample was family-based and included 436 subjects from 134 sibships discordant for AD that were analyzed using the sibship disequilibrium test (SDT, p = 0.68) and the sib transmission/disequilibrium test (Sib-TDT, p = 0.81). The second sample of 200 AD cases and 182 cognitively normal controls also failed to show significant differences in the allele or genotype distribution in cases versus controls (chi2, p = 0.91 and p = 0.88, respectively). In addition, two-point linkage analyses in an enlarged family sample (n = 670) did not show evidence for linkage of the chromosomal region around CTSD. Thus, our analyses on more than 800 subjects suggest that if an association between the CTSD exon 2 polymorphism and AD exists, it is likely to be smaller than previously reported.

Candidate genes showing no evidence for association or linkage with Alzheimer's disease using family-based methodologies

Alzheimer's disease (AD) is a genetically complex and heterogeneous disorder. To date, a large number of candidate genes have been associated with the disease, however none of these findings has been consistently replicated in independent datasets. In this study we report the results of family-based analyses for polymorphisms of five such candidates on chromosomes 2 (interleukin-1beta, IL-1B), 3 (butyrylcholinesterase, BCHE), 11 (cathepsin D, CTSD; Fe65, APBB1) and 12 (lipoprotein receptor-related protein-1, LRP1) that were all suggested to be associated with AD in recent case-control studies. To minimize the possibility of spurious findings due to population admixture, we used a family-based design applying the sibship disequilibrium test (SDT) as well as two-point parametric linkage analyses on families from the National Institute of Mental Health (NIMH) Genetics Initiative. Contrary to the initial reports, none of the polymorphisms that were analyzed showed evidence for association or linkage with AD in our families. Our results suggest that the previously reported associations from case-control studies are either (a) false positive results, e.g. due to type I error or population admixture, (b) smaller than initially proposed, or (c) due to linkage disequilibrium with an as yet unidentified polymorphism nearby.

(13)C-urea breath test without a test meal is highly accurate for the detection of Helicobacter pylori infection in Chinese

BACKGROUND

Conventional (13)C-urea breath testing ((13)C-UBT) includes a test meal to delay gastric emptying, which, theoretically, improves the accuracy of the test. Citric acid has been proposed as the best test meal. However, recent studies have suggested that a test meal may not be necessary.

AIM

To investigate a new (13)C-UBT protocol without a test meal in a Chinese population.

METHODS

Consecutive dyspeptic patients referred for upper endoscopy were recruited. (13)C-UBT was performed on two separate days with or without a test meal (2.4 Gm citric acid) and compared with the 'gold standard' (CLO test and histology).

RESULTS

Two hundred and two patients were tested. Using receiver operating characteristics (ROC) analysis, the optimal delta-value and optimal measurement interval for UBT were 5% and 30 min, respectively, both with or without a test meal. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of (13)C-UBT with citric acid (96.5%, 97.7%, 98.2%, 95.6%, 97.0%) were similar to (13)C-UBT without a test meal (94.7%, 97.7%, 98.2%, 93.5%, 96.0%).

CONCLUSION

This simplified (13)C-UBT protocol without a test meal produced highly accurate and reliable results in the Chinese population.

[Severe lightning pain during spinal anesthesia in a patient with diabetic neuropathy]

A 71-year-old woman with diabetic neuropathy who had undergone amputation of the right lower leg for diabetic gangrene 4 years previously, experienced severe lightning pain in both legs during spinal anesthesia. She was scheduled for skin grafting for a burn ulcer on her left foot. Her preoperative physical examination revealed hypesthesia in both legs due to diabetic neuropathy. Spinal anesthesia was performed with a combined spinal-epidural needle at the L 4-5 interspace using 2.0 ml of 0.3% hyperbaric dibucaine in the left lateral position. The region of hypesthesia was spread below Th 4. Ten minutes later, she complained of severe lightning pain in both legs and midazolam 1 mg was administered intravenously against agitation. The severe lightning pain diminished after the administration of pentazocine 7.5 mg intravenously in the recovery room. There was no worsening of neurological findings 5 hours later when the effect of spinal anesthesia disappeared. This clinical picture seems to be different from that of reported cases of phantom limb pain during spinal anesthesia in which severe lightning pain occurred in both legs. This case suggests that patients with diabetic neuropathy might develop severe lightning pain during spinal anesthesia using dibucaine.

[Coronary artery bypass grafting on the beating heart in patients with severe cardiac dysfunction; on the necessity of cardiopulmonary bypass]

Six patients with severe cardiac dysfunction due to acute myocardial infarction underwent coronary artery bypass grafting on beating hearts, because we were afraid of difficulty in weaning from the cardiopulmonary bypass (CPB). The first two operations were performed without use of CPB (group A) and the following cases were done with CPB (group B). All patients received emergent operations except one, and three patients needed intra-aortic balloon pumping support perioperatively. Although all patients had three vessel disease, the number of the graft was one or two. Anesthesia was maintained by fentanyl, midazolam, sevoflurane and nitrous oxide. All patients in group B could be weaned from the CPB easily. In a patient of group A, hypotension persisted during cardiac procedure. In a patient of group B, ventricular fibrillation occurred when the coronary artery was occluded by snares. In another patient of group B, we discontinued inotropic agents and used verapamil during CPB for a easy cardiac procedure and myocardial protection. We conclude that coronary artery bypass grafting on the beating heart in the patients with severe cardiac dysfunction due to acute myocardial infarction should be performed with CPB to maintain systemic hemodynamics, to protect myocardium during occlusion of the coronary artery, and to make the surgical procedure easy.

[Epidural fentanyl provide sufficient analgesia for extracorporeal shock wave lithotripsy (ESWL)]

Epidural fentanyl (0.2 mg in 10 ml normal saline) was administrated in 10 unpremedicated patients undergoing extracorporeal shock wave lithotripsy (ESWL). No test dose of local anesthetics was administrated and accessory drugs such as narcotics or analgesics were not used. Painful procedures except for shock wave such as insertion of urethral catheter were not applied. We observed analgesic effect using original score (grade 0-3) and monitored heart rate, blood pressure, respiratory rate and Spo2 during ESWL. At 1, 2, 3, 4 and 24 hours after ESWL, patients were questioned regarding the presence of postoperative nausea, vomiting, and motor disturbance. At the start of ESWL, nine patients experienced mild pain, although no patient requested additional analgesic treatment. Until the end of ESWL, local anesthetics were administered through the epidural catheter in three patients because of increase of pain, while the others completed ESWL with epidural fentanyl alone. No remarkable change in blood pressure and heart rate were observed. Respiratory rate and Spo2 slightly decreased during ESWL. Postoperative side effects were mild especially in the patients treated with epidural fentanyl alone. Epidural fentanyl is considered to be useful analgesic technique for ESWL.

Usefulness of ictal and interictal 99mTc ethyl cysteinate dimer single photon emission computed tomography in patients with refractory partial epilepsy

PURPOSE

Ictal perfusion single photon emission computed tomography (SPECT), using HMPAO, has been shown to localize epileptic foci in approximately 90% of studies. Unfortunately, HMPAO decomposes rapidly, precluding the performance of ictal studies. Ethyl cysteinate dimer (ECD) is a SPECT perfusion agent recently approved by the Food and Drug Administration. After preparation, this compound is stable for approximately 6 h. facilitating the performance of ictal studies.

METHODS

In a prospective, open-label, uncontrolled, non randomized study, we evaluated the potential benefits of the use of 99mTc-ECD SPECT for lateralization of the epileptic focus. Ten consecutive adult epilepsy surgery candidates were studied with ictal and interictal 99mTc-ECD SPECT.

RESULTS

The mean delay between seizure onset and ictal SPECT injection was 23.2 s. The mean seizure duration was 84.1 s. Ictal studies agreement between the epilepsy focus and area of hyperperfusion was evident in 8 of 10 cases. In one case, SPECT was lateralized in a patient with bilateral temporal lobe epilepsy (TLE); however, hyperperfusion was observed on the same side of that particular seizure. In another case, there was location disagreement. Interictal SPECT showed focal hypoperfusion in three cases.

CONCLUSIONS

99mTc-ECD proved to be an optimal tracer for ictal studies. Although this is a small series, the results of ictal and interictal findings using 99mTc-ECD are similar to those reported with 99mTc-HMPAO. Because 99mTc-ECD has a longer decomposition time, true ictal studies are easier to obtain. This new tracer will probably allow the use of ictal SPECT to become widely accepted in most epilepsy centers.

Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm

We administered potassium iodide and propylthiouracil per rectum, in conjunction with intravenous dexamethasone and propranolol, for emergent treatment of a patient in thyroid storm with small bowel obstruction. Shortly after initiation of this treatment, the patient successfully underwent two emergent surgical procedures for resection of an intestinal volvulus with advanced peritonitis. Serum levels of iodide and propylthiouracil showed substantial absorption of these drugs via the rectal route. Measurement of 24-h urinary-free iodide indicated that the bioavailability of potassium iodide delivered by retention enema was at least 40%. Parenteral iodide preparations have been unavailable in the past, and continue to be difficult to obtain emergently. Rectal administration of inorganic iodide is an effective, readily available and less expensive alternative to parenteral sodium iodide for patients in thyroid storm with upper gastrointestinal tract dysfunction.

Major histocompatibility complex class III genes and susceptibility to immunoglobulin A deficiency and common variable immunodeficiency

We have proposed that significant subsets of individuals with IgA deficiency (IgA-D) and common variable immunodeficiency (CVID) may represent polar ends of a clinical spectrum reflecting a single underlying genetic defect. This proposal was supported by our finding that individuals with these immunodeficiencies have in common a high incidence of C4A gene deletions and C2 rare gene alleles. Here we present our analysis of the MHC haplotypes of 12 IgA-D and 19 CVID individuals from 21 families and of 79 of their immediate relatives. MHC haplotypes were defined by analyzing polymorphic markers for 11 genes or their products between the HLA-DQB1 and the HLA-A genes. Five of the families investigated contained more than one immunodeficient individual and all of these included both IgA-D and CVID members. Analysis of the data indicated that a small number of MHC haplotypes were shared by the majority of immunodeficient individuals. At least one of two of these haplotypes was present in 24 of the 31 (77%) immunodeficient individuals. No differences in the distribution of these haplotypes were observed between IgA-D and CVID individuals. Detailed analysis of these haplotypes suggests that a susceptibility gene or genes for both immunodeficiencies are located within the class III region of the MHC, possibly between the C4B and C2 genes.

Failure of dipyridamole-thallium myocardial imaging to detect severe coronary disease

Three patients referred for peripheral vascular surgery who died of coronary artery disease complications despite normal dipyridamole-thallium scans are discussed. Although recent literature has shown enthusiasm for this test in this clinical setting, the dipyridamole-thallium scans are not absolute and patients remain at risk for major coronary artery events. Careful clinical screening and awareness of the signs of left main coronary disease on thallium images are important in the evaluation of these patients.

Enzyme linked immunosorbent assay for the measurement of nonenzymatically glucosylated proteins in serum and in tissues

We have developed an enzyme linked immunosorbent assay (ELISA) for glucosylated proteins. The polyclonal antiserum was prepared against reduced glucosylated lipoproteins and was specific for the glucose-lysine bond. The antiserum recognized, in a dose-dependent manner, all reduced glucosylated proteins tested, including albumin, fibrinogen, low density lipoprotein, high density lipoprotein and hemoglobin, yet had no affinity for native proteins or to glucosylated but nonreduced proteins. The sensitivity of the assay was in the order of 1-5 pmol glucosylated lysine/ml and half maximal displacement occurred at 8-24 pmol glucosylated lysine/ml. The inter- and intraassay variables were 10.8% and 13.5%, respectively. Serum proteins from diabetic patients (n = 30) contained 84 +/- 6 picomoles of glucosylated lysine/mg protein, compared to 28 +/- 3 in controls (n = 20), and the concentration of glycosylated proteins correlated with fasting blood glucose (r = 0.56, p less than 0.02), but not with glucosylated hemoglobin levels (r = 0.29, p greater than 0.1). Proteins from diabetic glomeruli and aortae similarly contained more glucosylated lysine residues than controls.

Genetic predisposition to acute lymphocytic leukemia in American blacks. A Pediatric Oncology Group study

Recent reports have shown an association between genes lying within the major histocompatibility complex (MHC), particularly HLA and factor B (Bf), and acute lymphocytic leukemia (ALL) in white children. The frequencies of Bf and complement component C4 phenotypes in 90 black American children with ALL were examined to determine if a genetic association existed. The Bf and C4 results for the black children with ALL were compared with frequencies in healthy black Americans from the same geographic region. The BfF allele was carried by 95.6% of the black ALL patients compared with 86.1% of the controls (P = 0.017; relative risk = 3.5). In contrast, only 2.2% of the patients with ALL were homozygous for BfS compared with 9.8% of the controls (P = 0.043; relative risk = 0.2). These findings are similar to those observed in white American children. The C4A6 phenotype was found in 11.9% of the black children with ALL compared with 0.6% of the controls (P = 0.0026; relative risk = 22.7). These findings represent the first reported association of a particular allele whose gene lies within the MHC with ALL in black American children. The results suggest that the occurrence of ALL in black American children may be partially due to a genetic influence.

Search for biological/genetic markers in a long-term epidemiological and morbid risk study of affective disorders

A long-term epidemiological genetic study was conducted in which all new patients were evaluated prospectively at the Foundation for Depression and Manic Depression and two Lithium/Affective Disorders clinics at the Columbia-Presbyterian Medical Center between the years of 1972 and 1978. All patients met Feighner, RDC and DSM III criteria for Major Depressive Disorder after initial clinical screening interviews and were further subtyped using the Fieve-Dunner 7-point criteria. All 604 probands and 90% of 2711 first-degree relatives were interviewed blindly by diagnosticians trained in the use of the SADS structured interview. Cumulative morbid risk in parents, siblings and children of 490 bipolar probands was 15.6 +/- 3% and 14.0 +/- 1.7% in the first-degree relatives of 114 unipolar probands. A number of biological and genetic marker studies were simultaneously performed on samples of the overall population. The enzymes catechol O-methyltransferase and dopamine beta-hydroxylase, and the dexamethasone suppression test (SDT) did not show any biological marker value for outpatients even though both enzymes were determined to have hereditability. The HLA system, monoamine oxidase and acetylcholinesterase segregated differently from normal controls in samples of the patient population. The positive association findings with monoamine oxidase and the HLA system conflicted with the positive findings of other investigators, leaving doubtful their biological marker value. Red cell acetylcholinesterase was found to be significantly lower in affective disorder patients than in controls. This positive association finding was recently replicated by Mathews et al. (1982) but needs further confirmation. Using 28 blood group markers, a prior association study between the trait defining susceptibility to affective disorder and the genetic marker was positive for haptoglobin GC, and properdinfactor B, confirming earlier findings. Using the sib-pair method on the remaining 25 blood groups revealed that none other than peptidase A showed significant linkage with affective disorder since one significant finding is expected by chance. We conclude from the overall morbid risk data and segregation analyses that bipolar manic-depressive illness is a spectrum disease inherited through a multifactorial mode of genetic transmission (which is not synonymous with polygenetic inheritance) with possible genetic heterogeneity and find no evidence for X-linkage. Additional studies with acetylcholinesterase, haptoglobin, GC, and properdin-factor B are needed to confirm their positive biological/genetic marker value suggested by our long-term epidemiological study.

Lack of association of genetic traits with alcoholism; C3, Ss and ABO systems

A study of association between markers of the Ss system, the C3 system and the ABO system showed no evidence of any association between alcoholism and specific phenotypes.