The UK Divide: Does Having a Pembrolizumab-Chemotherapy Option in Head and Neck Cancer Matter? Real-world Experience of First-line Palliative Pembrolizumab Monotherapy and Pembrolizumab-Chemotherapy Combination in Scotland

AIMS

The Scottish Medical Consortium recently approved first-line pembrolizumab monotherapy or in combination with chemotherapy for head and neck squamous cell carcinoma in the palliative setting, contrasting with the decision made by the National Institute for Health and Care Excellence, who approved monotherapy alone in England and Wales. The aim of this study was to provide real-world performance data for first-line pembrolizumab-containing treatments for head and neck squamous cell carcinoma in the palliative setting in Scotland.

MATERIALS AND METHODS

We analysed the electronic records of patients who started pembrolizumab-containing treatment between 1 March 2020 and 30 September 2021. Outcomes included overall survival, progression-free survival (PFS), the duration of response and the disease control rate. Data were compared with the KEYNOTE-048 study and clinical factors were evaluated for association with survival.

RESULTS

Our cohort included 91 patients (median follow-up 10.8 months). Patient characteristics were similar to those in the KEYNOTE-048 study, although our cohort had a higher proportion of patients with newly diagnosed, non-metastatic disease. For patients receiving monotherapy (n = 76), 12- and 24-month overall survival were 45% and 27%, respectively. For patients receiving pembrolizumab-chemotherapy (n = 15), 12-month overall survival was 60% (24-month overall survival had not yet been reached). Experiencing one or more immune-related adverse event (irAE; versus no irAEs), of any grade, was associated with favourable overall survival and PFS for patients receiving monotherapy in both univariable Log-rank analysis (median overall survival 17.4 months versus 8.6 months, respectively, P = 0.0033; median PFS 10.9 months versus 3.0 months, respectively, P < 0.0001) and multivariable analysis (Cox proportional hazards regression: overall survival hazard ratio 0.31, P = 0.0009; PFS hazard ratio 0.17, P < 0.0001).

CONCLUSION

Our real-world data support the KEYNOTE-048 study findings and the value of combination treatment options. Additionally, our data show that irAEs of any grade, as reported in routine clinical records, are associated with better outcomes in this patient group, adding to the growing body of evidence showing that irAEs are generally a positive marker of programmed death-ligand 1 (PD-L1) inhibitor response.

Unusual case report of concomitant lunate and scaphoid fractures without associated dislocation in a 16-year-old male

INTRODUCTION AND IMPORTANCE

Lunate fractures without associated dislocations are rare injuries, combination scaphoid-lunate fractures without an associated dislocation are even more rare of which few are reported in the literature.

CASE PRESENTATION

This case report describes a 16-year-old otherwise healthy male with ipsilateral scaphoid and lunate fractures after punching a goalpost with his left hand, for which he had surgical management. This patient had a successful treatment with two headless compression screws through a single extended carpal tunnel approach. Surgery was performed within two weeks of injury after initially immobilized with a thumb spica splint. The postoperative period was complicated by noncompliance with weight-bearing status and missed three-month followup. However, by six months, subsequent visits demonstrated radiographic and clinical healing as well as full wrist range of motion without any other sequelae.

CLINICAL DISCUSSION

This case offers more evidence regarding this rare injury. Lunate fractures and scaphoid fractures can both be treated with open reduction and internal fixation using headless compression screws, however little evidence exists when it comes to treating them in combination.

CONCLUSION

The use of headless compression screws through a single extended carpal tunnel approach led to clinical and radiographic healing in a 16 year-old-male with combined scaphoid and lunate fractures at 6 month follow up.

A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Inequalities in accessing quality healthcare, does insurance play a role? retrospective analysis of aortic emergencies from national inpatient sample 2019

Background

Aortic emergencies, dissection and rupture, are rare but catastrophic entities, with the cornerstone to survival being prompt diagnosis and treatment. Insurance status often limits access to healthcare, and our study aims to determine if it plays a role in the outcomes of aortic emergencies.

Method

A retrospective analysis of the 2019 Nationwide Inpatient Sample was conducted to identify hospitalization (Age ≥18 & non-elective) with aortic dissection and ruptured aortic aneurysms using ICD-10 codes. Discharge-level weight analysis was used to produce a national estimate. Variables were screened with univariate regression, and intermediate and co-linear variables were screened-out before a multivariable regression analysis model was built and performed to calculate the odds ratio.

Results

A total of 19,685 (0.06%) hospitalizations are identified for aortic emergencies (14965 dissections & 4720 ruptured aneurysms). The mean age was 58.56, 62.7% were males, and ethnic distribution was 65.1% white, 19.5% blacks, 7.6% Hispanics, and others.

11.4% of the hospitalizations underwent diagnostic imaging with either CTA/MRA/TEE/Aortography within 24 hours. Hypotension/shock was present in 32% of these hospitalizations and was a risk factor for mortality OR 3.21 (p&lt;0.00), increasing LOS by an average of 5.1 days and resource utilization by 156,000$. Another risk factor for mortality was stroke/TIA (OR-1.76, p&lt;0.00), increasing LOS and resource utilization by 3.1 days and 80,662$, respectively.

3220 hospitalizations (16.4%) did not survive the course, and the mortality rate in uninsured, Medicare, and Medicaid was 17%, 20%,9% compared with 12% in privately insured. On crude analysis, uninsured and medicare patients appeared to have higher odds of mortality [OR 1.50, p&lt;0.04, and OR 1.83 p-value &lt;0.002 respectively], however upon adjusting for confounders, only uninsured patients showed statistically significant difference (OR 2.13, p&lt;0.002). Similar results were corroborated on analyzing hospitalizations for aortic dissection; however, insurance status did not influence mortality in a ruptured aneurysm.

When comparing hospitalization of median household income of ≥79,000$ with household of median income of 59,000–78,999 $, 46,000–58,999 $ and &lt;46,000$ had higher odds of mortality (OR-1.38, p&lt;0.04), (OR-1.44, p&lt;0.02) and (OR-1.44, p&lt;0.03) respectively. Of all the insurance types, a statistically significant difference compared with private insurance, Medicaid on average, had 2.8 more days and incurred an additional 62,912$ in resource utilization (p&lt;0.00).

Conclusion

Inequalities in accessing healthcare, median household income, and insurance status are risk factors for mortality in aortic emergencies. Efforts are needed to bridge the gap in this particular facet of social determinants of health to find a sustainable and equitable solution for quality healthcare for aall regardless of their insurance status.

Funding Acknowledgement

Type of funding sources: None.

Instantaneous wave-free ratio and fractional flow reserve: effect of variation in left ventricular end diastolic pressure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Among patients with intermediate coronary artery stenosis (50-90%), assessment of functional significance of the lesion by instantaneous wave free ratio (iFR)/ fractional flow reserve (FFR) is recommended in latest guidelines. Though iFR is not much affected by change in hemodynamics compared to FFR, the change in iFR vs FFR due to various hemodynamic factors need a validation. Left ventricular end-diastolic pressure (LVEDP) is one of the hemodynamic factors whose variation and effect on FFR vs iFR is largely unknown. In the present study we evaluated the association of change in LVEDP on the changing pattern of iFR/FFR which may hold a clinical significance especially with percutaneous coronary intervention in heart failure patients.

Methods

This was a prospective, investigator-initiated, single-center study involving 20 patients with stable coronary artery disease and at least one intermediate coronary lesion (50-90%). The enrolled patients were subjected to both iFR and FFR along with baseline LVEDP measurement. Subsequently, intravenous nitroglycerine infusion was given to reduce LVEDP and corresponding iFR and FFR were re-evaluated. The dynamic changes in iFR and FFR were studied in relation to changes in LVEDP using Pearson’s correlation analysis and linear regression analysis.

Results

The mean LVEDP was lowered from 16.20 ± 1.54 mmHg to 9.50 ± 1.10 mmHg, the mean iFR and FFR got changed from 0.80 ± 0.12 to 0.76 ± 0.12 mmHg and 0.75 ± 0.09 to 0.72 ± 0.09 mmHg respectively. On Pearson’s correlation analysis, LVEDP change did not show statistically significant correlation (linear relationship) with iFR (p = 0.105, r2 = 0.373) and FFR (p = 0.227, r2 = 0.283) changes across the entire range of stenosis severity and in all vessels. Linear regression analysis did not state any independent correlation between LVEDP and iFR and FFR changes in the study group (p &gt;0.05). The % R2 value for iFR and FFR (as a coefficient of determination) of the regression equation were 13.9% and 8%, which means only these percentages of the total variance in iFR and FFR change were explained by LVEDP changes respectively. There was no serious adverse event related to the procedure.

Conclusion

To the best of our knowledge, this is the first study comparing the effect of changes in LVEDP on both iFR and FFR simultaneously. In our study, 1 mmHg change in LVEDP was associated with a change in FFR by 0.004 and change in iFR by 0.004 which didn’t reveal any significant association (p = 0.227 and 0.105 respectively). This helps us to put FFR at par with iFR under variable hemodynamics.  So either of the variables may be used interchangeably with confidence in varied hemodynamic conditions including patients with heart failure. The correlation was non-significant across entire range of stenosis severity, irrespective of sex, age, diabetes and hypertension. This study sets platform for further research with larger number of heterogeneous patient population. Abstract Figure. Box whisker plot

Comparison of traditional versus artificial intelligence based coronary artery disease risk prediction scores in young patients with acute coronary syndrome

Background

Ever since the concept of preventive cardiology has come into vogue, several risk identification models have come up which combine several risk factors to create a risk prediction score for occurrence of cardiovascular (CV) event. While carrying a proven validation in Western population, none of the risk prediction model has been satisfactorily evaluated in Indians especially young &lt;40 years old.

Objectives

To compare Artificial Intelligence based novel risk score with traditional risk scores in young (less than 40 years age) patients presenting with acute coronary syndrome (ACS) and to estimate the relative efficacy of different coronary artery disease (CAD) risk scores in young Indian Patients.

Design

Single center, Observational, Non-interventional study.

Participants

Cohort of Patients more than 20 but less than 40 years old with ACS in the department of Cardiology from 1st January 2019 to 31st October 2019.

Methods

314 young patients [mean age 36.14±4.17 years] presenting with acute coronary syndrome (ACS) were enrolled. The three clinically most pertinent risk assessment models [Framingham Risk score (FRS), World Health Organization risk prediction charts (WHO/ISH), and QRISK3 scores] and Artificial Intelligence based novel risk score (AICVD) were applied on day 1 of presentation, and tried to see whether one risk score versus other risk score could have predicted the event earlier had we applied it before the occurrence of ACS. Risk factors considered included those already in traditional scoring systems and new risk factors (diet, alcohol, tobacco, dyslipidemia, physical activity, family history of heart disease, history of heart disease, heart rate, respiratory rate, chronic heart symptoms and psychological stress).

Results

WHO/ISH provided the lowest high risk estimate with only 1 (0.9%) patient estimated to be having &gt;20% 10-year risk. The FRS estimated high risk (&gt;20% 10-year risk) in 3 (1%) patients. The QRISK3 estimated high risk (&gt;10% 10-year risk) in 20 (6.5%) patient. In comparison, AICVD risk prediction model stood tall by identifying 73 (23.2%) patients as high risk and 62.74% patients as more than moderate risk for having CV events at 7 years (p&lt;0.001).

Conclusion

Perhaps, this is the first study which has compared artificial intelligence based novel risk prediction model with the three most commonly applied models, in the young Indian patients. We found that a cohort of young Indian patients presenting with ACS, when studied retrospectively, was identified as “high risk” most likely by AICVD risk prediction model rather than the traditional counterparts. The WHO/ISH risk prediction charts and FRS were the poorest predictors. Performance of QRISK3 score also remained less than satisfactory. These findings suggested that AICVD risk prediction model is a promising tool to assess for CV risk in Indian population.

Funding Acknowledgement

Type of funding sources: None. Predictability of risk prediction models

AB0291 PROGNOSTIC VALUE OF LATE GADOLINIUM ENHANCEMENT ON CARDIAC MAGNETIC RESONANCE IMAGING IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Cardiac Magnetic Resonance Imaging (CMRI) with Late Gadolinium Enhancement (LGE) has an established value in the diagnostic and prognostic assessment of ischaemic and non-ischaemic cardiomyopathies. Although CMRI is widely used for the detection of myocardial involvement in subclinical Systemic Lupus Erythematosus (SLE), its prognostic value has not been determined.

Objectives:

To determine the prognostic value of CMRI with LGE for major adverse cardiovascular events (MACE) in patients with SLE, and investigate its correlation with the severity of systemic inflammation.

Methods:

A retrospective tertiary single-centre review of patients with SLE who underwent a CMRI study at Manchester Foundation Trust between 2009-2020 was conducted. Patients were categorized into two groups; those who experienced a MACE (cardiac death, myocardial infarction (MI), stroke/TIA or heart failure) and those who did not. We compared cardiovascular (CV) risk factors, CMRI findings, SLE risk scores and biochemistry between the 2 groups.

Results:

We identified 20 female patients who underwent a CMRI, with a mean age of 46 years at the time of the scan. Indications for CMRI were assessment for worsening dyspnoea and new onset left ventricular systolic dysfunction. Table 1 demonstrates the clinical, laboratory and CMRI characteristics of the two groups. There were no significant differences in the clinical background and traditional CV risk factors between the 2 groups. 5/20 (25%) patients experienced a MACE. The SLEDAI-2K score was >12 in 2/5 (40%) of patients who suffered a MACE and they presented with a stroke within a year of CMRI study, suggesting that systemic inflammation contributes to poor vascular outcomes. 3/5 (60%) patients who reported a MACE demonstrated LGE on their CMRI study compared to 3/15 (20%) of those who did not (p-0.045). The LGE was predominantly diffuse, mid myocardial in distribution and not ischaemic in pattern, signifying a complex pathophysiological substrate in the development of myocardial pathology in SLE. Additionally, an increase in left ventricular end-diastolic, end-systolic volumes and left atrial diameter was noted in patients who had a MACE (p<0.05). Patients who had a MACE showed a higher incidence of valvular abnormalities and pericardial disease in their CMRI studies. On looking at the medications around the CMRI, the majority of MACE positive patients 4/5 (80%) were on conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) such as Mycophenolate, Tacrolimus, Cyclophosphamide, Methotrexate or hydroxychloroquine and none on biologics like Rituximab or Belimumab. While 9/15 of the MACE negative patients were on DMARDs and 4/15 were on biologics.

Table 1.

clinical, laboratory and CMRI characteristics of SLE patients with and without MACE. LVEDV-left ventricular end-diastolic volume, LVESV-left ventricular end-systolic volume, LA-left atrial, LVEF-Left ventricular ejection fraction, SLEDAI- SLE Disease Activity Index, +ve-positive.

MACE+ (n = 5)MACE- (n = 15)Mean age of SLE diagnosis (years)35.634.4Mean duration to CMRI (years)8.811.71Lupus nephritis 20%20%Raynaud’s 40%27%Previous CV involvement02 SLEDAI-2K > 122(40%)11(73%)Lupus anticoagulant +ve20%27%Anticardiolipin +ve2(40%)2(14%)anti-dsDNA (iu/ml)+ve3(60%)6(40%)Low C3 (g/L)2(40%)6(40%)Mean prednisolone dose28.338.21 Conventional DMARDs4/5(80%)9/15(60%)Biologics0/54/15Mean LVEF (%)47.456.7CMR LGE3(60%)3(20%)Valvular abnormalities 2(40%) 4(27%)Mean LA area (cm2) 29.620.6Pericardial effusion 40%27%

Conclusion:

In our small SLE cohort, we add to existing knowledge that CMRI with LGE is an indispensable tool to investigate cardiac involvement in SLE and may indeed add important prognostic information. Larger scaled studies are required to confirm the use of CMRI with LGE as a predictor of MACE in patients with SLE.

Disclosure of Interests:

None declared

Is there a role for modified probiotics as beneficial microbes: a systematic review of the literature

Our objective was to conduct a systematic review and meta-analysis for the use of modified (heat-killed or sonicated) probiotics for the efficacy and safety to prevent and treat various diseases. Recent clinical research has focused on living strains of probiotics, but use in high-risk patients and potential adverse reactions including bacteremia has focused interest on alternatives to the use of live probiotics. We searched MEDLINE/PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, Alt Health Watch, Web of Science, Scopus, PubMed, from inception to February 14, 2017 for randomised controlled trials involving modified probiotic strains. The primary outcome was efficacy to prevent or treat disease and the secondary outcome was incidence of adverse events. A total of 40 trials were included (n=3,913): 14 trials (15 arms with modified probiotics and 20 control arms) for the prevention of diseases and 26 trials (29 arms with modified probiotics and 32 control arms) for treatment of various diseases. Modified microbes were compared to either placebo (44%), or the same living probiotic strain (39%) or to only standard therapies (17%). Modified microbes were not significantly more or less effective than the living probiotic in 86% of the preventive trials and 69% of the treatment trials. Modified probiotic strains were significantly more effective in 15% of the treatment trials. Incidence rates of adverse events were similar for modified and living probiotics and other control groups, but many trials did not collect adequate safety data. Although several types of modified probiotics showed significant efficacy over living strains of probiotics, firm conclusions could not be reached due to the limited number of trials using the same type of modified microbe (strain, daily dose and duration) for a specific disease indication. Further research may illuminate other strains of modified probiotics that may have potential as clinical biotherapeutics.

Comparison of the utility of Cocaine- and Amphetamine-Regulated Transcript (CART), chromogranin A, and chromogranin B in neuroendocrine tumor diagnosis and assessment of disease progression

CONTEXT

Prognosis in patients with neuroendocrine tumors (NETs) is often poor, frequently reflecting delayed diagnosis. Hence, accurate and practical NET markers are needed. Cocaine- and amphetamine-regulated transcript (CART) peptide is a potential novel NET marker.

DESIGN AND PARTICIPANTS

Circulating levels of CART peptide and the established NET markers chromogranin A (CgA) and chromogranin B (CgB) were measured using RIA in 353 patients with NET (normal renal function) and in controls. Clinical data were collected retrospectively.

MAIN OUTCOME MEASURE(S)

The comparative and combined utility of CART, CgA, and CgB for diagnosis and assessment of disease progression was measured in different NET subtypes.

RESULTS

CgA and CgB in combination improved diagnostic accuracy in patients with gut NETs, nongastroenteropancreatic NETs, and NETs with an unknown primary origin compared with each biomarker alone. Measuring CART did not further improve diagnosis in these NET subtypes. For pancreatic NETs, CgB was superior to CgA and CART in detecting stable disease (P < .007), whereas CgA and CART in combination were most effective in identifying progressive disease. In phaeochromocytomas/paragangliomas (PCC/PGL), CART was the most useful biomarker for identifying stable (P < .001) and progressive (P = .001) disease. Consistent with this, plasma CART decreased following PCC/PGL tumor resection, remaining low in all patients in remission, but increasing in those with progressive disease.

CONCLUSIONS

CART is a useful marker for identifying progressive pancreatic NETs. CART is superior to CgA and CgB in detecting stable and progressive PCC/PGLs, and may have a role as a surveillance marker for PCC/PGL patients.

Selection of natural health products for clinical trials: a preclinical template

In preparation for a clinical trial on the efficacy of Echinacea products with a pediatric population, a rational method for selection of test products was developed, based on phytochemical and bioassay evaluation. Ten currently available commercial products of Echinacea angustifolia (EA) or Echinacea purpurea (EP) were selected, and 3 bottles of each of 2 different lots were purchased for each product. Investigators were blinded to product identity before phytochemical analysis. Lot-to-lot variation was small, but product variation due to species and formulation was large. Products derived from ethanol extracts had low polysaccharide content and high levels of alkamides (EA), echinacoside (EA), cynarin (EA), cichoric acid (EP), and caftaric acid (EP). These products possessed high antiviral activities that differed between EA and EP products, but limited immune activation properties. In contrast, products derived without ethanol extraction had higher polysaccharide levels, but low levels of other components. These aqueous compounds showed immunostimulant activity as measured in a mouse macrophage model and a somewhat different antiviral profile. The choice of Echinacea product for clinical trial must therefore consider the impact of immune enhancement, the specific viral infection targeted, and the potential to reduce symptoms via antiinflammatory activity. Product selection may also depend on whether the intent of the trial is prophylaxis or treatment.

Epidemiology of NHP-drug interactions: identification and evaluation

Increasing numbers of adults and children around the world are using natural health products (NHPs) to promote wellbeing or alleviate illness. Although often considered safe due to their natural origin, NHPs are potentially pharmacologically active and, therefore may cause harm. Limited data suggest that NHPs can interact with other NHPs as well as with prescription medication and foods. Although some common NHP-drug interactions have been identified and studied, in general, the epidemiology of NHP-drug interactions is not well-understood, in part because these harms are often underreported. Users rarely disclose NHP use to their physicians, and physicians rarely enquire about such use. Even if physicians become aware of a potential NHP-drug interaction, passive surveillance systems mean that it is left to the physician's discretion whether or not to report it to the proper authority. It is likely that active surveillance of NHP-drug interactions would result in increased reporting of NHP-related harms as well as better quality reports. Subsequent lab investigation would determine if adulteration, contamination, species misidentification, or misuse was responsible for the harm, or if a pharmacokinetic or pharmacodynamic NHP-drug interaction occurred. This kind of thorough detection and investigation of potential NHP-drug interactions is necessary to ensure the safe use of NHPs.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories:1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants </=1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU(one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Cercarial dermatitis in central India: an emerging health problem among tribal communities

Although cercarial dermatitis is an emerging disease world-wide, cases of such dermatitis may often go undiagnosed, especially in communities that are affected by various skin infections. Between August 2001 and July 2002, 1336 individuals from tribal villages in central India were examined for dermatitis. Skin scrapings were collected and examined for Sarcoptes scabiei and each subject's response to antiscabies treatment was recorded. Freshwater snails were collected from the local ponds used for bathing, and examined for cercariae. The recorded prevalence of dermatitis ranged between 2.1% and 12.5% during the study year, peaking at the end of winter (February-March) and during the rainy season (August-October). Snail positivity for cercariae peaked in the rainy season. The prevalence and the severity of dermatitis were both higher in children than in adults. As most recorded cases of dermatitis were associated with a rash that developed soon after bathing in the local pond, all the skin scrapings were negative for itch mites, and the response to antiscabies treatment was poor, most if not all of the dermatitis observed was probably cercarial. Cercarial dermatitis therefore appears to be a significant health problem among the tribal populations of central India.

Computational studies of Family A and Family B GPCRs

A full picture of the similarities between Family A and Family B GPCRs (G-protein coupled receptors) has been frustrated by the lack of clear homology between the respective sequences. Here, we review previous computational studies on GPCR dimerization in which the putative dimerization interfaces have been analysed using entropy, the ET (evolutionary trace) method and related methods. The results derived from multiple sequence alignments of Family A subfamilies have been mapped on to the rhodopsin crystal structure using standard alignments. Similarly, the results for the Family B alignments have been mapped on to the rhodopsin crystal structure using the 'cold-spot' alignment. For both Family A and Family B GPCRs, the sequence analysis indicates that there are functional sites on essentially all transmembrane helices, consistent with the parallel daisy chain model of GPCR oligomerization in which each GPCR makes interactions with a number of neighbouring GPCRs. The results are not too sensitive to the quality of the alignment. Molecular Dynamics simulations of the activation process within a single transmembrane bundle of the rhodopsin and the beta(2)-adrenergic receptor have been reviewed; the key observation, which is consistent with other computational studies, is that there is a translation and bending of helix 6, which contributes to a significant opening out of the intracellular face of the receptor, as shown in the accompanying movies. The simulations required the application of specific experiment-derived harmonic and half-harmonic distance restraints and so the application of such simulations to Family B GPCRs requires considerable care because of the alignment problem. Thus, in order to address the alignment problem, we have exploited the observation that GCR1, a plant GPCR, has homology with Family A, Family B and Family E GPCRs. The resulting alignment for transmembrane helix 3 is presented.

Probiotics for the prevention of pediatric antibiotic-associated diarrhea

BACKGROUND

Antibiotics alter the microbial balance within the gastrointestinal tract. Probiotics may prevent antibiotic-associated diarrhea (AAD) via restoration of the gut microflora. Antibiotics are prescribed frequently in children and AAD is common in this population.

OBJECTIVES

To assess the efficacy and adverse effects of probiotics (any specified strain or dose) for the prevention of antibiotic-associated diarrhea in children. To assess adverse events associated with the use of probiotics when co-administered with antibiotics in children.

SEARCH STRATEGY

MEDLINE, EMBASE, CENTRAL, CINAHL , AMED, and the Web of Science (inception to August 2006) were searched along with specialized registers including the Cochrane IBD/FBD Review Group, CISCOM, Chalmers PedCAM Research Register and trial registries from inception to 2005. Letters were sent to authors of included trials, nutra/pharmaceutical companies, and experts in the field requesting additional information on ongoing or unpublished trials. Conference proceedings, dissertation abstracts, and reference lists from included and relevant articles were hand searched.

SELECTION CRITERIA

Randomized, parallel, controlled (placebo, active, or no treatment) trials comparing co-administered probiotics with antibiotics for the prevention of diarrhea secondary to antibiotic use in children (0 to 18 years).

DATA COLLECTION AND ANALYSIS

Methodological quality assessment and data extraction were conducted independently by two authors (BCJ, AS). Dichotomous data (incidence of diarrhea, adverse events) were combined using pooled relative risks, and continuous data (mean duration of diarrhea, mean daily stool frequency) as weighted mean differences, along with their corresponding 95% confidence intervals. Adverse events were summarized using risk difference. For overall pooled results on the incidence of diarrhea, a priori sensitivity analyses included per protocol versus intention to treat, random versus fixed effects, and methodological quality criterion. Subgroup analysis were conducted on probiotic strain, dose, definition of antibiotic-associated diarrhea, and antibiotic agent.

MAIN RESULTS

Ten studies met the inclusion criteria. Trials included treatment with either Lactobacilli spp., Bifidobacterium spp., Streptococcus spp., or Saccharomyces boulardii alone or in combination. Six studies used a single strain probiotic agent and four combined two probiotic strains. The per protocol analysis for 9/10 trials reporting on the incidence of diarrhea show statistically significant results favouring probiotics over active/non active controls (RR 0.49; 95% CI 0.32 to 0.74). However, intention to treat analysis showed non-significant results overall (RR 0.90; 95% CI 0.50 to 1.63). Five of ten trials monitored for adverse events (n = 647); none reported a serious adverse event.

AUTHORS' CONCLUSIONS

Probiotics show promise for the prevention of pediatric AAD. While per protocol analysis yields treatment effect estimates that are both statistically and clinically significant, as does analysis of high quality studies, the estimate from the intention to treat analysis was not statistically significant. Future studies should involve probiotic strains and doses with the most promising evidence (e.g., Lactobacillus GG, Lactobacillus sporogenes, Saccharomyces boulardii at 5 to 40 billion colony forming units/day). Research done to date does not permit determination of the effect of age (e.g., infant versus older children) or antibiotic duration (e.g., 5 days versus 10 days). Future trials would benefit from a validated primary outcome measure for antibiotic-associated diarrhea that is sensitive to change and reflects what treatment effect clinicians, parents, and children consider important. The current data are promising, but it is premature to routinely recommend probiotics for the prevention of pediatric AAD.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), with associated morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions, designed for prevention of hypothermia in preterm and/or low birthweight infants, applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to May Week 4 2004 ), CINAHL (1982 to May Week 4 2004), EMBASE (1974 to 09/07/04), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2004), conference/symposia proceedings using ZETOC (1993 to July 2004), ISI proceedings (1990 to 09/07/2004) and OCLC WorldCat (July 2004). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent reviewers. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories: 1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and 2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03) but not in the 28 to 31 week group. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress significantly kept infants </=1500 g warmer and reduced the incidence of hypothermia on admission to NICU (one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Influence of stressors on the rewarding effects of alcohol in Wistar rats: studies with alcohol deprivation and place conditioning

RATIONALE AND OBJECTIVES

Studies on laboratory animals have provided conflicting results regarding the actions of stressors on the rewarding effects of alcohol. In the present study, we first examined the effects of footshock or social defeat, given during deprivation, on the alcohol deprivation effect (ADE). We then tested the effects of stressors on place conditioning to alcohol, another technique used to measure drug reward.

METHODS

Male Wistar rats were trained to drink 10% alcohol in a 24 h access, free-choice design and received intermittent footshock or defeat 5 times during a 2-week alcohol deprivation period, followed by 2 weeks of free access to alcohol. There were three such cycles. In the place conditioning studies, animals received footshock, defeat, or no stress immediately prior to conditioning sessions where they received alcohol (0.6 or 1.0 g/kg, i.p.) or vehicle injections.

RESULTS

Alcohol intake of footshock-treated animals was significantly higher than that of controls following the first and second, but not the third period of alcohol deprivation and stress exposure. Defeat caused a smaller increase in alcohol intake that was significant only after the first deprivation and stress cycle. In the place conditioning studies, we found that either stressor blocked the place aversion induced by 1.0 g/kg alcohol.

CONCLUSIONS

These results demonstrate that stressors can modify the rewarding and aversive properties of alcohol, measured using two different paradigms. Footshock and defeat produced transient, but significant increases in the magnitude of ADE, while exposure to either stressor reduced the aversive effects of a high dose of alcohol measured using the place conditioning paradigm.

Hypothetical framework for a relationship between maternal thyroid function, nausea and vomiting of pregnancy, and congenital heart disease

Our objective was to investigate whether a relationship exists among maternal thyroid function, nausea and vomiting of pregnancy, and congenital heart disease. A Medline search from 1966 to the present was conducted to look for reports on the existence of this relationship. The results were supplemented by abstract searches and personal communication with relevant authors. Our search found independent evidence that maternal hyperthyroidism is related to increased rates of nausea and vomiting of pregnancy, which in turn is significantly related to a decrease in the incidence of congenital heart disease. Early evidence indicates that the converse may be true: maternal hypothyroidism and thyroid replacement therapy are associated with an increase in congenital heart disease in children. The potential relationship between maternal thyroid function, nausea and vomiting of pregnancy, and thyroid replacement therapy needs further study. We propose a case-control study of children presenting for echocardiography to elicit specific information regarding the pregnancy.

Tubulointerstitial nephritis and uveitis in children and adolescents. Four new cases and a review of the literature

We identified 35 cases of tubulointerstitial nephritis and uveitis (TINU), 31 from a MEDLINE search (1966-1996) of the English literature and 4 from our hospital records (1988-1996). To meet the case definition, the patient had to be less than 18 years old and have TINU of unknown cause. Common presenting symptoms included fatigue, weight loss, fever, and abdominal pain. The uveitis was usually anterior and could occur at any time with respect to the onset of the renal disease. Common laboratory features included anemia, increased erythrocyte sedimentation rate, and decreased creatinine clearance. Most patients (33 of 35) had renal biopsies that commonly revealed an intense inflammatory interstitial infiltrate, glomerular sparing, and negative immunofluorescence studies. Of the 35 patients, 26 received systemic corticosteroid therapy (5 of 26 for eye disease); 22 had follow-up for at least 1 year; 13 of 35 patients had a recurrence of their uveitis. The outcome in all 35 cases was normal renal function with no documented visual loss. In conclusion, TINU is a unique syndrome with characteristic clinical features, laboratory changes, and renal biopsy results. Treatment is controversial, and the outcome in children, even if untreated, is excellent.

Transitional cell carcinoma arising in a pyelocaliceal cyst. An unusual cystic renal lesion with cytologic and imaging findings

The differentiation between benign and malignant cystic lesions of the kidney is a diagnostic challenge. Medical imaging aids in this task, but many cystic renal lesions require further work-up, frequently by computed tomography-guided fine needle aspiration. We report on the pathological findings in a case of moderately differentiated papillary transitional carcinoma, which arose in a pre-existing pyelocaliceal cyst in a 53-year-old man. In the case of this lesion, the distinction between a benign and a malignant renal cyst is blurred. To our knowledge, this is the third such occurrence to be reported and the first to be diagnosed by fine needle aspiration biopsy.

Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial

OBJECTIVE

Significant evaporative heat loss in the very low birth weight infant can occur in the delivery room. We investigated the effect of polyethylene wrap applied immediately at birth (without drying) on rectal temperature measured at nursery admission.

STUDY DESIGN

Sixty-two consecutive infants delivered at <32 weeks' gestation were stratified by gestational age and randomly allocated to resuscitation with polyethylene wrap. All infants were resuscitated under radiant warmers. Wraps were removed on nursery admission. Rectal temperature was taken by digital electronic thermometer.

RESULTS

Fifty-nine of 62 recruited infants completed the study. Maternal temperature, delivery room temperature, transfer-incubator temperature, and time to admission were recorded. Use of occlusive wrapping resulted in a significantly higher admission rectal temperature in infants <28 weeks' gestation (difference in means = 1.9 C, P <.001). No significant difference was seen in admission rectal temperature in infants of 28 to 31 weeks' gestation (difference in means = 0.17 C, P =.47). All 5 deaths were in the nonwrap group (vs wrap, P =.04); their mean temperature was 35.1 C versus 36.5 C in survivors (P =.001).

CONCLUSIONS

Occlusive wrapping of very low birth weight infants at delivery reduces postnatal temperature fall. This may result in a decreased mortality rate.

Combined use of bowel and the artificial urinary sphincter in reconstruction of the lower urinary tract: infectious complications

Combined use of the artificial urinary sphincter and bowel in reconstruction of the lower urinary tract is currently being performed with increasing frequency. We reviewed our experience with 31 patients undergoing augmentation cystoplasty and insertion of the artificial urinary sphincter with respect to device infections to determine if a single operation was associated with increased morbidity compared to staged procedures. Of the patients who underwent simultaneous reconstruction 50% had prosthetic infections as opposed to 9.5% when the procedure was staged. More than half of the infections presented longer than 1 year after placement of the artificial urinary sphincter. The lowest incidence of device infection occurred in patients who underwent a staged procedure with implantation of the artificial urinary sphincter initially followed by augmentation cystoplasty. The discrepancy in infection rates between single and staged procedures is dramatic in this series and, therefore, a staged approach is recommended to decrease infectious complications.

Balanitis and balanoposthitis

Balanitis is an inflammation of the glans penis. There are several etiologic agents, including bacterial and yeast infections, parasitic infestations, and trauma or irritants. Plasma-cell balanitis and balanitis xerotica obliterans are two distinct clinical entities. The authors review the clinical and pathologic features and the treatment options for these conditions.

Virus leakage through natural membrane condoms

The authors determined virus leakage from condoms made from processed sheep caecum using two viral probes simultaneously. They poured a mixture of two viruses, the bacteriophage, phi X174 (4 X 10(7) pfu/ml), and the human pathogen, herpes simplex virus (about 1 X 10(6) pfu/ml), in a buffered solution into condoms, which were suspended into beakers also containing buffered solution. The authors then assayed aliquots from the beakers to measure the extent of virus leakage from the condoms. With one brand of condom, 10 out of 24 samples leaked small amounts of phi X174; with the other brand of condom, 13 out of 24 samples gave similar leakage. The extent of leakage varied over two orders of magnitude from condom to condom within each brand. Of the 23 condoms that leaked the smaller virus, phi X174 (27 nm in diameter), only two also leaked the larger herpesvirus (120-150 nm in diameter). These data demonstrate that (1) large and small viruses can leak from natural membrane condoms; (2) there is considerable variation from condom to condom in allowing leakage of the viruses; and (3) leakage of a small virus does not necessarily indicate that a larger virus will leak from that particular condom. The authors explain some inconsistencies in the published literature.

Effect of anaesthesia on the QT interval

A prolonged electrocardiographic QT interval may be harmful during general anaesthesia. It may be prudent, therefore, to select anaesthetic agents which have the least effect on the QT interval. In a controlled study, propofol has been shown to have less effect on the QT interval than thiopentone (P less than 0.05). Our data suggest also that any effects which may be caused by enflurane and isoflurane are masked by the effects of the induction agent.

Changes in the levels of pituitary and steroid hormones in ovine and human ovarian follicular fluid

Changes in the protein and steroid hormones of follicular fluid, aspirated from different follicles of sheep and human ovaries, have been measured and correlated with the size of the follicles. As the fluid contains a number of proteins, steroids have been measured directly and after ether extraction. The follicular fluid concentrations of progesterone and 17 beta-oestradiol measured directly in the fluid increased with the size of the follicles. The levels of free testosterone remained constant in all sizes of follicles, while those of bound hormone showed a 10- to 15-fold increase over the free testosterone concentrations in both the sheep and human follicular fluid. A decrease in the levels of bound testosterone in the fluid of large follicles (LFFL) coincided with the increase in bound 17 beta-oestradiol, suggesting the possible conversion of bound testosterone to oestrogen as the follicle attained maturity. The ratio of follicle-stimulating hormone (FSH) to luteinizing hormone (LH) varied in the fluid obtained from different size follicles, being 1:7 in small (SFFL), 1.3.5 in medium (MFFL) and 1:2.3 in large (LFFL) follicles of sheep ovaries. The LH content of follicular fluid of different size follicles appeared to be the same, with LFFL showing a minor increase over SFFL. In the human, the fluid from medium follicles contained very little LH compared to LFFL. These differences in the pattern of LH levels present in the fluid from different size follicles between human and sheep ovaries presumably reflect species variations in the entry of LH into the follicles.