Depression following small vessel stroke is common and more prevalent in women

OBJECTIVES

We sought to examine the frequency of depression after small vessel-type stroke (SVS) and associated risk factors.

MATERIALS AND METHODS

We conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which included 200 participants within 2-years of SVS and 79 controls without a history of stroke from 2007 to 2012 at four sites. The primary outcome was PHQ-8, with scores ≥10 consistent with post-stroke depression (PSD). A logistic regression adjusted for age, race, sex, history of diabetes and Short-Form Montreal Cognitive Assessment score (SF-MoCA) was used to compare the risk of having depression after SVS compared to controls. Another logistic regression, adjusted for age, sex, race, level of education, SF-MoCA, white matter disease (WMD) burden, stroke severity (NIHSS), time between stroke and depression screen, history of diabetes, and history of hypertension was used to identify factors independently associated with depression in participants with SVS.

RESULTS

The cohort included 161 participants with SVS (39 excluded due to missing data) and 79 controls. The mean interval between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n = 51) had PSD compared to 6.3% (n = 5) of controls (RR = 5.44, 95% CI = 2.21-13.38, p = 0.0002). The only two variables independently associated with PSD in participants with SVS were female sex (RR = 1.84, 95% CI = 1.09-3.09, p = 0.020) and diabetes (RR 1.69, 95% CI 1.03-2.79).

CONCLUSIONS

After adjusting for several demographic and clinical variables, having a SVS was associated with an approximate 5-fold increased risk of depression and was more frequent in women and in those with diabetes. The extent of WMD was not independently associated with PSD, suggesting that small vessel disease in the setting of an overt SVS may not account for the increased prevalence of depression.

Obstetric Racial Disparities in the Era of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial and the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

To evaluate the influence of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial and the coronavirus disease 2019 (COVID-19) pandemic on racial and ethnic differences in labor induction, pregnancy-associated hypertension, and cesarean delivery among non-Hispanic Black and non-Hispanic White low-risk, first-time pregnancies.

METHODS

We conducted an interrupted time series analysis of U.S. birth certificate data from maternal non-Hispanic Black and non-Hispanic White race and ethnicity, first pregnancy, 39 or more weeks of gestation, with no documented contraindication to vaginal delivery or expectant management beyond 39 weeks. We compared the rate of labor induction (primary outcome), pregnancy-associated hypertension, and cesarean delivery during three time periods: pre-ARRIVE (January 1, 2015-July 31, 2018), post-ARRIVE (November 1, 2018-February 29, 2020), and post-COVID-19 (March 1, 2020-December 31, 2021).

RESULTS

In the post-ARRIVE period, the rate of labor induction increased in both non-Hispanic White and non-Hispanic Black patients, with no statistically significant difference in the magnitude of increase between the two groups (rate ratio for race [RR race ] 0.98, 95% CI, 0.95-1.02, P =.289). Post-COVID-19, the rate of labor induction increased in non-Hispanic White but not non-Hispanic Black patients. The magnitude of the rate change between non-Hispanic White and non-Hispanic Black patients was significant (RR race 0.95, 95% CI, 0.92-0.99, P =.009). Non-Hispanic Black pregnant people were more likely to have pregnancy-associated hypertension and more often delivered by cesarean at all time periods.

CONCLUSION

Changes in obstetric practice after both the ARRIVE trial and the COVID-19 pandemic were not associated with changes in Black-White racial differences in labor induction, cesarean delivery, and pregnancy-associated hypertension.

Cryocompression to Reduce Peripheral Neuropathy in Gynecologic Cancer: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of cryocompression therapy to prevent chemotherapy-induced peripheral neuropathy.

METHODS

This single-institution, randomized, self-controlled trial of cryocompression enrolled gynecologic cancer patients planned for five to six cycles neurotoxic chemotherapy. Exclusion criteria were prior neurotoxic chemotherapy or baseline peripheral neuropathy. Participants were randomized to cryocompression on dominant versus non-dominant hand and foot (treatment), with no intervention on the opposite side (control). Compression socks and gloves and ice bags were applied 15 minutes before, during, and 15 minutes after infusion. Primary outcome measures included the PNQ (Patient Neurotoxicity Questionnaire) and the Semmes-Weinstein monofilament test; secondary outcomes included the FACT/GOG-NTX (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity) and patient acceptability and tolerability. Sixty patients completing the study were necessary to detect a 70% reduction in the odds of PNQ grade C or higher peripheral sensory neuropathy with 80% power.

RESULTS

Ninety-one patients were enrolled from January 2021 to October 2022; 69 were eligible for final analysis. Of the 91 patients, 64.8% were White, 30.8% were Black, and 1.1% were Hispanic or Latina. With successive cycles, more patients had sensory PNQ grade C or higher neuropathy on the control side compared with the cryocompression side. Cryocompression decreased the odds of sensory neuropathy (PNQ grade C or higher) by 46% at final visit (odds ratio 0.54, 95% CI 0.31-0.94; P =.03). There was no difference in tactile sensitivity based on the monofilament test between sides at the final visit. At the final visit, average FACT/GOG-NTX-11 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 11 Item Version) scores were significantly lower on the cryocompression than the control side (estimate -0.97, 95% CI -1.89 to -0.06; P =.04), as were FACT/GOG-NTX-4 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 4 Item Version) scores (estimate -0.35, 95% CI -0.64 to -0.05; P =.02). More than 85% of patients assessed the intervention as acceptable and tolerable.

CONCLUSIONS

Cryocompression therapy reduces subjective chemotherapy-induced peripheral sensory neuropathy in patients who are receiving paclitaxel or cisplatin for gynecologic cancer.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04563130.

Conjugation of HIV-1 envelope to hepatitis B surface antigen alters vaccine responses in rhesus macaques

An effective HIV-1 vaccine remains a critical unmet need for ending the AIDS epidemic. Vaccine trials conducted to date have suggested the need to increase the durability and functionality of vaccine-elicited antibodies to improve efficacy. We hypothesized that a conjugate vaccine based on the learned response to immunization with hepatitis B virus could be utilized to expand T cell help and improve antibody production against HIV-1. To test this, we developed an innovative conjugate vaccine regimen that used a modified vaccinia virus Ankara (MVA) co-expressing HIV-1 envelope (Env) and the hepatitis B virus surface antigen (HBsAg) as a prime, followed by two Env-HBsAg conjugate protein boosts. We compared the immunogenicity of this conjugate regimen to matched HIV-1 Env-only vaccines in two groups of 5 juvenile rhesus macaques previously immunized with hepatitis B vaccines in infancy. We found expansion of both HIV-1 and HBsAg-specific circulating T follicular helper cells and elevated serum levels of CXCL13, a marker for germinal center activity, after boosting with HBsAg-Env conjugate antigens in comparison to Env alone. The conjugate vaccine elicited higher levels of antibodies binding to select HIV Env antigens, but we did not observe significant improvement in antibody functionality, durability, maturation, or B cell clonal expansion. These data suggests that conjugate vaccination can engage both HIV-1 Env and HBsAg specific T cell help and modify antibody responses at early time points, but more research is needed to understand how to leverage this strategy to improve the durability and efficacy of next-generation HIV vaccines.

Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum

BACKGROUND

To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed.

OBJECTIVE

This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum.

STUDY DESIGN

This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists.

RESULTS

A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded.

CONCLUSION

The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.

Direct-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists

RESEARCH QUESTION

What is the utilization of direct-to-consumer fertility tests (DTCFT) among fertility patients? How does the perceived utility of DTCFT differ between patients and reproductive endocrinologists (REI)?

DESIGN

Infertility patients visiting the Duke Fertility Center between December 2020 and December 2021 were sent an electronic invitation to participate in a patient survey. Members of the Society of Reproductive Endocrinology and Infertility were also sent e-mail invitations to participate in the REI survey. DTCFT were defined as tests not ordered by a physician or performed at a physician's office, including calendar methods of ovulation prediction, urinary ovulation prediction kits, basal body temperature (BBT) monitoring, hormone analysis, ovarian reserve testing and semen analysis. Patients and REI were asked how likely they were to recommend a given DTCFT, on a 0-10 Likert scale.

RESULTS

In total, 425 patients (response rate 50.5%) and 178 REI (response rate 21.4%) completed the surveys. Patients reported the utilization of calendar methods of ovulation prediction (83.8%), urinary ovulation prediction (78.8%), BBT monitoring (30.8%), hormone analysis (15.3%), semen analysis (10.1%) and ovarian reserve testing (9.2%). REI rated the utility of all DTCFT significantly lower than patients did (average discordance -4.2, P < 0.001), except for urinary ovulation prediction, which REI gave a significantly higher score (discordance +1.0, P < 0.001). Prior pregnancy was significantly associated with home ovulation prediction utilization among patients (adjusted odds ratio 3.21, 95% confidence interval 1.2-9.83).

CONCLUSIONS

Methods of ovulation prediction are commonly used by fertility patients. Significant discordance exists in the perceived utility of DTCFT between patients and REI. Patient education and guidelines are needed to better inform individuals considering DTCFT.

Examining the Association Between Hospital-Documented Atrial Fibrillation and Central Retinal Artery Occlusion

Background: Carotid stenosis is thought to be the primary risk factor for central retinal artery occlusion (CRAO); however, it is not known whether atrial fibrillation (AF), a cardiac arrhythmia that underlies over 25% of cerebral ischemic strokes, predisposes patients to CRAO. Methods: A retrospective, observational, cohort study was performed using data from the State Inpatient Databases and State Emergency Department Databases from New York (2006-2015), California (2003-2011), and Florida (2005-2015) to determine the association between AF and CRAO. The primary exposure was hospital-documented AF. The primary endpoint was hospital-documented CRAO, defined as having an ICD-9-CM code 362.31 in the primary diagnosis position. Cause-specific hazard models were used to model CRAO-free survival among patients according to hospital-documented AF status. Results: Of 39,834,885 patients included in the study, 2,723,842 (median age: 72.7 years, 48.5% female) had AF documented during the exposure window. Patients with AF were older, more likely to be of non-Hispanic White race/ethnicity and had a higher burden of cardiovascular comorbidities compared to patients without AF. The cumulative incidence of CRAO was 7.09 per 100,000 at risk in those with AF and 2.34 per 100,000 at risk in those without AF over the study period. Before adjustment, AF was associated with higher risk of CRAO (HR 2.55, 95% CI 2.15-3.03). However, after adjustment for demographics, state, and cardiovascular comorbidities, there was an inverse association between AF and risk of CRAO (aHR 0.72, 95% CI 0.60-0.87). These findings were robust in our pre-specified sensitivity analyses. By contrast, positive control outcomes of embolic and ischemic stroke showed an expected strong relationship between AF and risk of stroke. Conclusions: We found an inverse association between AF and CRAO in a large, representative study of hospitalized patients; however, this cohort did not ascertain AF or CRAO occurring outside of hospital or emergency department settings.

Abstract 30: Association Between Hospital-ascertained Atrial Fibrillation And Central Retinal Artery Occlusion: A Study Of 12 Million Patients

Introduction: Atrial fibrillation (AF) is a major risk factor for cerebral ischemic stroke. However, it is not known whether AF predicts the development of central retinal artery occlusion (CRAO), a form of ischemic stroke affecting the retina.

Methods: A retrospective cohort study was undertaken using data from the California Healthcare Cost and Utilization Project (HCUP) State Inpatient and State Emergency Department Datasets (SID/SEDDs). Patients 18 years and older discharged from non-federal hospitals between 2005 and 2011 who did not have a history of CRAO were analyzed. The exposure variable was AF and the endpoint was CRAO, each identified using validated ICD-9-CM diagnosis codes. Association between AF and CRAO was modeled using a Fine-Gray method with death as a competing risk with adjustment for age, biological sex, race, and vascular co-morbidities.

Results: A total of 12,181,778 patients were included, among these 806,397 with AF and 11,375,381 without AF. In total, 309 patients had CRAO. In an unadjusted analysis, there was a higher risk of CRAO in patients with versus without AF (HR 2.24 (95% CI: 1.51 to 3.32)). After adjustment for pre-specified covariates, there appeared to be a lower hazard of CRAO in patients with AF (aHR 0.61 (95% CI: 0.45 to 0.98)). Further analyses including cerebral ischemic stroke (aHR 1.16 (95% CI: 1.14 to 1.18)) and specifically embolic stroke (aHR 4.29 (95% CI 4.10-4.48)) as positive controls argued against overadjustment bias. We present sensitivity analyses including CRAO identified in any position of the discharge ICD list, using different ascertainment windows for AF and using broader categories of retinal ischemia.

Conclusion: The incidence of CRAO was higher in patients with AF than those without AF, but the hazard of CRAO was not higher for patients with AF after adjustment for measured covariates. Endpoint and exposure ascertainment may have been limited by inclusion only of inpatient and emergency department encounters.

Suitability of Automated Writing Measures for Clinical Trial Outcome in Writer's Cramp

BACKGROUND

Writer's cramp (WC) dystonia is a rare disease that causes abnormal postures during the writing task. Successful research studies for WC and other forms of dystonia are contingent on identifying sensitive and specific measures that relate to the clinical syndrome and achieve a realistic sample size to power research studies for a rare disease. Although prior studies have used writing kinematics, their diagnostic performance remains unclear.

OBJECTIVE

This study aimed to evaluate the diagnostic performance of automated measures that distinguish subjects with WC from healthy volunteers.

METHODS

A total of 21 subjects with WC and 22 healthy volunteers performed a sentence-copying assessment on a digital tablet using kinematic and hand recognition softwares. The sensitivity and specificity of automated measures were calculated using a logistic regression model. Power analysis was performed for two clinical research designs using these measures. The test and retest reliability of select automated measures was compared across repeat sentence-copying assessments. Lastly, a correlational analysis with subject- and clinician-rated outcomes was performed to understand the clinical meaning of automated measures.

RESULTS

Of the 23 measures analyzed, the measures of word legibility and peak accelerations distinguished subjects with WC from healthy volunteers with high sensitivity and specificity and demonstrated smaller sample sizes suitable for rare disease studies, and the kinematic measures showed high reliability across repeat visits, while both word legibility and peak accelerations measures showed significant correlations with the subject- and clinician-rated outcomes.

CONCLUSIONS

Novel automated measures that capture key aspects of the disease and are suitable for use in clinical research studies of WC dystonia were identified. © 2022 International Parkinson and Movement Disorder Society.

Elevated Urinary Rab10 Phosphorylation in Idiopathic Parkinson Disease

BACKGROUND

Pathogenic leucine-rich repeat kinase 2 LRRK2 mutations may increase LRRK2 kinase activity and Rab substrate phosphorylation. Genetic association studies link variation in LRRK2 to idiopathic Parkinson disease (iPD) risk.

OBJECTIVES

Through measurements of the LRRK2 kinase substrate pT73-Rab10 in urinary extracellular vesicles, this study seeks to understand how LRRK2 kinase activity might change with iPD progression.

METHODS

Using an immunoblotting approach validated in LRRK2 transgenic mice, the ratio of pT73-Rab10 to total Rab10 protein was measured in extracellular vesicles from a cross-section of G2019S LRRK2 mutation carriers (N = 45 participants) as well as 485 urine samples from a novel longitudinal cohort of iPD and controls (N = 85 participants). Generalized estimating equations were used to conduct analyses with commonly used clinical scales.

RESULTS

Although the G2019S LRRK2 mutation did not increase pT73-Rab10 levels, the ratio of pT73-Rab10 to total Rab10 nominally increased over baseline in iPD urine vesicle samples with time, but did not increase in age-matched controls (1.34-fold vs. 1.05-fold, 95% confidence interval [CI], 0.004-0.56; P = 0.046; Welch's t test). Effect estimates adjusting for sex, age, disease duration, diagnosis, and baseline clinical scores identified increasing total Movement Disorder Society-Sponsored Revision of the Unified (MDS-UPDRS) scores (β = 0.77; CI, 0.52-1.01; P = 0.0001) with each fold increase of pT73-Rab10 to total Rab10. Lower Montreal Cognitive Assessment (MoCA) score in iPD is also associated with increased pT73-Rab10.

CONCLUSIONS

These results provide initial insights into peripheral LRRK2-dependent Rab phosphorylation, measured in biobanked urine, where higher levels of pT73-Rab10 are associated with worse disease progression. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson Movement Disorder Society.

Mapping and functional analysis of an instability element in phosphoenolpyruvate carboxykinase mRNA

Phosphoenolpyruvate carboxykinase (PEPCK) is a key regulatory enzyme of renal gluconeogenesis. The 3'-nontranslated region of the PEPCK mRNA contains an instability element that facilitates its rapid turnover and contributes to the regulation of PEPCK gene expression. Such processes are mediated by specific protein-binding elements. Thus RNA gel shift analysis was used to identify proteins in rat renal cortical cytosolic extracts that bind to the 3'-nontranslated region of the PEPCK mRNA. Deletion constructs were then used to map the binding interactions to two adjacent RNA segments (PEPCK-6 and PEPCK-7). However, competition experiments established that only the binding to PEPCK-7 was specific. Functional studies were performed by cloning similar segments in a luciferase reporter construct, pLuc/Zeo. This analysis indicated that both PEPCK-6 and PEPCK-7 segments were necessary to produce a decrease in luciferase activity equivalent to that observed with the full-length 3'-nontranslated region. Thus the PEPCK-7 segment binds a specific protein that may recruit one or more proteins to form a complex that mediates the rapid decay of the PEPCK mRNA.

Poppy tea dependence

A patient presenting with dependence on opium poppy tea infusion is reported. Poppy tea drinking, although previously described in certain parts of the UK, rarely presents in the form of a dependence syndrome. Issues relating to the management of poppy tea dependence are discussed, including the results of existing laboratory urinalysis for drugs of abuse, the calculation of opiate dose equivalence, and the likelihood of transition (or not) from use of poppy tea to use of other opiates.

Factors associated with relapse among opiate addicts in an out-patient detoxification programme

Relapse is a central problem in the treatment of addictive behaviour, and a specific problem in the out-patient treatment of the opiate withdrawal syndrome. This study investigated factors associated with relapse among 42 opiate addicts receiving out-patient detoxification treatment at a London drug-dependence clinic. All subjects completed a questionnaire about their social, psychological, and environmental circumstances in the week before interview, and were interviewed within the first two weeks of the programme. Forty per cent had lapsed to illicit heroin abuse within the previous week. Interpersonal factors and drug-related cues were associated with lapse to opiate use. Most subjects encountered a range of high-risk situations, such as regularly meeting other drug users and being offered drugs, and persistent negative mood states.

Binding of the bacteriophage T4 regA protein to mRNA targets: an initiator AUG is required

Bacteriophage T4 regA protein translationally represses the synthesis of a subset of early phage-induced proteins. The protein binds to the translation initiation site of at least two mRNAs and prevents formation of the initiation complex. We show here that the protein binds to the translation initiation sites of other regA-sensitive mRNAs. Analysis of mRNA binding by filtration and nuclease protection assays shows that AUG is necessary but not sufficient for specific binding of regA protein to its mRNA targets. Anticipating the need for large quantities of regA protein for structural studies to further define the regA protein-RNA ligand interaction, we also report cloning the regA gene into a T4 overexpression system. The expression of regA protein in uninfected E. coli is lethal, so in our system regA driven by a strong T7 promoter is sequestered in a T4 phage until 'induction' by phage infection is desired. We have replaced the regA sensitive wild-type ribosome binding site with a strong insensitive ribosome binding site at an optimal distance from the regA initiation codon for maximizing expression. We have obtained large amounts of regA protein.

Identification of the active-site arginine in rat neutral endopeptidase 24.11 (enkephalinase) as arginine 102 and analysis of a glutamine 102 mutant

Neutral endopeptidase 24.11 contains an active-site arginine residue involved in binding the free carboxylate of substrate peptides and inhibitors. This arginine reacts rapidly with [14C]phenylglyoxal, and its reaction is selectively blocked by the presence of either the substrate Met5-enkephalin, the competitive inhibitor phenylalanylalanine, or the transition state analog phosphoramidon. The phenylglyoxal-modified peptide was isolated by a procedure involving limited digestion by trypsin, separation of the tryptic peptides by high pressure liquid chromatography (HPLC), further digestion of the modified peptide by pepsin, and a final purification by HPLC. By this procedure arginine 102 was identified as the active-site arginine. Verification of this finding came from the use of site-directed mutagenesis in which this arginine was replaced by glutamine. Both the mutant and wild-type enzyme reacted equally well with an amide containing substrate, glutaryl-Ala-Ala-Phe-4-methoxy-2-naphthylamide. However, reaction of the mutant enzyme with a substrate containing a free COOH-terminal carboxylate, 5-dimethylaminonaphthalene-1-sulfonyl-D-Ala-Gly-(NO2)Phe-Gly, was barely detectable with the mutant enzyme. Similarly the mutant enzyme showed a loss of selectivity in inhibition by D-Ala2-Met5-enkephalin compared to the corresponding amide but exhibited no difference in the maximal velocity for hydrolysis of D-Ala2-Met5-enkephalin and its amide.

A high-performance liquid chromatography assay for asparagine synthetase

A highly sensitive method for assaying asparagine synthetase and its glutaminase activity is presented. The amino acids L-asparagine, L-aspartate, L-glutamate, and L-glutamine, are separated by derivatization with o-phthaldialdehyde followed by reversed-phase high-performance liquid chromatography on an Altex ultrasphere-ODS C18 column. The elution is isocratic and the mobile phase used is 50 mM sodium acetate buffer (pH 5.9) with 30% methanol. This assay can easily detect picomoles of asparagine, which may be difficult to do with the other assays that have been described.