A Geospatial Analysis of Social and Structural Determinants of Health and High HIV Prevalence in Alabama, USA

OBJECTIVE

This study utilizes geospatial analytic techniques to examine HIV hotspots in Alabama leveraging Medicaid utilization data.

METHODS

This cross-sectional study leveraged Medicaid utilization data from Alabama's 67 counties, averaging 9,861 Medicaid recipients aged > 18 years old per county. We used Alabama Medicaid administrative claims data from January 1, 2016, to December 31, 2020, to identify individuals with HIV. Using Microsoft SQL Server, we obtained the average annual count of HIV Medicaid claims in each of the 67 Alabama counties (numerator) and the number of adult Medicaid recipients in each county (denominator), and standardized with a multiplier of 100,000. We also examined several other area-level summary variables (e.g., non-high school completion, income greater than four times the federal poverty level, social associations, urbanicity/rurality) as social and structural determinants of health. County-boundary choropleth maps were created representing the geographic distribution of HIV rates per 100,000 adult Medicaid recipients in Alabama. Leveraging ESRI ArcGIS and local indicators of spatial association (LISA), results were examined using local Moran's I to identify geographic hotspots.

RESULTS

Eleven counties had HIV rates higher than 100 per 100,000. Three were hotspots. Being an HIV hotspot was significantly associated with relatively low educational attainment and less severe poverty than other areas in the state.

CONCLUSIONS

Findings suggesting that the HIV clusters in Alabama were categorized by significantly less severe poverty and lower educational attainment can aid ongoing efforts to strategically target resources and end the HIV epidemic in U.S.' Deep South.

The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients.

METHODS

A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines.

RESULTS

Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature.

CONCLUSIONS

The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.

Medication-assisted treatment and self-help group participation among military veterans with opioid or alcohol use disorder

INTRODUCTION

Medication-assisted treatment (MAT) is a combination of behavioural therapy and medications to assist with recovery and has been administered to individuals with alcohol and opioid withdrawal symptoms. Military veterans seeking MAT could have barriers preventing them from receiving the care they desire. The present study sought to compare outcomes in individuals who received MAT or those who participated in self-help groups for opioid or alcohol use disorder. In addition, the present study sought to compare outcomes between veterans and non-military-connected individuals.

METHODS

We used the 2015-2017 United States Treatment Episode Data Set Discharges data from the Substance Abuse and Mental Health Services Administration. The data set included 138 594 unique discharges. A multinomial logistic regression model was used to examine differences in substance use outcomes for veterans/non-veterans in MAT and a self-help group.

RESULTS

Fewer veterans (2.58%) than non-veterans (4.28%) reported usage of MAT. Fewer veterans (38.94%) than non-veterans (40.17%) reported signing up for a self-help group. Finally, those who participated in MAT and a self-help group had a better outcome (66.64%)-defined as no substance use at discharge-than those who only received MAT (43.02%) and those who did not participate in MAT or self-help groups (34.84%).

CONCLUSIONS

Recommendations for future research on MAT and implementation for the veteran population would benefit the literature base.

389 General Surgery Operative Cancellations Within Aberdeen Royal Infirmary 2019

Introduction

Operative cancellation rates can be up to 17.6%, resulting in delays to patient treatment and management. This audit was conducted to assess underlying reasons for operative cancellations with the aim to minimise cancellations in the future.

Method

A retrospective review of General surgery operative cancellations during 2019 at Aberdeen Royal Infirmary was undertaken. Data was obtained from Theatre Management.

Results

28548 operations were performed across all surgical specialities during 2019 with 2664 operations cancelled. Within General Surgery, 447 were cancelled (182 emergency (40.7%), 265 electives (59.3%)). The most common reason was lack of theatre time for elective cases and procedure no longer needed for emergency cases. For cancelled elective surgeries, there was a median time of 29 days before being operated.

Conclusions

We highlight that both elective and emergency operations are susceptible to cancellation. There are clear differences in the reason of cancellation between elective and emergency. Going forward, it is worth discussing booking emergency operations with the on-call consultant to ensure they are necessary. Regarding elective operation cancellations due to lack of theatre time it would be imperative to assess the exact cause of this as to minimise operative cancellations. We plan re-audit once a departmental discussion has been made.

Chemical composition and biological effects of kratom (Mitragyna speciosa): In vitro studies with implications for efficacy and drug interactions

The safety and efficacy of kratom (Mitragyna speciosa) for treatment of pain is highly controversial. Kratom produces more than 40 structurally related alkaloids, but most studies have focused on just two of these, mitragynine and 7-hydroxymitragynine. Here, we profiled 53 commercial kratom products using untargeted LC-MS metabolomics, revealing two distinct chemotypes that contain different levels of the alkaloid speciofoline. Both chemotypes were confirmed with DNA barcoding to be M. speciosa. To evaluate the biological relevance of variable speciofoline levels in kratom, we compared the opioid receptor binding activity of speciofoline, mitragynine, and 7-hydroxymitragynine. Mitragynine and 7-hydroxymitragynine function as partial agonists of the human µ-opioid receptor, while speciofoline does not exhibit measurable binding affinity at the µ-, δ- or ƙ-opioid receptors. Importantly, mitragynine and 7-hydroxymitragynine demonstrate functional selectivity for G-protein signaling, with no measurable recruitment of β-arrestin. Overall, the study demonstrates the unique binding and functional profiles of the kratom alkaloids, suggesting potential utility for managing pain, but further studies are needed to follow up on these in vitro findings. All three kratom alkaloids tested inhibited select cytochrome P450 enzymes, suggesting a potential risk for adverse interactions when kratom is co-consumed with drugs metabolized by these enzymes.

Illicit drug use and self-reported vision loss among military service members or veterans

INTRODUCTION

Little is known about differences in vision loss prevalence among service members or veterans (SMVs) and civilians; further, no study has compared vision loss risk factors in these two populations. As such, we seek to fill this gap in the literature.

METHODS

In this cross sectional study, we obtained data on 106 SMVs and 1572 civilians from the 2013-2018 National Health and Nutrition Examination Surveys. We compared the prevalence of or mean values of vision loss risk factors between SMVs and civilians using the Wald χ² statistic or Kruskal-Wallis test. Further, we examined the relative strength of 17 vision loss risk factors in predicting self-reported vision loss via Firth's logistic regression.

RESULTS

SMVs had a significantly higher prevalence of illicit drug use (20.75% vs 13.62%) and HIV (1.89% vs 0.41%), while civilians had a higher prevalence of poor dietary habits (7.61% vs 13.21%). SMVs also had higher mean values of systolic blood pressure (125.85 vs 122.53 mmHg), pack years of cigarette smoking (8.29 vs 4.25), and sedentary minutes per day (379.15 vs 337.07 min). More SMVs (8.49%) self-reported vision loss than civilians (4.48%). After adjustment for covariates, illicit drug use (adjusted β coefficient=0.72, p=0.02) was associated with self-reported vision loss.

CONCLUSIONS

This study indicates that self-reported vision loss among SMVs is more prevalent than among civilians, and vision loss in SMVs is associated with severe or prolonged illicit drug use.

An exploration of the relationship between phonological and phonics knowledge, and self-efficacy for teaching

The purpose of the present study was to survey trainee teachers to find out if there was a relationship between phonological and phonics content knowledge, perceived proficiency in this knowledge, and feelings of self-efficacy as teachers. Participants were 51 undergraduate international teacher trainees from Malaysia studying in a 4-year university program to teach English as another language. They completed a phonological and phonics knowledge survey as well as a short questionnaire relating to self-efficacy for teaching. The survey results showed, similar to previous studies of the linguistic knowledge of teachers and teacher trainees, difficulties with phonological and phonics knowledge. Students who thought they were proficient in phonological and phonics knowledge were higher in phonological knowledge but not in phonics scores than were students who thought they were less proficient. The results for teaching self-efficacy showed that students with higher phonological knowledge had higher levels of external teaching self-efficacy in that they tended to disagree that factors outside their control made it difficult for some pupils to succeed. This suggests that higher levels of phonological knowledge gives prospective teachers more self-belief in their ability to help all their pupils.

Alcohol screening and brief intervention among military service members and veterans: rural-urban disparities

BACKGROUND

Access to screening, brief intervention and referral to treatment programmes for alcohol use have been shown to be effective; however, little is known about access to these services among service members and veterans. We examined the association of service member or veteran rural-dwelling area and the following outcomes: recent general health check-up, alcohol screening and alcohol brief intervention.

METHODS

Data on 5080 military service members and veterans were obtained from the 2017 Behavioural Risk Factor Surveillance System of the USA. We estimated rural-urban disparities in the receipt of a recent voluntary general health check-up, as well as the receipt of alcohol screening and brief intervention, using a mixed logit model.

RESULTS

Of the 5080 participants in the study, a total of 4666 (90.49%, 95% CI 89.39% to 91.48%) reported a general health check-up in the last 2 years. Results showed 7.48% of the sample (95% CI 6.64% to 8.41%) exhibited heavy alcohol consumption patterns. Of the 414 participants who did not undergo a general health check-up, 13.80% (95% CI 9.63% to 19.41%) exhibited a pattern of heavy alcohol consumption. Rural individuals were less likely to report a recent health check-up (adjusted OR=0.82, 95% CI 0.79 to 0.87). Rurality was also independently associated with decreased likelihood of receiving an alcohol screening and brief intervention.

CONCLUSION

Greater access to telehealth or other geographically flexible screening and brief intervention programmes is needed in rural areas for service members and veterans.

Abstract GS3-02: PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib

Background: CDK4/6 inhibitors, such as palbociclib, are used to treat ER+ metastatic breast cancer in combination with endocrine therapy with trials ongoing in patients with primary disease. No biomarkers exist to identify those who do/do not benefit from added CDK4/6 inhibition. PALLET is an investigator-initiated/led phase II randomized trial collaboration between UK and NSABP investigators evaluating the biological and clinical effects of palbociclib with letrozole combination as neoadjuvant therapy.

Methods: Postmenopausal women with ER+ primary breast cancer and tumors >2.0cm (ultrasound) were randomized to one of 4 treatment groups (3:2:2:2 ratio): Group A: letrozole (2.5mg/d) for 14 weeks; Group B: letrozole for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group C: palbociclib for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group D: letrozole + palbociclib for 14 weeks. Palbociclib was given 125mg/d PO on a 21 days on, 7 days off schedule. Post-14 week treatment was at the discretion of the treating clinician including letrozole until surgery. Core-cut biopsies were taken at baseline, 2 weeks and 14 weeks. Co-primary endpoints for letrozole alone vs palbociclib groups (Group A vs Groups B+C+D) were: (i) change in Ki67 (IHC) between baseline and 14 weeks (log-fold change, Mann-Whitney test); (ii) clinical response (ultrasound) after 14 weeks (4 group, ordinal, Mann-Whitney test). Complete cell-cycle arrest (CCCA) (Ki67≤2.7%) was analyzed using a logistic regression model adjusting for recruitment region. Pre-specified exploratory biomarkers included c-PARP (apoptosis).

Results: 307 patients were recruited between 27 Feb 2015 and 08 Mar 2018; 103 were randomized to letrozole alone and 204 to letrozole + palbociclib. 279 (90.9%) patients were evaluable for 14 week clinical response. Clinical response was not significantly different between letrozole vs letrozole + palbociclib groups [(p=0.20; CR+PR 49.5% (46/93) vs 54.3% (101/186) and PD 5.4% (5/93) vs 3.2% (6/186)] nor was the small proportion of patients with pathological CR (1/87, 1.1% vs 6/180, 3.3%; p=0.43). 190 (61.9%) patients were evaluable for 14 week change in Ki67. The median log-fold change in Ki67 was greater with letrozole + palbociclib vs letrozole alone (-4.1 vs -2.2; p<0.001) corresponding to a geometric mean change of -97.4% vs -88.5%. Similarly, a greater proportion of patients who received letrozole + palbociclib achieved CCCA (90% vs 59%, p<0.001). 146 (47.6%) patients were evaluable for c-PARP and the log-fold change (suppression) was greater with letrozole + palbociclib vs letrozole alone (-0.80 vs -0.42; p=0.003) corresponding to a geometric mean change of -56.8% vs -31.4%. Other biomarkers of response / resistance are being evaluated. A higher proportion of patients had a grade ≥3 toxicity on letrozole + palbociclib than letrozole alone (49.8% vs 17.0%; p<0.001) mainly due to asymptomatic neutropenia.

Conclusion: Adding palbociclib to letrozole markedly enhanced the suppression of malignant cell proliferation as assessed by Ki67 but did not substantially increase the clinical response of primary ER+ breast cancer over a 14-week period. Concurrent reductions in cell death may have reduced the speed of tumor shrinkage.

Citation Format: Dowsett M, Jacobs S, Johnston S, Bliss J, Wheatley D, Holcombe C, Stein R, McIntosh S, Barry P, Dolling D, Snowdon C, Perry S, Batten L, Dodson A, Martins V, Modi A, Cornman C, Puhalla S, Wolmark N, Julian T, Pogue-Geile K, Robidoux A, Provencher L, Boileau JF, Shalaby I, Thirlwell M, Fisher K, Huang Bartlett C, Koehler M, Osborne K, Rimawi M. PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS3-02.

Abstract OT1-06-01: OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk in hormone-sensitive HER2-negative node-negative early breast cancer, allowing patients with low risk to safely avoid chemotherapy. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) aims to validate MPA's as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population.

Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The main eligibility criteria are women or men aged 40 or older with resected ER-positive, HER2-negative breast cancer and up to 9 involved axillary lymph nodes. Randomization is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment. Those with a “high risk” tumor MPA score receive standard management whilst those at “low risk” are treated with endocrine therapy alone. The preliminary phase (OPTIMA prelim) evaluated the performance of several MPAs to select a test to be used in the main efficacy trial based on economic analysis, and assessed the feasibility and acceptability of a large UK trial. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50) with Prosigna Score ≤60 defined as “low-risk”. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy. Secondary outcomes include IDFS in “low-risk” patients, quality of life and additional survival measures. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance.

Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites with a 47% acceptance rate. The main study opened in January 2017. Early progress indicates that the recruitment target is achievable in the intended 46-month timescale through the participation of >100 sites

Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer, is expected to have a global impact on breast cancer treatment. Experience from OPTIMA prelim showed that patient advocate support and close engagement with sites will aid trial success.

Funding: The project is funded in the UK by the NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Makris A, Hughes-Davies L, Macpherson IR, Hall PS, Cameron DA, Earl HM, Pinder SE, Poole CJ, Rea DW, McIntosh S, Harmer V, Morgan A, Rooshenas L, Conefrey C, Donovan JL, Hulme C, McCabe C, Stallard N, Campbell A, Higgins H, Bartlett JMS, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-01.

High and low doses of cocaine intake are differentially regulated by dopamine D2 receptors in the ventral tegmental area and the nucleus accumbens

Dopamine D2 receptors (D2Rs) in the ventral tegmental area (VTA) and the nucleus accumbens (NAc) are associated with vulnerability to addiction; however, whether D2Rs in these two brain regions play differential roles in regulation of drug intake is unknown. Here, we compared the effect of decreased mRNA level of Drd2 in each region on cocaine self-administration in a dose-response function. Drd2 mRNA levels in rat VTA or NAc were knocked down by bilateral microinjection of lentivirus coding shRNAs against rat Drd2 or scrambled shRNA. Drd2 knockdown was persistent and stable between 20 and 90 days after lentiviral infection. Animals were trained to self-administer cocaine 20 days after Drd2 shRNA treatment. Compared to scrambled shRNA treated rats, Drd2 knockdown in the VTA increased cocaine self-administration at all tested doses (0.02-0.56 mg/kg/infusion) producing an upward shift (both the ascending and descending limb) in the dose-response curve of cocaine self-administration. In contrast, intra-NAc knockdown increased cocaine self-administration only on the ascending limb of the dose-response curve (0.02-0.07 mg/kg/infusion). These data suggest that D2Rs in the VTA, not in the NAc, regulate high-dose cocaine intake. The present study not only demonstrates that low levels of D2Rs in either region increase low doses of cocaine intake, but also reveals for the first time their dissociable roles in limiting high doses of cocaine self-administration.

Potential use of feedlot cattle manure for bioethanol production

This paper reports on processing options for the conversion of feedlot cattle manures into composite sugars for ethanol fermentation. Small-scale anaerobic digestion trials revealed that the process significantly reduces the content of glucan and xylan (ca. 70%) without effecting lignin. Moreover, anaerobic digestate (AD) fibres were poor substrates for cellulase (Cellic® CTec 2) saccharification, generating a maximum combined sugar yield of ca. 12% per original dry weight. Dilute acid pretreatment and enzyme saccharification of raw manures significantly improved total sugar recoveries, totalling 264 mg/g (79% theoretical). This was attained when manures were pretreated with 2.5% H2SO4 for 90 min at 121°C and saccharified with 50 FPU CTec 2/g glucan. Saccharomyces cerevisiae efficiently fermented crude hydrolysates within 6 h, yielding 7.3 g/L ethanol, representing glucose to ethanol conversion rate of 70%. With further developments (i.e., fermentation of xylose), this process could deliver greater yields, reinforcing its potential as a biofuel feedstock.

Ethanol production from cotton gin trash using optimised dilute acid pretreatment and whole slurry fermentation processes

Cotton ginning trash (CGT) collected from Australian cotton gins was evaluated for bioethanol production. CGT composition varied between ginning operations and contained high levels of extractives (26-28%), acid-insoluble material (17-22%) and holocellulose (42-50%). Pretreatment conditions of time (4-20 min), temperature (160-220 °C) and sulfuric acid concentration (0-2%) were optimised using a central composite design. Response surface modelling revealed that CGT fibre pretreated at 180 °C in 0.8% H2SO4 for 12 min was optimal for maximising enzymatic glucose recoveries and achieved yields of 89% theoretical, whilst the total accumulated levels of furans and acetic acid remained relatively low at <1 and 2 g/L respectively. Response surface modelling also estimated maximum xylose recovery in pretreated liquors (87% theoretical) under the set conditions of 150 °C in 1.9% H2SO4 for 23.8 min. Yeast fermentations yielded high ethanol titres of 85%, 88% and 70% theoretical from glucose generated from: (a) enzymatic hydrolysis of washed pretreated fibres, (b) enzymatic hydrolysis of whole pretreated slurries and (c) simultaneous saccharification fermentations, respectively.

Disease associated with equine coronavirus infection and high case fatality rate

BACKGROUND

Equine coronavirus (ECoV) is associated with clinical disease in adult horses. Outbreaks are associated with a low case fatality rate and a small number of animals with signs of encephalopathic disease are described.

OBJECTIVES

The aim of this study is to describe the epidemiological and clinical features of two outbreaks of ECoV infection that were associated with an high case fatality rate.

ANIMALS

14 miniature horses and 1 miniature donkey testing fecal positive for ECoV from two related disease outbreaks.

METHODS

Retrospective study describing the epidemiological findings, clinicopathological findings, and fecal viral load from affected horses.

RESULTS

In EcoV positive horses, 27% (4/15) of the animals died or were euthanized. Severe hyperammonemia (677 μmol/L, reference range ≤ 60 μmol/L) was identified in one animal with signs of encephalopathic disease that subsequently died. Fecal viral load (ECoV genome equivalents per gram of feces) was significantly higher in the nonsurvivors compared to animals that survived (P = .02).

CONCLUSIONS AND CLINICAL IMPORTANCE

Equine coronavirus had a higher case fatality rate in this group of miniature horses than previously reported in other outbreaks of varying breeds. Hyperammonemia could contribute to signs of encephalopathic disease, and the fecal viral load might be of prognostic value in affected horses.

LQTS in Northern BC: homozygosity for KCNQ1 V205M presents with a more severe cardiac phenotype but with minimal impact on auditory function

Long QT syndrome (LQTS), a rare congenital cardiac condition associated with life-threatening ventricular arrhythmias is characterized by a prolonged QT interval on electrocardiograph corrected for heart rate [corrected QT (QTc)]. LQTS has been historically categorized into the autosomal dominant Romano-Ward syndrome (RWS) and the autosomal recessive Jervell and Lange-Nielsen syndrome (JLNS). JLNS is associated with prelingual sensorineural deafness. Both types of LQTS can be caused by mutations in channel genes (e.g. KCNQ1) responsible for potassium homeostasis in cardiac myocytes and cochlea. Autosomal dominant mutations often cause the RWS phenotype and homozygous or compound heterozygous mutations contribute to JLNS. Two First Nations communities in northern British Columbia are affected disproportionately with LQTS largely due to the V205M mutation in KCNQ1, however, the pathology and phenotypic expression for those V205M homozygous has been unknown. Here, we show that four V205M homozygous individuals have a significantly higher 'peak' QTc, and a more severe cardiac phenotype compared with 41 V205M heterozygous carriers and 57 first to third degree relatives without mutations. Given the lack of prelingual deafness the homozygous V205M LQTS patients present with a phenotype more typical of RWS than JLNS.

A Phase II, randomized, double-blind study of zibotentan (ZD4054) in combination with carboplatin/paclitaxel versus placebo in combination with carboplatin/paclitaxel in patients with advanced ovarian cancer sensitive to platinum-based chemotherapy (AGO-OVAR 2.14)

BACKGROUND

In platinum-sensitive relapsed ovarian cancer, paclitaxel plus carboplatin is a standard second-line treatment. Zibotentan (ZD4054) is an oral, specific ETA-receptor antagonist with demonstrated antitumour activity in xenograft models of human ovarian cancer.

METHODS

In this Phase II, randomized, placebo-controlled study, patients with relapsed ovarian cancer sensitive to platinum-based chemotherapy received zibotentan 10mg or placebo once-daily, plus paclitaxel 175 mg/m(2) iv followed by carboplatin iv (AUC 5) on day 1 of every 3-week cycle for a maximum of eight cycles. The primary endpoint was progression-free survival (PFS), evaluated by Response Evaluation Criteria In Solid Tumours (RECIST). Secondary and exploratory endpoints included objective tumour response rate, tumour size, CA-125/RECIST progression, and safety and tolerability.

RESULTS

A total of 120 patients were randomized (zibotentan: n=59; placebo: n=61). Addition of zibotentan 10mg/day to carboplatin and paclitaxel did not improve PFS compared with placebo (median PFS, 7.6 versus 10.0 months, respectively; HR=1.46, [80% CI: 1.10-1.94]; P=0.0870). No improvements in any of the secondary or exploratory efficacy endpoints were observed for patients receiving zibotentan compared with placebo. Median duration of total treatment exposure was 6.7 months. Total chemotherapy dose received was lower for zibotentan-treated versus placebo-treated patients (carboplatin: -16%; paclitaxel: -14%). The most common adverse events in the zibotentan arm were anaemia, nausea, alopecia, headache and neutropenia (43-48% of patients).

CONCLUSIONS

Zibotentan 10mg/day plus carboplatin and paclitaxel did not result in an improvement in PFS compared with chemotherapy alone in patients with advanced ovarian cancer sensitive to platinum-based chemotherapy. No unexpected safety concerns were identified.

Ethanol production from Eucalyptus plantation thinnings

Conditions for optimal pretreatment of eucalypt (Eucalyptus dunnii) and spotted gum (Corymbia citriodora) forestry thinning residues for bioethanol production were empirically determined using a 3(3) factorial design. Up to 161mg/g xylose (93% theoretical) was achieved at moderate combined severity factors (CSF) of 1.0-1.6. At CSF>2.0, xylose levels declined, owing to degradation. Moreover at high CSF, depolymerisation of cellulose was evident and corresponded to glucose (155mg/g, ∼33% cellulose) recovery in prehydrolysate. Likewise, efficient saccharification with Cellic® CTec 2 cellulase correlated well with increasing process severity. The best condition yielded 74% of the theoretical conversion and was attained at the height of severity (CSF of 2.48). Saccharomyces cerevisiae efficiently fermented crude E. dunnii hydrolysate within 30h, yielding 18g/L ethanol, representing a glucose to ethanol conversion rate of 0.475g/g (92%). Based on our findings, eucalyptus forest thinnings represent a potential feedstock option for the emerging Australian biofuel industry.

Phase III study of the efficacy and safety of zibotentan (ZD4054) in patients with bone metastatic castration-resistant prostate cancer (CRPC)

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Background: Endothelin-1 and the endothelin A (ETA) receptor have been implicated in prostate cancer progression in bone. Zibotentan, a specific ETA receptor antagonist, had a promising signal for prolonged overall survival (OS) in a phase II study of patients with CRPC and bone metastases who were pain free or mildly symptomatic for pain. The aim of this phase III study was to confirm the efficacy and safety of zibotentan in a similar but larger population.

Methods: Patients with CRPC and bone metastases were randomized 1:1 to zibotentan 10 mg/day po or placebo, plus standard of care including chemotherapy. The primary endpoint was OS. Secondary endpoints included times to pain progression, chemotherapy use, new bone metastases, and safety. Efficacy endpoints were analyzed using a log-rank test. At least 263 deaths were required for formal analysis. If the true hazard ratio (HR) for zibotentan versus placebo was 0.67, the analysis would have 90% power to demonstrate a statistically significant effect in OS at the 5% level.

Results: A total of 594 patients were randomized (299 to zibotentan; 295 to placebo). Baseline group demographics were similar. Mean age was ∼71 yrs, and 64% were Caucasian. Although median OS was longer in zibotentan-treated patients than those receiving placebo (median 24.5 vs 22.5 months), the difference did not reach significance (HR [95.2% confidence interval]; 0.87 [0.69–1.10]: P=0.240). No significant differences were observed for any secondary endpoints. The most commonly reported AEs in the zibotentan group, peripheral edema and headache, were consistent with the pharmacologic action of zibotentan as a vasodilator. Cardiac failure events, actively solicited following a phase II signal, were higher in the zibotentan group (any grade, 5.7%; Common Terminology Criteria for Adverse Events [CTCAE] grade ≥3, 3.0%) than placebo (any grade, 1.7%; CTCAE grade ≥3, 1.0%), but were manageable and reversible.

Conclusions: In this placebo-controlled phase III trial treatment with zibotentan 10 mg/day did not lead to a significant improvement in OS in patients with CRPC and bone metastases. Zibotentan had an acceptable safety profile.

[Table: see text]

Enhanced enzyme saccharification of Sorghum bicolor straw using dilute alkali pretreatment

The impacts of varying pretreatment parameters (temperature, time, and alkalinity) on enzymatic hydrolysis of sorghum straw were investigated. Following pretreatment, both solids and lignin content was found to be inversely proportional to the severity of the treatments. Higher temperatures and alkali strength were quintessential for maximising sugar recoveries from enzyme saccharifications. Total sugar release peaked when sorghum straw was pretreated in 2% NaOH at 121 degrees C for 60 min; representing a 5.6-fold higher yield compared to samples pretreated at 60 degrees C in the absence of alkali. Similarly, 4.3-fold increases in total sugars from samples treated with 2% NaOH at 60 degrees C for 90 min, confirmed the importance of alkali inclusion. Addition of beta-glucosidase and xylanase to saccharification mixtures enhanced reaction rates and final sugar yields, whilst reducing cellulase dosage 4-fold. Saccharification efficiency of pretreated solids approached 90% and 95% (w/w) with as little as 2.5 and 5.0 FPU cellulase/g, respectively.

Tobacco use in the Dominican Republic: understanding the culture first

OBJECTIVE

To conduct formative research on the landscape of tobacco use to guide survey and subsequent intervention development in the Dominican Republic (DR).

DESIGN

Rapid Assessment Procedures, systematic qualitative methods (participant-observations, in-depth interviewing, focus groups) using bilingual mixed age and gendered teams from the United States and DR.

SUBJECTS

Over 160 adults (men and women), ages 18 to 90 years, current, former and never smokers, community members and leaders from six underserved, economically disadvantaged DR communities.

MAIN OUTCOME MEASURES

Key domains: tobacco use patterns and attitudes; factors affecting smoking initiation, continuation, quitting; perceived risks/benefits/effects of smoking; and awareness/effects of advertising/regulations.

RESULTS

Perceptions of prevalence varied widely. While "everybody" smokes, smokers or ex-smokers were sometimes difficult to find. Knowledge of health risks was limited to the newly mandated statement "Fumar es prejudicial para la salud" [Smoking is harmful to your health]. Smokers started due to parents, peers, learned lifestyle, fashion or as something to do. Smoking served as an escape, relaxation or diversion. Quit attempts relied on personal will, primarily for religious or medical reasons. Social smoking (custom or habit) (< 10 cigarettes per day) was viewed as a lifestyle choice rather than a vice or addiction. Out of respect, smokers selected where they smoked and around whom. Health care providers typically were reactive relative to tobacco cessation, focusing on individuals with smoking related conditions. Tobacco advertising was virtually ubiquitous. Anti-tobacco messages were effectively absent. Cultures of smoking and not smoking coexisted absent a culture of quitting.

CONCLUSIONS

Systematic qualitative methods provided pertinent information about tobacco attitudes and use to guide subsequent project steps. Integrating qualitative then quantitative research can be replicated in similar countries that lack empirical data on the cultural dimensions of tobacco use.

A NOMOGRAM TO CLASSIFY MEN WITH LOWER URINARY TRACT SYMPTOMS USING URINE FLOW AND NONINVASIVE MEASUREMENT OF BLADDER PRESSURE

PURPOSE

Bladder pressure during voiding can be estimated by a noninvasive technique using controlled inflation of a penile cuff. This test provides a valid and reliable estimate of isovolumetric bladder pressure but to our knowledge the role of the test for the routine clinical treatment of patients with lower urinary tract symptoms (LUTS) has yet to be demonstrated. As a first step, we evaluated a proposed nomogram for the diagnosis of bladder outlet obstruction in men with LUTS using noninvasive measurements of pressure and flow.

MATERIALS AND METHODS

Using a combination of theoretical calculation and experimental data the existing International Continence Society pressure flow nomogram was modified to allow noninvasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the nomogram for classifying obstruction was then tested in a group of 144 men with LUTS who underwent an invasive and a noninvasive pressure flow study.

RESULTS

The modified nomogram identified men with obstruction with 68% positive predictive value and 78% negative predictive value. Predictive accuracy could be improved by adding an additional criterion of obstruction, that is maximum urine flow less than 10 ml second, whereby an identifiable 69% of all cases could be classified as obstructed (88% positive predictive value) or not obstructed (86% negative predictive value). In the remaining 31% of patients invasive pressure flow studies would provide additional information, although some results would remain equivocal.

CONCLUSIONS

The proposed nomogram combined with the additional flow rate criterion can classify more than two-thirds of cases without recourse to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the treatment of men with LUTS.

The management of radial scars of the breast - does core biopsy help?

PURPOSE

To compare the effectiveness of fine needle aspiration cytology (FNAC) with core biopsy (CB) in the pre-operative diagnosis of radial scar (RS) of the breast.

PATIENTS AND METHODS

A retrospective analysis was made of all radial scars diagnosed on surgical histology over an 8-year period. Comparison was made between the results of different preoperative needle biopsy techniques and surgical histology findings.

RESULTS

Forty of 47 patients with a preoperative radiological diagnosis of radial scar were included in this analysis. Thirty-eight patients had impalpable lesions diagnosed on mammography and two presented with a palpable lump. FNAC (n=17) was inadequate in 47% of patients, missed two co-existing carcinomas found in this group, and gave a false positive or suspicious result for malignancy in 4 patients. CB (n=23) suggested a RS in 15 patients, but only diagnosed 4 out of 7 co-existing carcinomas found in this group.

CONCLUSION

CB is more accurate than FNAC in the diagnosis of RS. However, these data demonstrate that CB may offer little to assist in the management of patients with RS. In summary, this paper advocates the use of CB in any lesion with a radiological suspicion of carcinoma and diagnostic excision of all lesions thought to be typical of RS on mammography.

Smokers ages 50+: who gets physician advice to quit?

BACKGROUND

Smoking-related morbidity and mortality, and benefits associated with quitting, extend across the life span. Health care provider interventions enhance quitting. The present study examined perceived influence of physician advice to quit and characteristics of subjects receiving this advice.

METHODS

Subjects were 1,454 smokers ages 50+ with at least one physician visit in the past year. Subjects were surveyed at baseline for receipt of and reactions to physician advice to quit and for smoking, health, and demographic characteristics.

RESULTS

Over half of subjects welcomed physician advice to quit, about half said the advice influenced their quitting decision "extremely" or "quite a lot," and about one-third indicated that it increased their confidence in quitting. Physicians were more likely to advise sicker patients, indicated by poorer health status, at least one past year hospitalization, and presence of cardiovascular, cerebrovascular, or respiratory diseases.

CONCLUSIONS

Midlife and older smokers reacted generally favorably to physician advice to quit. Physicians were more likely to advise patients with commonly recognized smoking-related diseases. Discrepancies were noted in advice given to sicker vs healthier patients. Additional physician training in less commonly recognized smoking-related illnesses, intervening with healthier patients to prevent disease, and enhancing patients' confidence in quitting may improve outcomes.

Very high Q measurements on a fused silica monolithic pendulum for use in enhanced gravity wave detectors

We present for the first time the results of very high Q factor measurements for a 2.8 kg fused silica mass suspended by two fused quartz fibers attached by a novel technique for joining fused silica or quartz. The Q for the pendulum mode at 0.93 Hz was (2.3+/-0. 2)x10(7), the highest value demonstrated to date for a mass of this size. By employing such a new suspension system the sensitivity of the gravitational wave detectors currently under construction can be increased up to 1 order of magnitude.

Recruitment strategies and success in a multi-county smoking cessation study

The current paper focuses on the process evaluation of recruitment strategies and success in a large study of self-help smoking interventions with mid-life and older smokers in a 15-county area. Recruitment 'channels' were examined: (1) multiple paid newspaper advertisements, (2) free media (i.e., TV and radio), (3) referrals, (4) HMO newsletters, (5) targeted mailings, (6) face-to-face, and (7) passive recruitment. Data were analyzed to determine (1) which channels produced the greatest numbers of information requests, or initial 'recruits', and (2) which produced the greatest number of enrolled subjects. Overall, four channels resulted in the enrollment of 96.4% of the final sample of 1972 subjects. The most reliable, cost-controlled channel was paid newspaper advertisements ($18-19 per enrolled subject), while face-to-face recruitment was inefficient and costly (over $140 per subject). Results can be used to help guide other studies in selecting recruitment strategies for large, geographically diverse, smoking intervention trials.

Carotid sinus hypersensitivity--a modifiable risk factor for fractured neck of femur

BACKGROUND

the potential impact on morbidity, mortality and health care economics makes it important to identify patients at risk of fracture, in particular fractured neck of femur (FNOF). Older patients with carotid sinus hypersensitivity (CSH) are more likely to have unexplained falls and to experience fractures, particularly FNOF. Our objective was to determine the prevalence of CSH in patients with FNOF.

DESIGN

case-controlled prospective series.

METHODS

consecutive cases were admissions over 65 years with FNOF. Controls were consecutive patients admitted for elective hip surgery, frail elderly people admitted to hospital medical wards and day-hospital patients. All patients had a clinical assessment of cognitive function, physical abilities and history of previous syncope, falls and dizziness, in addition to repeated carotid sinus massage with continuous heart rate and phasic blood pressure measurement.

RESULTS

heart rate slowing and fall in systolic blood pressure was greater for patients with FNOF than those admitted for elective hip surgery (P < 0.05 and P < 0.001). CSH was present in 36% of the FNOF group, none of the elective surgery group, 13% of the acutely ill controls and 17% of the outpatients. It was more likely to be present in FNOF patients with a previous history of unexplained falls or an unexplained fall causing the index fracture. The heart rate and systolic blood pressure responses to carotid sinus stimulation were reproducible.

CONCLUSION

older patients with an acute neck of femur fracture who do not give a clear history of an accidental fall or who have had previously unexplained falls are likely to have CSH. CSH may be a modifiable risk factor for older patients at risk of hip fracture.

Syndet, an adipocyte target SNARE involved in the insulin-induced translocation of GLUT4 to the cell surface

In adipocytes, insulin stimulates the translocation of the glucose transporter, GLUT4, from an intracellular storage compartment to the cell surface. Substantial evidence exists to suggest that in the basal state GLUT4 resides in discrete storage vesicles. A direct interaction of GLUT4 storage vesicles with the plasma membrane has been implicated because the v-SNARE, vesicle-associated membrane protein-2 (VAMP2), appears to be a specific component of these vesicles. In the present study we sought to identify the cognate target SNAREs for VAMP2 in mouse 3T3-L1 adipocytes. Membrane fractions were isolated from adipocytes and probed by far Western blotting with the cytosolic portion of VAMP2 fused to glutathione S-transferase. Two plasma membrane-enriched proteins, p25 and p35, were specifically labeled with this probe. By using a combination of immunoblotting, detergent extraction, and anion exchange chromatography, we identified p35 as Syntaxin-4 and p25 as the recently identified murine SNAP-25 homologue, Syndet (mSNAP-23). By using surface plasmon resonance we show that VAMP2, Syntaxin-4, and Syndet form a ternary SDS-resistant SNARE complex. Microinjection of anti-Syndet antibodies into 3T3-L1 adipocytes, or incubation of permeabilized adipocytes with a synthetic peptide comprising the C-terminal 24 amino acids of Syndet, inhibited insulin-stimulated GLUT4 translocation to the cell surface by approximately 40%. GLUT1 trafficking remained unaffected by the presence of the peptide. Our data suggest that Syntaxin-4 and Syndet are important cell-surface target SNAREs within adipocytes that regulate docking and fusion of GLUT-4-containing vesicles with the plasma membrane in response to insulin.

Characterization of Munc-18c and syntaxin-4 in 3T3-L1 adipocytes. Putative role in insulin-dependent movement of GLUT-4

We have previously identified three mammalian Sec1/Munc-18 homologues in adipocytes (Tellam, J. T., McIntosh, S., and James, D. E. (1995) J. Biol. Chem. 270, 5857-5863). These proteins are thought to modulate the interaction between vesicle membrane and target membrane soluble N-ethylmaleimide-sensitive factor attachment protein receptors (SNAREs) and thus regulate intracellular vesicular transport. This study aimed to further characterize these Munc-18 isoforms and to define their potential role in the trafficking of GLUT-4 in adipocytes, a process reported to involve the vesicle membrane SNARE, VAMP-2. Using an in vitro binding assay with recombinant fusion proteins, we show that Munc-18a and Munc-18b bind to syntaxin-1A, -2, and -3, while Munc-18c binds only to syntaxin-2 and -4. The specific interaction between Munc-18c and syntaxin-4 is of interest because aside from syntaxin-1A, which is not expressed in adipocytes, syntaxin-4 is the only syntaxin that binds to VAMP-2. Using a three-way binding assay, it was shown that Munc-18c inhibits the binding of syntaxin-4 to VAMP-2. The subcellular distribution of syntaxin-4 and Munc-18c was almost identical, both being enriched in the plasma membrane, and both exhibiting an insulin-dependent movement out of an intracellular membrane fraction similar to that observed for GLUT-4. Munc-18b had a similar distribution to Munc-18c and so may also be involved in vesicle transport to the cell surface, whereas Munc-18a was undetectable by immunoblotting in adipocytes. Microinjection of a syntaxin-4 antibody into 3T3-L1 adipocytes blocked the insulin-dependent recruitment of GLUT-4 to the cell surface. These data suggest that syntaxin-4/Munc-18c/VAMP-2 may play a role in the docking/fusion of intracellular GLUT-4-containing vesicles with the cell surface in adipocytes.