Lethal complication of a rare cardiac tumor

Cardiac tumors, especially malignant ones, are rare and diagnosis is challenging since symptoms manifest late and are often non-specific. Achieving a histological diagnosis prior to resection is also difficult because biopsies often fail to yield conclusive results. Due to the low frequency, no standard treatment protocol exists and the prognosis is poor. We present a case of a cardiac sarcoma, which was found during an autopsy performed with regard to medical malpractice, because the patient died due to a medical intervention. To report cases like this is important to gain more knowledge about possible complications regarding rare diseases.

Can a ToF-PET photon attenuation reconstruction test stopping-power estimations in proton therapy? A phantom study

Objective. The aim of the phantom study was to validate and to improve the computed tomography (CT) images used for the dose computation in proton therapy. It was tested, if the joint reconstruction of activity and attenuation images of time-of-flight PET (ToF-PET) scans could improve the estimation of the proton stopping-power.Approach. The attenuation images, i.e. CT images with 511 keV gamma-rays (γCTs), were jointly reconstructed with activity maps from ToF-PET scans. Theβ⁺activity was produced with FDG and in a separate experiment with proton-induced radioactivation. The phantoms contained slabs of tissue substitutes. The use of theγCTs for the prediction of the beam stopping in proton therapy was based on a linear relationship between theγ-ray attenuation, the electron density, and the stopping-power of fast protons.Main results. The FDG based experiment showed sufficient linearity to detect a bias of bony tissue in the heuristic look-up table, which maps between x-ray CT images and proton stopping-power.γCTs can be used for dose computation, if the electron density of one type of tissue is provided as a scaling factor. A possible limitation is imposed by the spatial resolution, which is inferior by a factor of 2.5 compared to the one of the x-ray CT.γCTs can also be derived from off-line, ToF-PET scans subsequent to the application of a proton field with a hypofractionated dose level.Significance. γCTs are a viable tool to support the estimation of proton stopping with radiotracer-based ToF-PET data from diagnosis or staging. This could be of higher potential relevance in MRI-guided proton therapy.γCTs could form an alternative approach to make use of in-beam or off-line PET scans of proton-inducedβ⁺activity with possible clinical limitations due to the low number of coincidence counts.

Infections in Infants with SCID: Isolation, Infection Screening, and Prophylaxis in PIDTC Centers

PURPOSE

The Primary Immune Deficiency Treatment Consortium (PIDTC) enrolled children with severe combined immunodeficiency (SCID) in a prospective natural history study of hematopoietic stem cell transplant (HSCT) outcomes over the last decade. Despite newborn screening (NBS) for SCID, infections occurred prior to HSCT. This study's objectives were to define the types and timing of infection prior to HSCT in patients diagnosed via NBS or by family history (FH) and to understand the breadth of strategies employed at PIDTC centers for infection prevention.

METHODS

We analyzed retrospective data on infections and pre-transplant management in patients with SCID diagnosed by NBS and/or FH and treated with HSCT between 2010 and 2014. PIDTC centers were surveyed in 2018 to understand their practices and protocols for pre-HSCT management.

RESULTS

Infections were more common in patients diagnosed via NBS (55%) versus those diagnosed via FH (19%) (p = 0.012). Outpatient versus inpatient management did not impact infections (47% vs 35%, respectively; p = 0.423). There was no consensus among PIDTC survey respondents as to the best setting (inpatient vs outpatient) for pre-HSCT management. While isolation practices varied, immunoglobulin replacement and antimicrobial prophylaxis were more uniformly implemented.

CONCLUSION

Infants with SCID diagnosed due to FH had lower rates of infection and proceeded to HSCT more quickly than did those diagnosed via NBS. Pre-HSCT management practices were highly variable between centers, although uses of prophylaxis and immunoglobulin support were more consistent. This study demonstrates a critical need for development of evidence-based guidelines for the pre-HSCT management of infants with SCID following an abnormal NBS.

TRIAL REGISTRATION

NCT01186913.

FRI0555 DO TNF INHIBITORS DECREASE RISK OF INCIDENT PSORIATIC ARTHRITIS IN PSORIASIS PATIENTS COMPARED TO THOSE TREATED WITH METHOTREXATE ALONE?

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis characterized by joint and entheseal inflammation seen in 30% patients with psoriasis (Pso). In 90% of patients, Pso precedes PsA. Inhibitors of tumor necrosis factor (TNFi) are efficacious treatment options for both, though whether they prevent development of incident PsA in Pso patients is unknown.

Objectives:

To determine if the use of TNFi reduces the risk of developing psoriatic arthritis in Pso patients compared to those treated with methotrexate alone.

Methods:

Records on all Pso patients seen at dermatology clinic at our University from January 2006 - June 2019 were reviewed. Patients with any musculoskeletal symptoms were referred to rheumatology and were considered to have PsA if they were diagnosed by a rheumatologist. We used Student’s t-test to compare continuous covariates and Pearson’s chi-squared test or Fisher’s exact test to compare categorical covariates. Variables that were found to be significantly associated with PsA diagnosis were included as potential confounders in the multivariate model. We used Cox proportional hazards models to compare the risk of incident PsA diagnosis for those who initiated TNFi compared to those who initiated methotrexate. A propensity score of TNFi therapy compared to methotrexate therapy was calculated using variables associated with treatment choice and adjusted for in the model. Variables that were associated with both treatment choice and PsA risk were not included in the propensity score. We used backwards stepwise variable selection to build the final model.

Results:

Out of 154 Pso patients who did not have PsA at baseline, and were started exclusively on a TNFi or methotrexate during the study period,, 85 (55.2%) initiated methotrexate and 69 (44.8%) initiated a TNFi. Mean duration of therapy for those on TNFi was 3.95 (standard error: 0.50) years while mean duration of therapy for those on methotrexate was 1.93 years (standard error: 0.28). Mean follow-up time for those on TNFi was 5.18 years (standard error: 0.49) and for those on methotrexate was 2.71 years (standard error: 0.37) Seventy nine (51.3%) of the cohort were women. Thirty five (22.7%) of subjects developed PsA over the course of the study. After adjusting for propensity score, nail pitting, body surface area (BSA) involved in psoriasis, and depression, TNFi did not significantly reduce the risk of PsA as compared to methotrexate (HR: 0.68 [95% CI: 0.32, 1.41]).

Conclusion:

Use ofTNFi was not associated with a statistically significant decreased risk of incident PsA compared to methotrexate in this study, but a larger cohort with longer follow up will have better power to estimate the true association.

Table 1.

Characteristics of the psoriasis cohort starting exclusively TNFi or methotrexate

Incident PsAn = 35PsA negativen = 119p-valueTreatment [n (%)]0.37TNFi18 (51.4)51 (42.9)Methotrexate17 (48.6)68 (57.1)Sex [n (%)]0.24Female21 (60.0)58 (48.7)Male14 (40.0)61 (51.3)Age [median (IQR)]47.0 (39.4, 59.7)48.9 (35.3, 61.7)0.71Pso manifestations [n (%)]Nail pitting27 (77.1)51 (42.9)<0.01Scalp psoriasis31 (88.6)105 (89.0)0.95Inverse psoriasis14 (40.0)37 (31.09)0.33BSA [median (IQR)]6 (3, 15)12 (5, 22)0.06BMI [median (IQR)]31.7 (25.9, 40.4)29.1 (26.3, 34.7)0.30Therapy duration (years)TNFi [median (IQR)]4.38 (1.34, 8.13)2.26 (0.76, 5.82)0.29Methotrexate [median (IQR)]2.44 (0.06, 3.44)0.94 (0.27, 2.39)0.43

Disclosure of Interests:

Noah Lininger: None declared, Sarah Siegel: None declared, Sonam Kiwalkar: None declared, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, Alex Ortega Loayza Consultant of: Adviser board for Janssen, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB

FRI0314 ANNUAL DIAGNOSTIC PREVALENCE OF ANKYLOSING SPONDYLITIS (AS) IN THE UNITED STATES USING MEDICARE AND MARKETSCAN DATA

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that affects the axial skeleton and sacroiliac joints, and can be classified as ankylosing spondylitis (AS) or non-radiographic (nr)-axSpA.1A 2016 analysis estimated the US diagnostic prevalence of axSpA to be 0.2% and AS to be 0.1%.2Previous studies use disparate populations and diagnostic definitions;3,4it is therefore unclear how AS prevalence has changed over time.

Objectives:

To investigate the annual diagnostic prevalence of AS in US healthcare insurance claims databases.

Methods:

A retrospective, observational cohort study was conducted using 2006–2014 data from US Medicare Fee-for-Service Claims (5% random sample of all enrolled patients [pts]) and Truven MarketScan®. Eligible pts were ≥20 years (yrs) and had ≥6 months of continuous medical and pharmacy enrolment prior to diagnosis. Diagnoses used relevant International Classification of Disease, 9thversion (ICD-9) diagnosis codes: ICD-9 720.x [x=any number] for “AS and other inflammatory spondylopathies [SpA]” or 720.0 for “AS”. Two diagnosis definitions were used: Definition 1, ≥1 relevant ICD-9 code from hospital discharge or ≥2 from rheumatologist visit; Definition 2, ≥1 relevant ICD-9 code from hospital discharge or rheumatologist visit. Annual diagnostic prevalence of SpA/AS was calculated as “number of enrolled pts who met the definition of SpA/AS within each calendar yr and had full insurance coverage (medical and pharmacy)”, divided by “total number of pts with full insurance coverage in the same yr”. A primary analysis of SpA prevalence rates used Definitions 1 and 2, followed by a sensitivity analysis for AS prevalence rates using only Definition 2. All prevalence rates are shown per 10,000 pts enrolled.

Results:

The annual diagnostic prevalence of SpA appeared to increase from 2006–2014 (Table). Similarly, the sensitivity analysis showed the annual diagnostic prevalence of AS appeared to increase during the period from 2006 (Medicare: 2.87/10,000 pts [n=501,031]; MarketScan: 1.37/10,000 pts [n=17,562,637]) to 2014 (Medicare: 4.77/10,000 pts [n=1,046,107]; MarketScan: 2.14/10,000 pts [n=34,553,135];Figure).

Conclusion:

The apparent increase in diagnostic prevalence of SpA and AS during the period from 2006–‍2014 may be a consequence of increased awareness and availability of effective treatments. Furthermore, the 2009 Assessment of SpondyloArthritis international Society development of the axSpA classification criteria to include pts with both established AS and nr-axSpA may have accelerated this increase.5

References:

[1]Strand V. Mayo Clin Proc 2017;92:555–64;

[2]Curtis J. Perm J 2016;20:15–151;

[3]Reveille J. Arthritis Care Res (Hoboken) 2012;64:905–10;

[4]Danve A. Clin Rheumatol 2019;38:625–34;

[5]Rudwaleit M. Ann Rheum Dis 2009;68:777–83.

Table.

Prevalence of SpA by calendar year and data source

Medicare (5% random sample)MarketScanCalendar yrTotal number of eligible ptsPrevalence/10,000 ptsTotal number of eligible ptsPrevalence/10,000 ptsDefinition 1Definition 2Definition 1Definition 22006501,0314.397.6217,562,6371.332.172007816,9705.258.7219,518,0661.472.372008825,4454.898.7828,603,5251.582.532009830,9675.229.2131,757,0691.903.092010844,5285.499.9031,126,1721.963.172011879,9966.3010.7138,295,1211.943.112012921,9946.1710.8840,320,4371.913.0420131,032,8276.7410.8233,826,0412.003.1920141,046,1076.5210.8534,553,1352.213.51

Medicare data included a 5% random sample of all enrolled pts age ≥20 yrs. pts: patients; SpA: ankylosing spondylitis and other inflammatory spondylopathies; yr: year.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corona, Crescendo, Genentech, Janssen, Pfizer, Roche and UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corona, Crescendo, Genentech, Janssen, Pfizer, Roche and UCB Pharma, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, Benjamin Chan: None declared, Sarah Siegel: None declared, Jeffrey Stark Employee of: UCB Pharma, Robert Suruki Employee of: UCB Pharma, Rhonda Bohn Consultant of: UCB Pharma, Fenglong Xie: None declared, Huifeng Yun Grant/research support from: Bristol-Myers Squibb and Pfizer, Lang Chen: None declared, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB

SAT0370 TUMOUR NECROSIS FACTOR INHIBITOR THERAPY DOES NOT REDUCE THE INCIDENCE OF COMORBIDITIES AND EXTRA-ARTICULAR MANIFESTATIONS IN ANKYLOSING SPONDYLITIS: AN ANALYSIS OF THREE US CLAIMS DATABASES

Background:

Comorbidities and extra-articular manifestations (EAMs) substantially increase disease burden and mortality risk in patients (pts) with ankylosing spondylitis (AS).1,2Tumour necrosis factor inhibitors (TNFi) are highly efficacious and effective in AS treatment (tx), and are used after inadequate response to non-steroidal anti-inflammatory drugs.3,4However, the impact of TNFi on the incidence of comorbidities and EAMs in pts with AS is unknown.5

Objectives:

To determine the incidence of comorbidities and EAMs in TNFi vs non-TNFi treated pts with AS in the US.

Methods:

This was a retrospective, observational cohort study using data from 3 healthcare insurance claims databases: Multi-Payer Claims Database (MPCD Optum Insight; 2007–2010), Truven MarketScan®(2010–2014) and US Medicare Fee-for-Service Claims database (2006–2014). Eligible pts: ≥20 years (yrs) for MarketScan/MPCD or ≥65 yrs for Medicare, had an AS diagnosis (≥2 International Classification of Disease, 9thversion [ICD-9] diagnosis codes of 720.0 from a rheumatologist) and ≥12 months’ continuous medical and pharmacy enrolment prior to AS diagnosis (AS index date). Pts with AS not receiving tx were excluded. Tx exposure was reported from the first date of a new prescription/administration of an AS tx (no prior exposure) after the AS index date. Crude incidence rates (IR; shown as cases/100 pt-yrs) were calculated for EAMs (uveitis, psoriasis [PSO], psoriatic arthritis [PsA], inflammatory bowel disease [IBD]), with follow-up until the earliest of: death, lost medical/pharmacy coverage, study period end, first outcome occurrence, tx switch/discontinuation. Hazard ratios (HRs) of comorbidities (hospitalised infection, solid cancers) and EAMs for propensity score (PS)-matched pt groups were calculated using Cox proportional hazard regression models. Pts with the specific comorbidity/EAM of interest prior to AS index date were excluded. PS analyses assessed probability of TNFi initiation vs non-TNFi tx and adjusted for factors including comorbidities and demographics. HRs with confidence intervals crossing 1 are not reported.

Results:

20,460 pts with AS were eligible (MPCD: 2,384; MarketScan: 9,032; Medicare: 9,044). In all databases, crude IR of EAMs were higher for TNFi vs non-TNFi treated pts (Figure 1). In the PS-matched cohort, incidences of hospitalised infections were lower in TNFi vs non-TNFi treated pts from the MarketScan and Medicare databases (Figure 2). Higher incidences of solid cancers and EAMs were observed in TNFi vs non-TNFi treated pts; Medicare data (Figure 2). A higher risk of PsA and PSO was seen in TNFi vs non-TNFi treated pts; MarketScan data (Figure 2). PS-matched cohort data from the MPCD database were non-significant.

Conclusion:

Despite strong efficacy in treating AS-related signs and symptoms, similar incidence of comorbidities and increased incidence of some EAMs (IBD, PSO/PsA, uveitis) was seen in TNFi vs non-TNFi treated pts in the PS-matched analyses. This may be due to channelling of pts with more severe AS to receive TNFi, despite the PS-matched analysis aiming to overcome this. Moreover, prior medical history of Medicare pts may not be captured in the database, as pts are typically older with longer disease durations. While these results confirm previous findings,6a prospective observational study is required to generalise to pts outside the US.

References:

[1]Stolwijk C. Ann Rheum Dis 2015;74:1373–8;

[2]Bremander A. Arthritis Care Res 2011;63:550–6;

[3]Braun J. Scand J Rheumatol 2005;34:178–90;

[4]Ji X. Front Pharmacol 2019;10:1476;

[5]Maxwell LJ. Cochrane Database Syst Rev 2015:CD005468;

[6]Walsh J. J Pharm Health Serv Res 2018;9:115–21.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, Rhonda Bohn Consultant of: UCB Pharma, Benjamin Chan: None declared, Robert Suruki Employee of: UCB Pharma, Jeffrey Stark Employee of: UCB Pharma, Huifeng Yun Grant/research support from: Bristol-Myers Squibb and Pfizer, Sarah Siegel: None declared, Lang Chen: None declared, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corona, Crescendo, Genentech, Janssen, Pfizer, Roche and UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corona, Crescendo, Genentech, Janssen, Pfizer, Roche and UCB Pharma

Male-specific deficits in natural reward learning in a mouse model of neurodevelopmental disorders

Neurodevelopmental disorders, including autism spectrum disorders, are highly male biased, but the underpinnings of this are unknown. Striatal dysfunction has been strongly implicated in the pathophysiology of neurodevelopmental disorders, raising the question of whether there are sex differences in how the striatum is impacted by genetic risk factors linked to neurodevelopmental disorders. Here we report male-specific deficits in striatal function important to reward learning in a mouse model of 16p11.2 hemideletion, a genetic mutation that is strongly associated with the risk of neurodevelopmental disorders, particularly autism and attention-deficit hyperactivity disorder. We find that male, but not female, 16p11.2 deletion animals show impairments in reward-directed learning and maintaining motivation to work for rewards. Male, but not female, deletion animals overexpress mRNA for dopamine receptor 2 and adenosine receptor 2a in the striatum, markers of medium spiny neurons signaling via the indirect pathway, associated with behavioral inhibition. Both sexes show a 50% reduction of mRNA levels of the genes located within the 16p11.2 region in the striatum, including the kinase extracellular-signal related kinase 1 (ERK1). However, hemideletion males show increased activation in the striatum for ERK1, both at baseline and in response to sucrose, a signaling change associated with decreased striatal plasticity. This increase in ERK1 phosphorylation is coupled with a decrease in the abundance of the ERK phosphatase striatum-enriched protein-tyrosine phosphatase in hemideletion males. In contrast, females do not show activation of ERK1 in response to sucrose, but notably hemideletion females show elevated protein levels for ERK1 as well as the related kinase ERK2 over what would be predicted by mRNA levels. These data indicate profound sex differences in the impact of a genetic lesion linked with neurodevelopmental disorders, including mechanisms of male-specific vulnerability and female-specific resilience impacting intracellular signaling in the brain.

Expression pattern of neuronal intermediate filament α-internexin in anterior pituitary gland and related tumors

PURPOSE

α-Internexin (INA) is a class IV neuronal intermediate filament protein that maintains the morphogenesis of neurons. It is expressed in developing neuroblasts and represents the major component of the cytoskeleton in cerebellar granule cells of adult central nervous system tissue. Data concerning INA expression in the human frontal pituitary lobe and related adenomas (PA) is missing.

METHODS

Using immunohistochemistry we examined the distribution pattern of INA in a large cohort of 152 PA, 11 atypical PA, 4 pituitary carcinomas and 20 normal pituitaries (overall n = 187). Quantity of INA protein expression was semi-quantitatively evaluated and grouped into five categories (0 = 0%; 1 = >0-5%; 2 = >5-35%; 3 = >35-80%; 4 = >80% of cells).

RESULTS

Cellular staining intensity of INA appeared significantly higher in gonadotropinomas (Go, n = 62), null cell adenomas (NC, n = 7) and thyrotropinomas (TSHomas, n = 7) compared to the other tumor subtypes (p ≤ 0.001). Furthermore, Go and NC showed a peculiar pseudorosette-like staining pattern surrounding blood vessels in 85.5% (59/69) of cases. Interestingly, areas exhibiting homogenous INA staining were often associated with oncocytic cell changes and decreased immunohistochemically detectable hormone expression. Only 8.5% (8/94) of other PA showed a comparable INA distribution (p ≤ 0.001).

CONCLUSION

Go, NC as well as TSHomas exhibit high levels of intracellular INA protein indicating neuronal transdifferentiation. A possible impact on pathogenesis and endocrine activity needs further investigation.

Predictors of changes in daily alcohol consumption in the aftermath of military deployment

BACKGROUND

Several studies have documented factors related to increase in alcohol consumption in the context of stressful experiences. However, little is known about predictors of different courses of alcohol use in this context. This study aims to investigate diverse predictors and correlates of increase and decrease of average daily alcohol consumption (aDAC) in the aftermath of military deployment taking into account a variety of potentially relevant factors.

METHODS

N=358 soldiers were examined before (T1) and 12 months after return from deployment (T2) using standardized interviews. Change in aDAC was categorized into decreased (n=72), stable (n=215) and increased (n=71) aDAC.

RESULTS

Overall, aDAC did not change significantly between T1 and T2 (median change=0.0 g, inter quartile range=11.3g). Compared to stable aDAC, increase was characterized by a lower proportion of high-educated individuals (OR: 0.3 (0.1-0.7), p=0.008), lower rank (marginally significant: OR: 2.0 (1.0-4.1), p=0.050), and less acceptance (trend: MR: 0.97 (0.93-1.00), p=0.053). Correlates of increased aDAC were less social support (MR: 0.84 (0.71-0.99), p=0.043), more sleeping problems (MR: 1.15 (1.00-1.31), p=0.045) and more negative post-event cognitions following deployment (MR: 2.32 (1.28-4.21), p=0.006). Decrease in aDAC was predicted by lower PTSD symptom severity before deployment (MR: 0.34 (0.16-0.72), p=0.005) and less childhood emotional neglect (marginally significant: MR: 0.78 (0.60-1.00), p=0.050).

CONCLUSIONS

Increase and decrease in alcohol use after stressful experiences might have differential risk factors and correlates. Findings might stimulate future research that could result in improved measures to prevent increases as well as in interventions that could foster decreases in alcohol consumption in the context of stressful experiences.

Newborn screening for severe combined immunodeficiency in 11 screening programs in the United States

IMPORTANCE

Newborn screening for severe combined immunodeficiency (SCID) using assays to detect T-cell receptor excision circles (TRECs) began in Wisconsin in 2008, and SCID was added to the national recommended uniform panel for newborn screened disorders in 2010. Currently 23 states, the District of Columbia, and the Navajo Nation conduct population-wide newborn screening for SCID. The incidence of SCID is estimated at 1 in 100,000 births.

OBJECTIVES

To present data from a spectrum of SCID newborn screening programs, establish population-based incidence for SCID and other conditions with T-cell lymphopenia, and document early institution of effective treatments.

DESIGN

Epidemiological and retrospective observational study.

SETTING

Representatives in states conducting SCID newborn screening were invited to submit their SCID screening algorithms, test performance data, and deidentified clinical and laboratory information regarding infants screened and cases with nonnormal results. Infants born from the start of each participating program from January 2008 through the most recent evaluable date prior to July 2013 were included. Representatives from 10 states plus the Navajo Area Indian Health Service contributed data from 3,030,083 newborns screened with a TREC test.

MAIN OUTCOMES AND MEASURES

Infants with SCID and other diagnoses of T-cell lymphopenia were classified. Incidence and, where possible, etiologies were determined. Interventions and survival were tracked.

RESULTS

Screening detected 52 cases of typical SCID, leaky SCID, and Omenn syndrome, affecting 1 in 58,000 infants (95% CI, 1/46,000-1/80,000). Survival of SCID-affected infants through their diagnosis and immune reconstitution was 87% (45/52), 92% (45/49) for infants who received transplantation, enzyme replacement, and/or gene therapy. Additional interventions for SCID and non-SCID T-cell lymphopenia included immunoglobulin infusions, preventive antibiotics, and avoidance of live vaccines. Variations in definitions and follow-up practices influenced the rates of detection of non-SCID T-cell lymphopenia.

CONCLUSIONS AND RELEVANCE

Newborn screening in 11 programs in the United States identified SCID in 1 in 58,000 infants, with high survival. The usefulness of detection of non-SCID T-cell lymphopenias by the same screening remains to be determined.

Newborn screening for SCID in New York State: experience from the first two years

PURPOSE

To describe the process and assess outcomes for the first 2 years of newborn screening for severe combined immunodeficiency (SCID NBS) in New York State (NYS).

METHODS

The NYS algorithm utilizes a first-tier molecular screen for TRECs (T-cell receptor excision circles), the absence of which is indicative of increased risk of immunodeficiency.

RESULTS

During the first 2 years, 485,912 infants were screened for SCID. Repeat specimens were requested from 561 premature and 746 non-premature infants with low or borderline TRECs. A total of 531 infants were referred for diagnostic evaluation leading to identification of 10 infants with SCID and 87 with a clinically significant non-SCID abnormality based on flow cytometry or CBC results (positive predictive value 20.3 %). Nine infants were diagnosed with typical SCID and one with leaky SCID. SCID diagnoses included two patients with adenosine deaminase deficiency, three patients with typical and one with leaky IL2RG-related SCID, one patient with IL7Rα-related SCID, and three cases of typical SCID, etiology unknown. TRECs were undetectable in eight of the nine babies with typical SCID. Infants with other non-SCID conditions included 27 patients with a syndrome that included T-cell impairment, 18 of which had DiGeorge syndrome. Seventeen infants had T-cell impairment secondary to another clinically significant condition, and 13 were classified as 'other'. Among 30 infants classified as idiopathic T-cell lymphopenia, 11 have since resolved, and the remainder continues to be followed. One infant with undetectable TRECs had normal follow-up studies. Molecular studies revealed the presence of two changes in the infant's DNA.

CONCLUSIONS

Overall, ten infants with SCID were identified during the first 2 years of screening in NYS, yielding an incidence of approximately 1 in 48,500 live births, which is consistent with the incidence observed by other states screening for SCID. The incidence of any clinically significant laboratory abnormality was approximately 1 in 5,000; both estimates are higher than estimates prior to the onset of newborn screening for SCID. Improvements to the NYS algorithm included the addition of a borderline category that reduced the proportion of infants referred for flow cytometric analysis, without decreasing sensitivity. We identified a large number of infants with abnormal TRECs and subsequent idiopathic T-cell lymphopenia. Long-term follow-up studies are needed to determine the prognosis and optimal treatment for this group of patients, some of whom may present with previously unrecognized, transient lymphopenia of infancy.

Headache and pituitary disease: a systematic review

Headache is very common in pituitary disease and is reported to be present in more than a third of all patients with pituitary adenomas. Tumour size, cavernous sinus invasion, traction or displacement of intracranial pain-sensitive structures such as blood vessels, cranial nerves and dura mater, and hormonal hypersecretion are implicated causes. The present review attempts to systematically review the literature for any combination of headache and pituitary or hormone overproduction or deficiency. Most data available are retrospective and/or not based on the International Headache Society (IHS) classification. Whereas in pituitary apoplexy a mechanical component explains the almost universal association of the condition with headaches, this correlation is less clear in other forms of pituitary disease and a positive impact of surgery on headaches is not guaranteed. Similarly, invasion into the cavernous sinus or local inflammatory changes have been linked to headaches without convincing evidence. Some studies suggest that oversecretion of GH and prolactin may be important for the development of headaches, and treatment, particularly with somatostatin analogues, has been shown to improve symptoms in these patients. Otherwise, treatment rests on general treatment options for headaches based on an accurate clinical history and a precise classification which includes assessment of the patient's psychosocial risk factors.

Fatal varicella due to the vaccine-strain varicella-zoster virus

We describe a death in a 15-mo-old girl who developed a varicella-like rash 20 d after varicella vaccination that lasted for 2 mo despite acyclovir treatment. The rash was confirmed to be due to vaccine-strain varicella-zoster virus (VZV). This is the first case of fatal varicella due to vaccine-strain VZV reported from the United States. The patient developed severe respiratory complications that worsened with each new crop of varicella lesions; vaccine-strain VZV was detected in the bronchial lavage specimen. Sepsis and multi-organ failure led to death. The patient did not have a previously diagnosed primary immune deficiency, but her failure to thrive and repeated hospitalizations early in life (starting at 5 mo) for presumed infections and respiratory compromise treated with corticosteroids were suggestive of a primary or acquired immune deficiency. Providers should monitor for adverse reactions after varicella vaccination. If severe adverse events develop, acyclovir should be administered as soon as possible. The possibility of acyclovir resistance and use of foscarnet should be considered if lesions do not improve after 10 d of treatment (or if they become atypical [e.g., verrucous]). Experience with use of varicella vaccine indicates that the vaccine has an excellent safety profile and that serious adverse events are very rare and mostly described in immunocompromised patients. The benefit of vaccination in preventing severe disease and mortality outweigh the low risk of severe events occurring after vaccination.

Variation of the baseline characteristics and treatment parameters over time: an analysis of 15 years of growth hormone replacement in adults in the German KIMS database

The purpose of this study is to examine potential implications of changes in the approach to adult growth hormone (GH) replacement (GHR) over the last 15 years. Therefore, we analysed the German KIMS database as one of the largest single country pharmacoepidemiological databases on adult GH deficiency (GHD). Based on the date of their first GH application patients were assigned to three intervals (1995-1999, 2000-2004, 2005-2009). A multivariate analysis of variance with interval and sex as independent variables was conducted. Differences were analysed with respect to IGF-I standard deviation score (SDS), quality of life, latency between GHD diagnosis and first GH dose, body mass index, waist-hip ratio, lipid profile, and GH dose. All analyses were conducted at baseline, 1 year, and 3 years of GHR. We detected significant associations between time interval and patient characteristics at baseline and with treatment effects. Recently, patients with less severe GHD (mean IGF-I SDS: -2.1, -1.6, -1.0 in the 1st, 2nd and 3rd interval; p = 0.000) are treated with lower GH starting doses (mean 0.30, 0.19, 0.21 mg/day in the 1st, 2nd and 3rd interval; p = 0.000). In the first time interval, IGF-I SDS was not normalized in females after 3 years of GHR. The results of our analysis demonstrate prominent changes in patient characteristics and handling of GHR. They highlight that approach to therapy and patient inclusion criteria change over time and may represent an important confounder for any analysis in epidemiological surveillance surveys.

A randomized trial investigating the efficacy and safety of water soluble micellar paclitaxel (Paccal Vet) for treatment of nonresectable grade 2 or 3 mast cell tumors in dogs

BACKGROUND

Effective treatments for dogs with advanced stage mast cell tumors (MCT) remain a pressing need. A micellar formulation of paclitaxel (paclitaxel [micellar]) has shown promise in early-phase studies.

HYPOTHESIS/OBJECTIVES

The objective was to demonstrate greater activity for paclitaxel (micellar) compared with lomustine. The null hypothesis was μ(p) = μ(L) (ie, proportion of responders for the paclitaxel [micellar] and lomustine groups, respectively).

ANIMALS

Two hundred and fifty-two dogs with advanced stage nonresectable grade 2 or 3 MCT.

METHODS

Prospective multicenter randomized double-blind positive-controlled clinical trial. The primary endpoint was confirmed overall response rate (CORR) at 14 weeks. A secondary endpoint, biologic observed response rate (BORR), also was calculated. Safety was assessed by the characterization and grading of adverse events (AE).

RESULTS

Overall CORR (7% versus 1%; P = .048) and BORR (23% versus 10%; P = .012) were greater for paclitaxel (micellar) compared with lomustine. Paclitaxel (micellar)-treated dogs were 6.5 times more likely to have a confirmed response and 3.1 times more likely to experience a biologic observed response. The majority of AE with paclitaxel (micellar) were transient and clinically manageable. Twenty-seven dogs (33%) receiving lomustine were discontinued because of hepatopathy compared with 3 dogs (2%) receiving paclitaxel (micellar) (P < .0001; odds ratio 26.7).

CONCLUSIONS AND CLINICAL IMPORTANCE

Paclitaxel (micellar)'s activity and safety profile are superior to lomustine. The addition of an active and novel taxane to the veterinary armamentarium could fill a substantial need and, as its mechanism of action and AE profile do not overlap with currently available TKI, its availability could lead to effective combination protocols.

Preliminary evaluation of a combined microPET-MR system

There are many motivations for adding simultaneously acquired MR images to PET scanning. The most straight forward are, superior registration of MR and PET images, the addition of morphological detail when there is non-rigid motion and for pre-clinical studies simultaneous imaging could lead to a significant reduction in the time that animals are required to be anesthetised. In addition simultaneous MR has the potential to provide accurate motion correction for PET image reconstruction. For functional imaging simultaneous acquisition is required to assess the subject in the same physiological state, such as acute stroke studies. The elimination of the additional radiation associated with combining CT with PET, by providing anatomic detail with MR, would be a crucial advantage for cancer screening. Combining the two instruments necessitates some engineering tradeoffs, especially associated with the use of the highly developed photomultiplier tube (PMT) used for light amplification, because of its incompatibility with strong magnetic fields. Our approach is to provide a split in the magnet and gradients to locate the magnetic sensitive components, the PMTs, in regions of low magnetic field, leaving only the essential PET components, the scintillator blocks, in the strong magnetic field region. The crystals are coupled to the PMTs by extending the optical fibres. A further advantage accrues by moving the PET electronics out of the region seen by the MR radio-frequency (RF) and gradient coils as electromagnetic interference effects between the PET and MR systems, which could cause artefacts in either modality, are eliminated. Here we describe a preliminary evaluation of the system, which is essentially a microPET Focus-120 located in a 1T split magnet, and compare its performance to previous microPET instruments.

Ethical opinions and personal attitudes of young adults conceived by in vitro fertilisation

BACKGROUND

Today in vitro fertilisation (IVF) is a widespread and important technique of reproductive medicine. When the technique was first used, it was considered ethically controversial. This is the first study conducted of adult IVF-offspring in order to learn about their ethical opinions and personal attitudes towards this medical technology.

METHODS

We recruited the participants from the first cases of in vitro fertilisation in Germany at the Gynaecological Clinic of the University Hospital Erlangen. Our qualitative interview study consisted of in-depth, face-to-face interviews with 16 adults who had been conceived by IVF. Our data was analysed with methods of Grounded Theory.

RESULTS

For these adults, the most important factor influencing their personal attitudes towards IVF was the knowledge that they were deeply wanted children. The artificiality of their conception seemed irrelevant for their ethical opinion. All participants mentioned that it was important for them to be informed about the circumstances of their conception by their parents.

CONCLUSIONS

IVF seems to be a medical technique which, although it affects intimate aspects of human existence, can be integrated into the lives of the affected persons without any great difficulties. The findings suggest that parents should inform their children about their fertilisation at an early age and as part of a process over time, not only on a single occasion. Physicians should advise IVF-parents accordingly.

Effect of hydroxyl group position and system parameters on the features of hydroxystearic Acid monolayers

The characteristic features of hydroxystearic acid monolayers OH-substituted in the mid position of the alkyl chain deviate considerably from those of the usual nonsubstituted stearic acid. The phase behavior, domain morphology, and two-dimensional lattice structure of 9-, 11-, and 12-hydroxystearic acids are studied, using pi-A isotherms, Brewster angle microscopy (BAM), and grazing incidence X-ray diffraction (GIXD), to obtain detailed information on the effect of the exact position of the OH-substitution. The pi-A isotherms of all three hydroxyoctadecanoic acids have an extended flat plateau region, the extension of which only slightly decreases with the increase of temperature. At the same temperature, the extension of the plateau region increases and the plateau pressure decreases from 9-hydroxyoctadecanoic acid to 12-hydroxyoctadecanoic acid. The absolute -DeltaH and -DeltaS values for the phase transition increase slightly from 9-hydroxyoctadecanoic acid to 12- hydroxyoctadecanoic acid and indicate differences in the ordering of the condensed phase under consideration of the special reorientation mechanism of these bipolar amphiphiles at the fluid/condensed phase transition. The morphology of the condensed phase domains formed in the fluid/condensed coexistence region is specific for the position of the OH-substitution of the alkyl chain, just as the lattice structures of the condensed monolayer phase. 11-hydroxyoctadecanoic acid monolayers form centered rectangular lattices with the chain tilt toward the NNN (next nearest neighbor) direction, and 12-hydroxyoctadecanoic acid monolayers have an oblique lattice over the entire pressure range. A special feature of 9-hydroxystearic acid monolayers is the phase transition between two condensed phases observed in the pi-A isotherm of 5 degrees C at approximately 18 mN/m, where the centered rectangular lattice shows a NNN/NN transition. The morphology of the condensed phase domains formed in the fluid/condensed coexistence region, just as the lattice structures of the condensed monolayer phase, reveal the high specifity of the monolayer feature of the bipolar hydroxystearic acids OH-substituted in the mid position.

Brushing Abrasion of Softened and Remineralised Dentin: An in situ Study

The aim of the present in situ study was to evaluate the effect of different periods of intra-oral remineralisation on the susceptibility of softened dentin to toothbrushing abrasion. Groups of 6 human dentin specimens (A-F) were recessed in the buccal aspects of intra-oral appliances which were worn for 21 days by 11 volunteers. The samples were demineralised twice a day extra-orally in the acidic beverage Sprite Light (pH 2.9) for 90 s. Subsequently, the dentin specimens were brushed at different times. Specimen A was brushed immediately after demineralisation. Specimens B-E were brushed after the intra-oral appliances had been worn for various periods in the mouth: specimen B for 10 min, C for 20 min, D for 30 min and E for 60 min. Specimen F was not brushed (control). After 21 days, dentin wear was measured with a profilometer. The following values (means +/- standard deviation) were recorded (microm): A, 23.6 +/- 16.7; B, 37.9 +/- 29.7; C, 31.8 +/- 26.5; D, 18.5 +/- 10.5; E, 15.3 +/- 11.6; F, 12.6 +/- 6.7. There was a statistically significantly increased dentin loss for groups A, B and C as compared to the controls (U test: p < 0.05). However, after intra-oral periods of 30 and 60 min, wear was not significantly higher than in unbrushed controls. It is concluded that for protection of dentin surfaces at least 30 min should elapse before toothbrushing after an erosive attack.

Effects of experimental hypogravity on peroxidase and cell wall constituents in the dwarf marigold

Dwarf Marigolds grown from seed under experimental hypogravity are modified in lignin content, hemicellulose composition, and peroxidase activity. The two conditions used, clinostats and flotation, induced changes differing in magnitude but qualitatively similar. Most responses on clinostats required corrections for vertical axis rotational effects, thus limiting the value of these instruments in free-fall simulation. These findings extend earlier observations suggesting that increased peroxidase and decreased lignin are characteristic of growth under experimental hypogravity.