Developmental and reproductive toxicity hazard characterization of 2-amino-2-methyl-1-propanol (AMP)

2-Amino-2-methyl-1-propanol (AMP™) is a widely used pH stabilizer in personal care products (PCPs); thus, the safety implications of dermal AMP exposure remain of interest. We have previously reported that exposure to AMP in PCPs when used as intended is not anticipated to result in an increased risk of hepatotoxicity (primarily steatosis and altered phospholipid homeostasis). The current study focuses on AMP in PCP's potential for developmental and reproductive toxicity (DART) in humans, based on data from animal studies. Animal studies suggest that exposure to AMP can result in post-implantation loss. However, such effects occur at maternally toxic doses, posing a challenge for determining appropriate hazard classifications in the context of relevant consumer use scenarios. Our assessment concluded that human exposure to AMP in PCPs is not anticipated to result in DART at non-maternally toxic doses. Further, mode of action (MOA) analysis elucidated the potential biological pathways underlying DART effects observed in high-dose animal studies, such that perturbation of uterine choline synthesis was the most well-supported MOA hypothesis. Downstream uterine effects might reflect choline-dependent changes in epigenetic control of pathways important for implantation maintenance and uterine cell energetics. Since AMP-induced post-implantation loss occurs at doses higher than pathology related to liver toxicity, maintaining AMP exposures from exceeding the onset dose for maternal liver effects will also be protective of DART effects. Furthermore, dermal exposure to AMP expected from the use of PCPs is highly unlikely to result in toxicologically significant systemic AMP concentrations; thus, DART is not anticipated.

Predicting incident heart failure from population-based nationwide electronic health records: protocol for a model development and validation study

INTRODUCTION

Heart failure (HF) is increasingly common and associated with excess morbidity, mortality, and healthcare costs. Treatment of HF can alter the disease trajectory and reduce clinical events in HF. However, many cases of HF remain undetected until presentation with more advanced symptoms, often requiring hospitalisation. Predicting incident HF is challenging and statistical models are limited by performance and scalability in routine clinical practice. An HF prediction model implementable in nationwide electronic health records (EHRs) could enable targeted diagnostics to enable earlier identification of HF.

METHODS AND ANALYSIS

We will investigate a range of development techniques (including logistic regression and supervised machine learning methods) on routinely collected primary care EHRs to predict risk of new-onset HF over 1, 5 and 10 years prediction horizons. The Clinical Practice Research Datalink (CPRD)-GOLD dataset will be used for derivation (training and testing) and the CPRD-AURUM dataset for external validation. Both comprise large cohorts of patients, representative of the population of England in terms of age, sex and ethnicity. Primary care records are linked at patient level to secondary care and mortality data. The performance of the prediction model will be assessed by discrimination, calibration and clinical utility. We will only use variables routinely accessible in primary care.

ETHICS AND DISSEMINATION

Permissions for CPRD-GOLD and CPRD-AURUM datasets were obtained from CPRD (ref no: 21_000324). The CPRD ethical approval committee approved the study. The results will be submitted as a research paper for publication to a peer-reviewed journal and presented at peer-reviewed conferences.

TRIAL REGISTRATION DETAILS

The study was registered on Clinical Trials.gov (NCT05756127). A systematic review for the project was registered on PROSPERO (registration number: CRD42022380892).

Comparative effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir for preventing severe COVID-19 outcomes in non-hospitalised high-risk patients during Omicron waves: observational cohort study using the OpenSAFELY platform

Background

Timely evidence of the comparative effectiveness between COVID-19 therapies in real-world settings is needed to inform clinical care. This study aimed to compare the effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir in preventing severe COVID-19 outcomes in non-hospitalised high-risk COVID-19 adult patients during Omicron waves.

Methods

With the approval of NHS England, we conducted a real-world cohort study using the OpenSAFELY-TPP platform. Patient-level primary care data were obtained from 24 million people in England and were securely linked with data on COVID-19 infection and therapeutics, hospital admission, and death, covering a period where both nirmatrelvir/ritonavir and sotrovimab were first-line treatment options in community settings (February 10, 2022-November 27, 2022). Molnupiravir (third-line option) was used as an exploratory comparator to nirmatrelvir/ritonavir, both of which were antivirals. Cox proportional hazards model stratified by area was used to compare the risk of 28-day COVID-19 related hospitalisation/death across treatment groups.

Findings

A total of 9026 eligible patients treated with nirmatrelvir/ritonavir (n = 5704) and sotrovimab (n = 3322) were included in the main analysis. The mean age was 52.7 (SD = 14.9) years and 93% (8436/9026) had three or more COVID-19 vaccinations. Within 28 days after treatment initiation, 55/9026 (0.61%) COVID-19 related hospitalisations/deaths were observed (34/5704 [0.60%] treated with nirmatrelvir/ritonavir and 21/3322 [0.63%] with sotrovimab). After adjusting for demographics, high-risk cohort categories, vaccination status, calendar time, body mass index and other comorbidities, we observed no significant difference in outcome risk between nirmatrelvir/ritonavir and sotrovimab users (HR = 0.89, 95% CI: 0.48-1.63; P = 0.698). Results from propensity score weighted model also showed non-significant difference between treatment groups (HR = 0.82, 95% CI: 0.45-1.52; P = 0.535). The exploratory analysis comparing nirmatrelvir/ritonavir users with 1041 molnupiravir users (13/1041 [1.25%] COVID-19 related hospitalisations/deaths) showed an association in favour of nirmatrelvir/ritonavir (HR = 0.45, 95% CI: 0.22-0.94; P = 0.033).

Interpretation

In routine care of non-hospitalised high-risk adult patients with COVID-19 in England, no substantial difference in the risk of severe COVID-19 outcomes was observed between those who received nirmatrelvir/ritonavir and sotrovimab between February and November 2022, when Omicron subvariants BA.2, BA.5, or BQ.1 were dominant.

Funding

UK Research and Innovation, Wellcome Trust, UK Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

First dose COVID-19 vaccine coverage amongst adolescents and children in England: an analysis of 3.21 million patients' primary care records in situ using OpenSAFELY

Background: The coronavirus disease 2019 (COVID-19) vaccination programme in England was extended to include all adolescents and children by April 2022. The aim of this paper is to describe trends and variation in vaccine coverage in different clinical and demographic groups amongst adolescents and children in England by August 2022. Methods: With the approval of NHS England, a cohort study was conducted of 3.21 million children and adolescents' records in general practice in England,  in situ and within the infrastructure of the electronic health record software vendor TPP using OpenSAFELY. Vaccine coverage across various demographic (sex, deprivation index and ethnicity) and clinical (risk status) populations is described. Results: Coverage is higher amongst adolescents than it is amongst children, with 53.5% adolescents and 10.8% children having received their first dose of the COVID-19 vaccine. Within those groups, coverage varies by ethnicity, deprivation index and risk status; there is no evidence of variation by sex. Conclusion: First dose COVID-19 vaccine coverage is shown to vary amongst various demographic and clinical groups of children and adolescents.

Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics

Objective

To implement complex, PINCER (pharmacist led information technology intervention) prescribing indicators, on a national scale with general practice data to describe the impact of the covid-19 pandemic on safe prescribing.

Design

Population based, retrospective cohort study using federated analytics.

Setting

Electronic general practice health record data from 56.8 million NHS patients by use of the OpenSAFELY platform, with the approval of the National Health Service (NHS) England.

Participants

NHS patients (aged 18-120 years) who were alive and registered at a general practice that used TPP or EMIS computer systems and were recorded as at risk of at least one potentially hazardous PINCER indicator.

Main outcome measure

Between 1 September 2019 and 1 September 2021, monthly trends and between practice variation for compliance with 13 PINCER indicators, as calculated on the first of every month, were reported. Prescriptions that do not adhere to these indicators are potentially hazardous and can cause gastrointestinal bleeds; are cautioned against in specific conditions (specifically heart failure, asthma, and chronic renal failure); or require blood test monitoring. The percentage for each indicator is formed of a numerator of patients deemed to be at risk of a potentially hazardous prescribing event and the denominator is of patients for which assessment of the indicator is clinically meaningful. Higher indicator percentages represent potentially poorer performance on medication safety.

Results

The PINCER indicators were successfully implemented across general practice data for 56.8 million patient records from 6367 practices in OpenSAFELY. Hazardous prescribing remained largely unchanged during the covid-19 pandemic, with no evidence of increases in indicators of harm as captured by the PINCER indicators. The percentage of patients at risk of potentially hazardous prescribing, as defined by each PINCER indicator, at mean quarter 1 (Q1) 2020 (representing before the pandemic) ranged from 1.11% (age ≥65 years and non-steroidal anti-inflammatory drugs) to 36.20% (amiodarone and no thyroid function test), while Q1 2021 (representing after the pandemic) percentages ranged from 0.75% (age ≥65 years and non-steroidal anti-inflammatory drugs) to 39.23% (amiodarone and no thyroid function test). Transient delays occurred in blood test monitoring for some medications, particularly angiotensin-converting enzyme inhibitors (where blood monitoring worsened from a mean of 5.16% in Q1 2020 to 12.14% in Q1 2021, and began to recover in June 2021). All indicators substantially recovered by September 2021. We identified 1 813 058 patients (3.1%) at risk of at least one potentially hazardous prescribing event.

Conclusion

NHS data from general practices can be analysed at national scale to generate insights into service delivery. Potentially hazardous prescribing was largely unaffected by the covid-19 pandemic in primary care health records in England.

Changes in COVID-19-related mortality across key demographic and clinical subgroups in England from 2020 to 2022: a retrospective cohort study using the OpenSAFELY platform

BACKGROUND

COVID-19 has been shown to differently affect various demographic and clinical population subgroups. We aimed to describe trends in absolute and relative COVID-19-related mortality risks across clinical and demographic population subgroups during successive SARS-CoV-2 pandemic waves.

METHODS

We did a retrospective cohort study in England using the OpenSAFELY platform with the approval of National Health Service England, covering the first five SARS-CoV-2 pandemic waves (wave one [wild-type] from March 23 to May 30, 2020; wave two [alpha (B.1.1.7)] from Sept 7, 2020, to April 24, 2021; wave three [delta (B.1.617.2)] from May 28 to Dec 14, 2021; wave four [omicron (B.1.1.529)] from Dec 15, 2021, to April 29, 2022; and wave five [omicron] from June 24 to Aug 3, 2022). In each wave, we included people aged 18-110 years who were registered with a general practice on the first day of the wave and who had at least 3 months of continuous general practice registration up to this date. We estimated crude and sex-standardised and age-standardised wave-specific COVID-19-related death rates and relative risks of COVID-19-related death in population subgroups.

FINDINGS

18 895 870 adults were included in wave one, 19 014 720 in wave two, 18 932 050 in wave three, 19 097 970 in wave four, and 19 226 475 in wave five. Crude COVID-19-related death rates per 1000 person-years decreased from 4·48 deaths (95% CI 4·41-4·55) in wave one to 2·69 (2·66-2·72) in wave two, 0·64 (0·63-0·66) in wave three, 1·01 (0·99-1·03) in wave four, and 0·67 (0·64-0·71) in wave five. In wave one, the standardised COVID-19-related death rates were highest in people aged 80 years or older, people with chronic kidney disease stage 5 or 4, people receiving dialysis, people with dementia or learning disability, and people who had received a kidney transplant (ranging from 19·85 deaths per 1000 person-years to 44·41 deaths per 1000 person-years, compared with from 0·05 deaths per 1000 person-years to 15·93 deaths per 1000 person-years in other subgroups). In wave two compared with wave one, in a largely unvaccinated population, the decrease in COVID-19-related mortality was evenly distributed across population subgroups. In wave three compared with wave one, larger decreases in COVID-19-related death rates were seen in groups prioritised for primary SARS-CoV-2 vaccination, including people aged 80 years or older and people with neurological disease, learning disability, or severe mental illness (90-91% decrease). Conversely, smaller decreases in COVID-19-related death rates were observed in younger age groups, people who had received organ transplants, and people with chronic kidney disease, haematological malignancies, or immunosuppressive conditions (0-25% decrease). In wave four compared with wave one, the decrease in COVID-19-related death rates was smaller in groups with lower vaccination coverage (including younger age groups) and conditions associated with impaired vaccine response, including people who had received organ transplants and people with immunosuppressive conditions (26-61% decrease).

INTERPRETATION

There was a substantial decrease in absolute COVID-19-related death rates over time in the overall population, but demographic and clinical relative risk profiles persisted and worsened for people with lower vaccination coverage or impaired immune response. Our findings provide an evidence base to inform UK public health policy for protecting these vulnerable population subgroups.

FUNDING

UK Research and Innovation, Wellcome Trust, UK Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Protocol for an OpenSAFELY cohort study collecting patient-reported outcome measures using the TPP Airmid smartphone application and linked big data to quantify the health and economic costs of long COVID (OpenPROMPT)

INTRODUCTION

The impact of long COVID on health-related quality of-life (HRQoL) and productivity is not currently known. It is important to understand who is worst affected by long COVID and the cost to the National Health Service (NHS) and society, so that strategies like booster vaccines can be prioritised to the right people. OpenPROMPT aims to understand the impact of long COVID on HRQoL in adults attending English primary care.

METHODS AND ANALYSIS

We will ask people to participate in this cohort study through a smartphone app (Airmid), and completing a series of questionnaires held within the app. Questionnaires will ask about HRQoL, productivity and symptoms of long COVID. Participants will be asked to fill in the questionnaires once a month, for 90 days. Questionnaire responses will be linked, where possible, to participants' existing health records from primary care, secondary care, and COVID testing and vaccination data. Analysis will take place using the OpenSAFELY data platform and will estimate the impact of long COVID on HRQoL, productivity and cost to the NHS.

ETHICS AND DISSEMINATION

The Proportionate Review Sub-Committee of the South Central-Berkshire B Research Ethics Committee has reviewed and approved the study and have agreed that we can ask people to take part (22/SC/0198). Our results will provide information to support long-term care, and make recommendations for prevention of long COVID in the future.

TRIAL REGISTRATION NUMBER

NCT05552612.

First dose COVID-19 vaccine coverage amongst adolescents and children in England: an analysis of 3.21 million patients' primary care records in situ using OpenSAFELY

Background: The coronavirus disease 2019 (COVID-19) vaccination programme in England was extended to include all adolescents and children by April 2022. The aim of this paper is to describe trends and variation in vaccine coverage in different clinical and demographic groups amongst adolescents and children in England. Methods: With the approval of NHS England, a cohort study was conducted of 3.21 million children and adolescents’ records in general practice in England, in situ and within the infrastructure of the electronic health record software vendor TPP using OpenSAFELY. Vaccine coverage across various demographic (sex, deprivation index and ethnicity) and clinical (risk status) populations is described. Results: Coverage is higher amongst adolescents than it is amongst children, with 53.5% adolescents and 10.8% children having received their first dose of the COVID-19 vaccine. Within those groups, coverage varies by ethnicity, deprivation index and risk status; there is no evidence of variation by sex. Conclusion: First dose COVID-19 vaccine coverage is shown to vary amongst various demographic and clinical groups of children and adolescents.

Factors associated with COVID-19 vaccine uptake in people with kidney disease: an OpenSAFELY cohort study

OBJECTIVE

To characterise factors associated with COVID-19 vaccine uptake among people with kidney disease in England.

DESIGN

Retrospective cohort study using the OpenSAFELY-TPP platform, performed with the approval of NHS England.

SETTING

Individual-level routine clinical data from 24 million people across GPs in England using TPP software. Primary care data were linked directly with COVID-19 vaccine records up to 31 August 2022 and with renal replacement therapy (RRT) status via the UK Renal Registry (UKRR).

PARTICIPANTS

A cohort of adults with stage 3-5 chronic kidney disease (CKD) or receiving RRT at the start of the COVID-19 vaccine roll-out was identified based on evidence of reduced estimated glomerular filtration rate (eGFR) or inclusion in the UKRR.

MAIN OUTCOME MEASURES

Dose-specific vaccine coverage over time was determined from 1 December 2020 to 31 August 2022. Individual-level factors associated with receipt of a 3-dose or 4-dose vaccine series were explored via Cox proportional hazards models.

RESULTS

992 205 people with stage 3-5 CKD or receiving RRT were included. Cumulative vaccine coverage as of 31 August 2022 was 97.5%, 97.0% and 93.9% for doses 1, 2 and 3, respectively, and 81.9% for dose 4 among individuals with one or more indications for eligibility. Delayed 3-dose vaccine uptake was associated with younger age, minority ethnicity, social deprivation and severe mental illness-associations that were consistent across CKD severity subgroups, dialysis patients and kidney transplant recipients. Similar associations were observed for 4-dose uptake.

CONCLUSION

Although high primary vaccine and booster dose coverage has been achieved among people with kidney disease in England, key disparities in vaccine uptake remain across clinical and demographic groups and 4-dose coverage is suboptimal. Targeted interventions are needed to identify barriers to vaccine uptake among under-vaccinated subgroups identified in the present study.

Trends, variation, and clinical characteristics of recipients of antiviral drugs and neutralising monoclonal antibodies for covid-19 in community settings: retrospective, descriptive cohort study of 23.4 million people in OpenSAFELY

Objective

To ascertain patient eligibility status and describe coverage of antiviral drugs and neutralising monoclonal antibodies (nMAB) as treatment for covid-19 in community settings in England.

Design

Retrospective, descriptive cohort study, approved by NHS England.

Setting

Routine clinical data from 23.4 million people linked to data on covid-19 infection and treatment, within the OpenSAFELY-TPP database.

Participants

Outpatients with covid-19 at high risk of severe outcomes.

Interventions

Nirmatrelvir/ritonavir (paxlovid), sotrovimab, molnupiravir, casirivimab/imdevimab, or remdesivir, used in the community by covid-19 medicine delivery units.

Results

93 870 outpatients with covid-19 were identified between 11 December 2021 and 28 April 2022 to be at high risk of severe outcomes and therefore potentially eligible for antiviral or nMAB treatment (or both). Of these patients, 19 040 (20%) received treatment (sotrovimab, 9660 (51%); molnupiravir, 4620 (24%); paxlovid, 4680 (25%); casirivimab/imdevimab, 50 (<1%); and remdesivir, 30 (<1%)). The proportion of patients treated increased from 9% (190/2220) in the first week of treatment availability to 29% (460/1600) in the latest week. The proportion treated varied by high risk group, being lowest in those with liver disease (16%; 95% confidence interval 15% to 17%); by treatment type, with sotrovimab favoured over molnupiravir and paxlovid in all but three high risk groups (Down's syndrome (35%; 30% to 39%), rare neurological conditions (45%; 43% to 47%), and immune deficiencies (48%; 47% to 50%)); by age, ranging from ≥80 years (13%; 12% to 14%) to 50-59 years (23%; 22% to 23%); by ethnic group, ranging from black (11%; 10% to 12%) to white (21%; 21% to 21%); by NHS region, ranging from 13% (12% to 14%) in Yorkshire and the Humber to 25% (24% to 25%) in the East of England); and by deprivation level, ranging from 15% (14% to 15%) in the most deprived areas to 23% (23% to 24%) in the least deprived areas. Groups that also had lower coverage included unvaccinated patients (7%; 6% to 9%), those with dementia (6%; 5% to 7%), and care home residents (6%; 6% to 7%).

Conclusions

Using the OpenSAFELY platform, we were able to identify patients with covid-19 at high risk of severe outcomes who were potentially eligible to receive treatment and assess the coverage of these new treatments among these patients. In the context of a rapid deployment of a new service, the NHS analytical code used to determine eligibility could have been over-inclusive and some of the eligibility criteria not fully captured in healthcare data. However targeted activity might be needed to resolve apparent lower treatment coverage observed among certain groups, in particular (at present): different NHS regions, ethnic groups, people aged ≥80 years, those living in socioeconomically deprived areas, and care home residents.

Comparative effectiveness of sotrovimab and molnupiravir for prevention of severe covid-19 outcomes in patients in the community: observational cohort study with the OpenSAFELY platform

OBJECTIVE

To compare the effectiveness of sotrovimab (a neutralising monoclonal antibody) with molnupiravir (an antiviral) in preventing severe outcomes of covid-19 in adult patients infected with SARS-CoV-2 in the community and at high risk of severe outcomes from covid-19.

DESIGN

Observational cohort study with the OpenSAFELY platform.

SETTING

With the approval of NHS England, a real world cohort study was conducted with the OpenSAFELY-TPP platform (a secure, transparent, open source software platform for analysis of NHS electronic health records), and patient level electronic health record data were obtained from 24 million people registered with a general practice in England that uses TPP software. The primary care data were securely linked with data on SARS-CoV-2 infection and treatments, hospital admission, and death, over a period when both drug treatments were frequently prescribed in community settings.

PARTICIPANTS

Adult patients with covid-19 in the community at high risk of severe outcomes from covid-19, treated with sotrovimab or molnupiravir from 16 December 2021.

INTERVENTIONS

Sotrovimab or molnupiravir given in the community by covid-19 medicine delivery units.

MAIN OUTCOME MEASURES

Admission to hospital with covid-19 (ie, with covid-19 as the primary diagnosis) or death from covid-19 (ie, with covid-19 as the underlying or contributing cause of death) within 28 days of the start of treatment.

RESULTS

Between 16 December 2021 and 10 February 2022, 3331 and 2689 patients were treated with sotrovimab and molnupiravir, respectively, with no substantial differences in baseline characteristics. Mean age of all 6020 patients was 52 (standard deviation 16) years; 59% were women, 89% were white, and 88% had received three or more covid-19 vaccinations. Within 28 days of the start of treatment, 87 (1.4%) patients were admitted to hospital or died of infection from SARS-CoV-2 (32 treated with sotrovimab and 55 with molnupiravir). Cox proportional hazards models stratified by area showed that after adjusting for demographic information, high risk cohort categories, vaccination status, calendar time, body mass index, and other comorbidities, treatment with sotrovimab was associated with a substantially lower risk than treatment with molnupiravir (hazard ratio 0.54, 95% confidence interval 0.33 to 0.88, P=0.01). Consistent results were found from propensity score weighted Cox models (0.50, 0.31 to 0.81, P=0.005) and when restricted to people who were fully vaccinated (0.53, 0.31 to 0.90, P=0.02). No substantial effect modifications by other characteristics were detected (all P values for interaction >0.10). The findings were similar in an exploratory analysis of patients treated between 16 February and 1 May 2022 when omicron BA.2 was the predominant variant in England.

CONCLUSIONS

In routine care of adult patients in England with covid-19 in the community, at high risk of severe outcomes from covid-19, those who received sotrovimab were at lower risk of severe outcomes of covid-19 than those treated with molnupiravir.

Antineutrophil cytoplasmic antibody associated vasculitis: a converging diagnosis from neuropathy and testicular infarcts

Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis encompasses a group of rare multi-system affecting diseases that can present with unremitting cases of common conditions. We present a case of a middle-aged gentleman admitted under Urology with epidymo-orchitits on multiple occasions. Ultrasound revealed segmental testicular infarcts, and he was managed conservatively. He re-presented shortly after discharge to the medical assessment unit with ulnar nerve paraesthesia, thought to be due to ulnar nerve entrapment syndrome. Less than 1 week later he was re-admitted again, with severe peripheral nerve pain in all limbs and multifocal weakness. Initial history and examination gave a provisional diagnosis of mononeuritis multiplex. Following investigations and treatment, this was deemed to be caused by a converging diagnosis of C-ANCA PR3 positive vasculitis, a small vessel vasculitis. This case highlights that patients with unremitting cases of epididymo-orchitis with testicular infarcts may benefit from autoimmune screening.

Recording of 'COVID-19 vaccine declined': a cohort study on 57.9 million National Health Service patients' records in situ using OpenSAFELY, England, 8 December 2020 to 25 May 2021

BackgroundPriority patients in England were offered COVID-19 vaccination by mid-April 2021. Codes in clinical record systems can denote the vaccine being declined.AimWe describe records of COVID-19 vaccines being declined, according to clinical and demographic factors.MethodsWith the approval of NHS England, we conducted a retrospective cohort study between 8 December 2020 and 25 May 2021 with primary care records for 57.9 million patients using OpenSAFELY, a secure health analytics platform. COVID-19 vaccination priority patients were those aged ≥ 50 years or ≥ 16 years clinically extremely vulnerable (CEV) or 'at risk'. We describe the proportion recorded as declining vaccination for each group and stratified by clinical and demographic subgroups, subsequent vaccination and distribution of clinical code usage across general practices.ResultsOf 24.5 million priority patients, 663,033 (2.7%) had a decline recorded, while 2,155,076 (8.8%) had neither a vaccine nor decline recorded. Those recorded as declining, who were subsequently vaccinated (n = 125,587; 18.9%) were overrepresented in the South Asian population (32.3% vs 22.8% for other ethnicities aged ≥ 65 years). The proportion of declining unvaccinated patients was highest in CEV (3.3%), varied strongly with ethnicity (black 15.3%, South Asian 5.6%, white 1.5% for ≥ 80 years) and correlated positively with increasing deprivation.ConclusionsClinical codes indicative of COVID-19 vaccinations being declined are commonly used in England, but substantially more common among black and South Asian people, and in more deprived areas. Qualitative research is needed to determine typical reasons for recorded declines, including to what extent they reflect patients actively declining.

Safety of COVID-19 vaccination and acute neurological events: A self-controlled case series in England using the OpenSAFELY platform

INTRODUCTION

We investigated the potential association of COVID-19 vaccination with three acute neurological events: Guillain-Barré syndrome (GBS), transverse myelitis and Bell's palsy.

METHODS

With the approval of NHS England we analysed primary care data from >17 million patients in England linked to emergency care, hospital admission and mortality records in the OpenSAFELY platform. Separately for each vaccine brand, we used a self-controlled case series design to estimate the incidence rate ratio for each outcome in the period following vaccination (4-42 days for GBS, 4-28 days for transverse myelitis and Bell's palsy) compared to a within-person baseline, using conditional Poisson regression.

RESULTS

Among 7,783,441 ChAdOx1 vaccinees, there was an increased rate of GBS (N = 517; incidence rate ratio 2·85; 95% CI2·33-3·47) and Bell's palsy (N = 5,350; 1·39; 1·27-1·53) following a first dose of ChAdOx1 vaccine, corresponding to 11.0 additional cases of GBS and 17.9 cases of Bell's palsy per 1 million vaccinees if causal. For GBS this applied to the first, but not the second, dose. There was no clear evidence of an association of ChAdOx1 vaccination with transverse myelitis (N = 199; 1·51; 0·96-2·37). Among 5,729,152 BNT162b2 vaccinees, there was no evidence of any association with GBS (N = 283; 1·09; 0·75-1·57), transverse myelitis (N = 109; 1·62; 0·86-3·03) or Bell's palsy (N = 3,609; 0·89; 0·76-1·03). Among 255,446 mRNA-1273 vaccine recipients there was no evidence of an association with Bell's palsy (N = 78; 0·88, 0·32-2·42).

CONCLUSIONS

COVID-19 vaccines save lives, but it is important to understand rare adverse events. We observed a short-term increased rate of Guillain-Barré syndrome and Bell's palsy after first dose of ChAdOx1 vaccine. The absolute risk, assuming a causal effect attributable to vaccination, was low.

OpenSAFELY: Representativeness of electronic health record platform OpenSAFELY-TPP data compared to the population of England

Background: Since its inception in March 2020, data from the OpenSAFELY-TPP electronic health record platform has been used for more than 20 studies relating to the global COVID-19 emergency. OpenSAFELY-TPP data is derived from practices in England using SystmOne software, and has been used for the majority of these studies. We set out to investigate the representativeness of OpenSAFELY-TPP data by comparing it to national population estimates.    Methods: With the approval of NHS England, we describe the age, sex, Index of Multiple Deprivation and ethnicity of the OpenSAFELY-TPP population compared to national estimates from the Office for National Statistics. The five leading causes of death occurring between the 1st January 2020 and the 31st December 2020 were also compared to deaths registered in England during the same period.  Results: Despite regional variations, TPP is largely representative of the general population of England in terms of IMD (all within 1.1 percentage points), age, sex (within 0.1 percentage points), ethnicity and causes of death. The proportion of the five leading causes of death is broadly similar to those reported by ONS (all within 1 percentage point).  Conclusions: Data made available via OpenSAFELY-TPP is broadly representative of the English population. Users of OpenSAFELY must consider the issues of representativeness, generalisability and external validity associated with using TPP data for health research. Although the coverage of TPP practices varies regionally across England, TPP registered patients are generally representative of the English population as a whole in terms of key demographic characteristics.

Dose and Exposure Route Analyses Inform Relationships Between Liver Steatosis and 2-amino-2-methyl-1-propanol (AMP): Implications for Hazard Characterization

2-Amino-2-methylpropanol (AMP™) is widely used as a neutralizer/pH stabilizer in personal care products (PCP); however, the potential health implications of dermal AMP exposure remain to be fully elucidated. Consequently, an in-depth analysis was performed to determine if personal care products containing AMP pose an elevated risk in humans under the intended use conditions. Animal studies have shown that at high doses, oral AMP exposure could lead to liver steatosis; thus, this study focused on hepatotoxicity. Our assessment revealed that the derived margin of exposure (MoE) values for AMP-containing personal care products were above 100, indicating that dermal exposure to AMP is unlikely to present an elevated risk of hepatotoxicity. Further, mode of action (MOA) analysis was conducted to elucidate the potential mechanisms underlying the observed hepatotoxicity in animal studies. Our analysis proposed that AMP interferes with the CDP-choline pathway in hepatocytes via the inhibition of one or more enzymes integral to the pathway and/or the replacement of choline in the assembly of the phospholipid unit. Ultimately, these events halt the lipid export via very low density lipoproteins, which can subsequently develop into fatty liver accompanied by hepatotoxicity and other pathological changes if AMP exposure persists at sufficiently high doses. MOA analysis corroborated that dermal exposure to AMP expected from use of personal care products is highly unlikely to result in toxicologically-significant systemic concentrations of AMP, and thus hepatotoxicity. We concluded that dermal exposure to AMP in personal care products is not anticipated to result in an increased risk of hepatotoxicity.

Traumatic Transposition of the Ulnar Nerve Through the Distal Radioulnar Joint: A Case Report

CASE

A 27-year-old woman sustained a left open distal radius fracture with dislocation of the distal radioulnar joint (DRUJ). Postoperatively after initial temporizing treatment, the patient reported numbness in an ulnar distribution and was noted to have intrinsic hand weakness. At the time of conversion to internal fixation, the ulnar nerve was found to be translocated through the DRUJ and was narrowed and felt to benefit from resection and grafting.

CONCLUSION

The combination of ulnar nerve palsy and wide displacement of the distal radius with DRUJ dislocation should raise the possibility of translocation of the ulnar nerve through the DRUJ.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom

OBJECTIVE

In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK.

MATERIALS AND METHOD

A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data.

RESULTS

529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs.

CONCLUSION

Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general practice electronic health records, antibiotic prescribing and health outcomes

BACKGROUND

The prevalence of reported penicillin allergy (PenA) and the impact these records have on health outcomes in the UK general population are unknown. Without such data, justifying and planning enhanced allergy services is challenging.

OBJECTIVES

To determine: (i) prevalence of PenA records; (ii) patient characteristics associated with PenA records; and (iii) impact of PenA records on antibiotic prescribing/health outcomes in primary care.

METHODS

We carried out cross-sectional/retrospective cohort studies using patient-level data from electronic health records. Cohort study: exact matching across confounders identified as affecting PenA records. Setting: English NHS general practices between 1 April 2013 and 31 March 2014. Participants: 2.3 million adult patients. Outcome measures: prevalence of PenA, antibiotic prescribing, mortality, MRSA infection/colonization and Clostridioides difficile infection.

RESULTS

PenA prevalence was 5.9% (IQR = 3.8%-8.2%). PenA records were more common in older people, females and those with a comorbidity, and were affected by GP practice. Antibiotic prescribing varied significantly: penicillins were prescribed less frequently in those with a PenA record [relative risk (RR)  = 0.15], and macrolides (RR = 4.03), tetracyclines (RR = 1.91) nitrofurantoin (RR = 1.09), trimethoprim (RR = 1.04), cephalosporins (RR = 2.05), quinolones (RR = 2.10), clindamycin (RR = 5.47) and total number of prescriptions were increased in patients with a PenA record. Risk of re-prescription of a new antibiotic class within 28 days (RR = 1.32), MRSA infection/colonization (RR = 1.90) and death during the year subsequent to 1 April 2013 (RR = 1.08) increased in those with PenA records.

CONCLUSIONS

PenA records are common in the general population and associated with increased/altered antibiotic prescribing and worse health outcomes. We estimate that incorrect PenA records affect 2.7 million people in England. Establishing true PenA status (e.g. oral challenge testing) would allow more people to be prescribed first-line antibiotics, potentially improving health outcomes.

A Systematic Review of UK Educational and Training Materials Aimed at Health and Social Care Staff about Providing Appropriate Services for LGBT+ People

Background: There is greater dissatisfaction with health services by LGBT people compared to heterosexual and cisgender people and some of this is from lack of equality and diversity training for health professionals. Core training standards in sexual orientation for health professionals have been available since 2006. The purpose of this project is to systematically review educational materials for health and social care professionals in lesbian, gay, bisexual, and transgender (LGBT) issues. Methods: A protocol was developed and searches conducted in six databases. Selection criteria: any studies reporting delivery or evaluation of UK education of health and/or social care professionals in LGBT issues, with no language or setting restrictions. Inclusions and data extraction were conducted in duplicate. Narrative synthesis of educational evaluations was used. Educational materials were assessed using thematic synthesis. Results: From the searches, 165 full papers were evaluated and 19 studies were included in the narrative synthesis. Three were successful action-research projects in cancer services and in residential care. Sixteen sets of educational/training materials have been available since 2010. These varied in length, scope, target audience, and extent of development as classroom-ready materials. Conclusions: Despite the availability of appropriate training programmes for post-qualifying staff, recommendations to undertake training, best practice examples, and statements of good intent, LGBT people continue to report that they are experiencing discrimination or direct prejudice from health and/or social care services. Better training strategies using behaviour change techniques are needed.

Cancer control in small island nations: from local challenges to global action

Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.

Abstract P3-08-13: Exploring the role of ctDNA in triple negative breast cancer

BACKGROUND: Previously published work shows that triple negative (TNBC) is a heterogeneous disease with varying levels of genomic instability, where higher genomic instability is associated with poorer prognosis. Subgroups of TNBC patients with distinct patterns of genome aberrations may indicate pathologies in specific genome maintenance/repair processes. Circulating tumor DNA (ctDNA) as assessed by next generation sequencing (NGS) is a relatively non-invasive test that may provide prognostic and predictive information.

AIM OF STUDY: To analyze genomic alterations with serial plasma samples using NGS methods of ctDNA analysis and determine the utility for actionability and disease burden monitoring. We shall also determine whether TNBC subgroups differ in their ctDNA profiles. Shallow whole genome sequencing vs targeted capture at depth will be contrasted to determine sensitivity for relapse detection.

METHODS: Enrollment of a planned cohort of TNBC patients (N=300) with any stage, at diagnosis (dx) or within 2 years of dx, or at relapse of disease with ongoing plasma sampling every 3 -6 months. Patient age, stage, grade, type of chemotherapy, date of relapse and date of last followup are collected. Tumor tissue (FFPE), saliva for germline mutations and serial blood draws for ctDNA are analyzed with two NGS sequencing methods: (i) a high sensitivity small hotspot gene panel (33 genes, 170 hotspots), directed purely at actionable findings (ii) capture sequencing directed at multiple regions of the genome or shallow whole genome sequencing.

RESULTS: Preliminary analysis in 20 patient cases using the targeted hotspot panel. . Median followup 151 days. Two cases had plasma drawn at time of relapsed disease and 1 at the time of de novo metastatic disease; 12 had plasma samples drawn prior to neoadjuvant chemotherapy (clinical T1/T2N1, T3/T4Nany), and 5 had plasma draws after primary surgery (pathologic T1N0, T2N0). Of the neoadjuvant cases, 5 (42%) had a pathologic complete response (pCR); 4 with ctDNA mutations and 1 without. Six (58%) neoadjuvant cases did not achieve a pCR; 3 with ctDNA mutations, 3 without. One patient is awaiting surgery. Twelve (60%) cases had mutations in TP53, one case had 2 different TP53 mutations (no pCR) and one case had 3 mutations: TP53, PIK3CA, KRAS (achieved pCR). Of the cases treated with curative intent, with short followup (FU), there have been no relapses including the case of the sample containing 3 mutations.

CONCLUSION: TP53 mutations may be a marker of higher genomic alteration burden and may have prognostic value in patients with newly diagnosed, non-metastatic TNBC with longer FU. Ongoing analysis of serial plasma samples and FFPE analysis may provide further insight into the prognostic value of ctDNA. Full genome sequencing may be needed identify other mutations that have prognostic and/or predictive value. We have accrued over 200 patients with samples being analyzed and plan to present an interim analysis of the cohort at SABCS 2018.

Citation Format: den Brok WD, Kong E, Bates C, Aguirre-Hernandez R, Miller RR, Lum A, Wan A, Shah S, Aparicio S, Gelmon KA. Exploring the role of ctDNA in triple negative breast cancer [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 P3-08-13.

Accumulation of particulate matter, heavy metals, and polycyclic aromatic hydrocarbons on the leaves of Tilia cordata Mill. in five Polish cities with different levels of air pollution

Urbanized areas are struggling with the problem of air pollution and as the number of people living in cities is increasing, the situation is likely to deteriorate. One of the most harmful pollutants is particulate matter (PM). Increased levels of PM in the atmosphere are likely to have a negative impact on human health. Phytoremediation technology could be a solution. It involves plants acting as bio-filters by accumulating particles on, and in the leaves, thus removing the particles from the atmosphere. This study investigates the accumulation of PM including heavy metals (HMs) and polycyclic aromatic hydrocarbons (PAHs), on the foliage of small-leaved lime (Tilia cordata Mill.) in five Polish cities. There were significantly different PM amounts found in the trees between the cities which related to the different quantities of PM in the atmosphere at these cities. Significant differences were found between cities for the amounts of the different particulate size fractions, and the HMs and PAHs in leaves. Strong winds reduced the amount of PM on leaves, especially the smallest fractions, but no relationship with precipitation was found. The results suggest that T. cordata improves the air quality in cities and can be used as an effective bioindicator for PM air pollution.

The effect of ambient temperature on type-2-diabetes: case-crossover analysis of 4+ million GP consultations across England

BACKGROUND

Given the double jeopardy of global increases in rates of obesity and climate change, it is increasingly important to recognise the dangers posed to diabetic patients during periods of extreme weather. We aimed to characterise the associations between ambient temperature and general medical practitioner consultations made by a cohort of type-2 diabetic patients. Evidence on the effects of temperature variation in the primary care setting is currently limited.

METHODS

Case-crossover analysis of 4,474,943 consultations in England during 2012-2014, linked to localised temperature at place of residence for each patient. Conditional logistic regression was used to assess associations between each temperature-related consultation and control days matched on day-of-week.

RESULTS

There was an increased odds of seeking medical consultation associated with high temperatures: Odds ratio (OR) = 1.097 (95% confidence interval = 1.041, 1.156) per 1 °C increase above 22 °C. Odds during low temperatures below 0 °C were also significantly raised: OR = 1.024 (1.019, 1.030). Heat-related consultations were particularly high among diabetics with cardiovascular comorbidities: OR = 1.171 (1.031, 1.331), but there was no heightened risk with renal failure or neuropathy comorbidities. Surprisingly, lower odds of heat-related consultation were associated with the use of diuretics, anticholinergics, antipsychotics or antidepressants compared to non-use, especially among those with cardiovascular comorbidities, although differences were not statistically significant.

CONCLUSIONS

Type-2 diabetic patients are at increased odds of medical consultation during days of temperature extremes, especially during hot weather. The common assumption that certain medication use heightens the risk of heat illness was not borne-out by our study on diabetics in a primary care setting and such advice may need to be reconsidered in heat protection plans.

Abstract P4-06-10: Rates of successful engraftment in breast cancer xenograft models based on tissue type: Primary vs relapsed disease

Purpose: As we have published expertise in breast cancer xenograft models and clonal dynamics, our aim was to explore rates of engraftment based on type of tissue for attempted xenografting (primary vs relapsed/metastatic disease) and clinical breast biomarker subtype.

Methods: Tissue from patients (pts) enrolled in a locally advanced/metastatic study and a breast tumour tissue repository (ie. resectable primaries) between Sept. 2008 and July 2015 underwent xenografting using NodScid/IL2rgKO (NSG) mice. Xenografts were passaged when tumour volume reached 1 cm3. Mice with no engraftment after 12 months (mos) were sacrificed. Pt charts were reviewed to determine biomarker status (hormone receptor [HR], HER2), date and type of tissue collection for xenografting. Prediction of successful engraftment based on tissue type and biomarker status was performed using nominal logistic regression.

Results: A total of 70 tissue samples with known engraftment status were included in the analysis: 51 from primary breast tumour, 10 from relapsed disease (dz) with ≤ 1 line of therapy in the advanced setting and 9 from relapsed dz with &gt; 1 line of therapy in the advanced setting. Tumours from pts treated with &gt; 1 line of therapy were more likely to engraft compared to primary or recurrent dz with ≤ 1 line of therapy (89%, 35%, and 40% respectively; p=.008). HR- primary tumours were more likely to engraft compared to HR+ primary tumours: 71% of HR-/HER2- (triple negative) and 67% of HR-/HER2+ tumours versus 4% of HR+/HER2- and 38% of HR+/HER2+ tumours; p&lt;.0001. Combining all tissue types, HR- tumours were more likely to engraft compared to HR+ tumours: 76% of HR-/HER2- and 67% of HR-/HER2+ tumours versus 37% of HR+/HER2+ and 22% of HR+/HER2- tumours; p=.0007. Table 1 shows the rate of engraftment for each tissue type and biomarker status. Combining these 2 variables predicts engraftment in 80% of cases.

Conclusion: This preliminary study highlights potential differences in successful xenoengraftment based on biomarker status at diagnosis and type of tissue, primary vs relapsed tumour, the latter suggesting that the underlying biology of primary or first relapsed recurrent disease is distinct from more refractory disease, and warrants further exploration. This work is ongoing. (Funded by CBCRA, BCCF)

Engraftment of primary tumour vs relapsed disease Primary tumour (N=52) N, (%)Recurrent disease and ≤ 1 line of Rx in advanced setting (N=10) N, (%)Recurrent disease and &gt; 1 line of Rx in advanced setting (N=9) N, (%)Engraftment Yes18 (35)4 (40)8 (89)HR-/HER2-10 (55)1 (25)2 (25)HR-/HER2+4 (22)1 (25)1 (13)HR+/HER2+3 (17)00HR+/HER2-1 (6)2 (50)5 (62)Engraftment No33 (65)6 (60)1 (11)HR-/HER2-4 (12)00HR-/HER2+2 (6)1 (17)0HR+/HER2+5 (15)00HR+/HER2-22 (67)5 (83)1 (100)

Citation Format: den Brok W-l, Chia S, Kalloger S, Bates C, Aparicio S, Mar C, Gelmon K, Eirew P. Rates of successful engraftment in breast cancer xenograft models based on tissue type: Primary vs relapsed disease [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-06-10.

Nicorandil-induced penile ulceration: a case report

Background

Penile ulceration in older patients is commonly neoplastic or infective. However, there are rarer causes of these ulcerations that we have to exclude. We present a rare complication of penile ulceration secondary to nicorandil, a nicotinamide ester.

Case presentation

An 86-year-old white British man was referred with a bloody discharge from under his phimotic foreskin and a lump on the shaft of his penis for the past year. He had angina which has been controlled with nicorandil for the past 5 years. A surgical biopsy of the ulcer showed inflammation with no evidence of malignancy. His penile ulceration spontaneously resolved when he stopped his nicorandil treatment.

Conclusions

Nicorandil-induced ulceration is a rare complication; however, it should not be missed in a clinical setting. If there is any doubt about the cause of penile ulceration, then referral to dermatology or urology for consideration of biopsy is essential.

Advanced oxidation degradation kinetics as a function of ultraviolet LED duty cycle

Ultraviolet (UV) light emitting diodes (LEDs) may be a viable option as a UV light source for advanced oxidation processes (AOPs) utilizing photocatalysts or oxidizing agents such as hydrogen peroxide. The effect of UV-LED duty cycle, expressed as the percentage of time the LED is powered, was investigated in an AOP with hydrogen peroxide, using methylene blue (MB) to assess contaminant degradation. The UV-LED AOP degraded the MB at all duty cycles. However, adsorption of MB onto the LED emitting surface caused a linear decline in reactor performance over time. With regard to the effect of duty cycle, the observed rate constant of MB degradation, after being adjusted to account for the duty cycle, was greater for 5 and 10% duty cycles than higher duty cycles, providing a value approximately 160% higher at 5% duty cycle than continuous operation. This increase in adjusted rate constant at low duty cycles, as well as contaminant fouling of the LED surface, may impact design and operational considerations for pulsed UV-LED AOP systems.

Acute liver failure in Scotland between 1992 and 2009; incidence, aetiology and outcome

AIM

To describe incidence, aetiology and outcome data for Scotland since the inception of the Scottish Liver Transplant Unit (SLTU) in 1992.

BACKGROUND

Acute liver failure (ALF) is a rare but frequently fatal condition. Few studies have adequate patient numbers to draw convincing conclusions over demographic features, aetiology and outcome.

DESIGN

Statistical analysis of prospectively collected data on aetiology, demographic, clinical and outcome of all admissions, including those with ALF, to the SLTU.

METHODS

Incidence data presented for admissions and ALF. Descriptive frequencies for aetiology, clinical, demographic and outcome data presented; including split analysis for paracetamol and non-paracetamol aetiologies. Univariate and multivariate analysis of admission factors predictive of outcome is described.

RESULTS

Nine hundred and forty-nine patients were admitted to the SLTU between 1992 and 2009. Five hundred and twenty-four patients had ALF. The annual incidence of ALF in the Scottish population is 0.62 per 100,000 and paracetamol overdose (POD) was the largest causative factor; responsible for 0.43 cases of ALF per 100,000 population per year. The odds ratio (OR) of transplantation or death was 0.47 in the POD group compared to other aetiologies; yet of not being a transplant candidate having met the Kings College Hospital poor prognostic criteria OR was 4.9. Of admissions listed for transplant 76.0% were transplanted. Of those listed and not transplanted mortality was approaching 100% and 76.1% of those transplanted survived to discharge.

CONCLUSION

This large, prospective, single centre study with a defined geographical area and well-recorded population provides accurate data regarding ALF between 1992 and 2009.

Soft tissue attachment to titanium implants coated with growth factors

BACKGROUND

Enhancing the connective tissue seal around dental implants may be an important factor in implant survival.

PURPOSE

The objective of the study was to investigate the effect of implant surface modification with either platelet-derived growth factor (PDGF) or enamel matrix derivative (EMD) on connective tissue attachment to titanium implants.

MATERIALS AND METHODS

Eighteen implants (Branemark® Mk III Groovy NP (3.3 mmØ × 10 mm, Nobel Biocare) were implanted subcutaneously into 12 rats. Six implants each were coated with either PDGF or EMD immediately prior to implantation and six implants were left uncoated. Implants were retrieved at 4 and 8 weeks and assessed histologically to compare the soft tissue adaptation to the implant surfaces.

RESULTS

Ingrowth by soft connective tissue into the threads of all implants was noted at 4 and 8 weeks. Coating with growth factors did not alter the orientation of fibroblasts and collagen fibers. The depth of connective tissue penetration into the implant grooves was significantly greater for the implants coated with PDGF at 4 weeks. The thickness of the connective tissue in growth was significantly less for the implants coated with PDGF at 8 weeks.

CONCLUSION

Coating of the implant surface with rhPDGF-BB or EMD can increase the speed and quantity of soft tissue healing around the implant surface.

Weed Hosts of Globodera pallida from Idaho

The potato cyst nematode, Globodera pallida (PCN), a restricted pest in the United States, was first reported in Bingham and Bonneville counties of Idaho in 2006 (1). The U.S. government and Idaho State Department of Agriculture hope to eradicate it from infested fields. Eradicating PCN will require depriving the nematodes of their hosts over a protracted time period. Functional eradication might be achieved with relatively high, proven to be efficacious dosages of soil fumigants. The presence of host weeds of PCN can play a significant role in the success of the eradication program. To determine the host status of common weeds found in potato fields of the Pacific Northwest, host suitability tests were conducted in a secured greenhouse located at the University of Idaho at Moscow. Reproduction of PCN on nine weeds including hairy nightshade (Solanum physalifolium formerly S. sarrachoides) and cutleaf nightshade (S. triflorum) (biotypes from Idaho and Washington), black nightshade (S. nigrum) (Washington biotype), bittersweet nightshade (S. dulcamara) (Idaho biotype), redroot pigweed (Amaranthus retroflexus), kochia (Kochia scoparia), and common lambsquarters (Chenopodium album) were compared with reproduction on Desiree, Russet Burbank (known hosts), and Santé (poor host) potatoes (S. tuberosum). Plants were grown in 10-cm-diameter clay pots containing sandy loam soil previously fumigated with methyl bromide and inoculated with 10 to 150 cysts that were either collected from infested fields or raised in the secured greenhouse (ample diapause period elapsed). Treatments were replicated five times and each trial lasted 3 months. Cysts were extracted from soil with a Fenwick can, and the reproductive factor (RF = final cyst count ÷ initial inoculum) was determined. While both biotypes of hairy nightshade were suitable hosts of PCN (161-668 ÷ 150; RF = >1), cutleaf biotypes, black, and bittersweet nightshades were poor hosts (1-108 ÷ 150; RF = <1). Russet Burbank (77 ÷ 40; RF = 1.9) and Desiree (21-119 ÷ 75; RF = >1) proved to be suitable hosts and Santé (1-20 ÷ 150; RF = <1) a poor host of Idaho PCN. Although some cysts were recovered from pots containing the remaining weed species, they may have been part of the original inoculum. The significance of nightshade species (whether suitable or poor hosts) in eradication of potato cyst nematode from infested fields cannot be overemphasized. Reference: (1) A. M. Skantar et al. J. Nematol. 39:133, 2007.

First Report of Laurel Wilt Disease Caused by Raffaelea lauricola on Sassafras in Florida and South Carolina

Laurel wilt disease, caused by Raffaelea lauricola (T.C. Harr., Fraedrich & Aghayeva sp. nov.), which is a fungal symbiont of the nonnative redbay ambrosia beetle (Xyleborus glabratus Eichhoff), has caused widespread mortality of native redbay (Persea borbonia (L.) Spreng) in Georgia, South Carolina, and Florida since 2002. The disease has been noted on other species in the Lauraceae including sassafras in Georgia (1), and more recently, on avocado and camphor in Florida (4). Since 2005, wilted shoots, branch dieback, and tree death have been observed in sassafras trees (Sassafras albidum (L.)) in Liberty, McIntosh, Chatham, Effingham, Bulloch, Evans, and Screven counties in Georgia; Bamberg, Beaufort, Charleston, Colleton, Hampton, and Orangeburg counties in South Carolina; and Putnam County in Florida. Symptomatic sassafras trees ranged from 1 to 12 m high and 2.5 to 25 cm in diameter at breast height. In contrast to red bay trees that retain wilted foliage, symptomatic sassafras defoliate rapidly as trees wilt and die. Multiple symptomatic ramets originating from a common root system have been observed. Removal of bark from stem and root sections from wilted trees revealed black-to-brownish staining in the sapwood, characteristic of laurel wilt. Wood chips from symptomatic areas of branches and roots were surface sterilized and plated on cycloheximide-streptomycin malt agar as previously described (1) and R. lauricola was routinely isolated. Small subunit (18S) sequences from rDNA were amplified by PCR and sequenced using primers NS1 and NS4 (3) for isolates from sassafras from Florida and South Carolina. BLASTn searches revealed homology to Raffaelea sp. C2203 (GenBank Accession No. EU123076, 100% similarity) described by Fraedrich et al. (1) from redbay and later named R. lauricola (2). The small subunit rDNA sequences for these isolates have been deposited into GenBank ( http://www.ncbi.nlm.nih.gov/Genbank/index.html ) and assigned Accession Nos. EU980448 (Florida) and GQ329704 (South Carolina). Koch's postulates have been completed with R. lauricola on this host previously (1). Laurel wilt on sassafras often was geographically isolated from other symptomatic hosts in Georgia and South Carolina and appears to occur on this host independently of proximity to redbay. Further studies to determine the epidemiology of laurel wilt on sassafras, potential resistance, and impact on sassafras life history and distribution are needed. Given the clonal nature of sassafras, the disease would appear to have the potential to move through roots of trees once established in a stand. References: (1) S. W Fraedrich et al. Plant Dis. 92:215, 2008. (2) T. C. Harrington et al. Mycotaxon 104:399, 2008. (3) M. A. Innis et al. PCR Protocols, A Guide to Methods and Applications. Academic Press, San Diego, CA, 1990. (4) J. A. Smith et al. Plant Dis. 93:198, 2009.