Impact of molecular ciprofloxacin resistance testing in management of gonorrhoea in a large urban clinic

OBJECTIVES

Antibiotic resistance in gonorrhoea is of significant public health concern with the emergence of resistance to last-line therapies such as ceftriaxone. Despite around half of Neisseria gonorrhoeae isolates tested in the UK being susceptible to ciprofloxacin, very little ciprofloxacin is used in clinical practice. Testing for the S91F mutation associated with ciprofloxacin resistance is now available in CE-marked assays and may reduce the requirement for ceftriaxone, but many patients are treated empirically, or as sexual contacts, which may limit any benefit. We describe the real-world impact of such testing on antimicrobial use and clinical outcomes in people found to have gonorrhoea in a large urban UK sexual health clinic.

METHODS

Molecular ciprofloxacin resistance testing (ResistancePlus GC assay (SpeeDx)) was undertaken as an additional test after initial diagnosis (m2000 Realtime CT/NG assay (Abbott Molecular)) in those not already known to have had antimicrobial treatment. Data from a 6-month period (from March to September 2022) were analysed to determine treatment choice and treatment outcome.

RESULTS

A total of 998 clinical samples tested positive for N. gonorrhoeae in 682 episodes of infection. Of the 560 (56%) samples eligible for resistance testing, 269 (48.0%) were reported as wild-type, 180 (32.1%) were predicted to be resistant, 63 (11.3%) had an indeterminate resistance profile, and in 48 (8.6%) samples, N. gonorrhoeae was not detected. Ciprofloxacin was prescribed in 172 (75%) of 228 episodes in which the wild-type strain was detected. Four (2%) of those treated with ciprofloxacin had a positive test-of-cure sample by NAAT, with no reinfection risk. All four had ciprofloxacin-susceptible infection by phenotypic antimicrobial susceptibility testing.

CONCLUSIONS

In routine practice in a large UK clinic, molecular ciprofloxacin resistance testing led to a significant shift in antibiotic use, reducing use of ceftriaxone. Testing can be targeted to reduce unnecessary additional testing. Longer term impact on antimicrobial resistance requires ongoing surveillance.

Directions of change in intrinsic case severity across successive SARS-CoV-2 variant waves have been inconsistent

OBJECTIVES

To determine how the intrinsic severity of successively dominant SARS-CoV-2 variants changed over the course of the pandemic.

METHODS

A retrospective cohort analysis in the NHS Greater Glasgow and Clyde (NHS GGC) Health Board. All sequenced non-nosocomial adult COVID-19 cases in NHS GGC with relevant SARS-CoV-2 lineages (B.1.177/Alpha, Alpha/Delta, AY.4.2 Delta/non-AY.4.2 Delta, non-AY.4.2 Delta/Omicron, and BA.1 Omicron/BA.2 Omicron) during analysis periods were included. Outcome measures were hospital admission, ICU admission, or death within 28 days of positive COVID-19 test. We report the cumulative odds ratio; the ratio of the odds that an individual experiences a severity event of a given level vs all lower severity levels for the resident and the replacement variant after adjustment.

RESULTS

After adjustment for covariates, the cumulative odds ratio was 1.51 (95% CI: 1.08-2.11) for Alpha versus B.1.177, 2.09 (95% CI: 1.42-3.08) for Delta versus Alpha, 0.99 (95% CI: 0.76-1.27) for AY.4.2 Delta versus non-AY.4.2 Delta, 0.49 (95% CI: 0.22-1.06) for Omicron versus non-AY.4.2 Delta, and 0.86 (95% CI: 0.68-1.09) for BA.2 Omicron versus BA.1 Omicron.

CONCLUSIONS

The direction of change in intrinsic severity between successively emerging SARS-CoV-2 variants was inconsistent, reminding us that the intrinsic severity of future SARS-CoV-2 variants remains uncertain.

The SARS-CoV-2 Alpha variant was associated with increased clinical severity of COVID-19 in Scotland: A genomics-based retrospective cohort analysis

OBJECTIVES

The SARS-CoV-2 Alpha variant was associated with increased transmission relative to other variants present at the time of its emergence and several studies have shown an association between Alpha variant infection and increased hospitalisation and 28-day mortality. However, none have addressed the impact on maximum severity of illness in the general population classified by the level of respiratory support required, or death. We aimed to do this.

METHODS

In this retrospective multi-centre clinical cohort sub-study of the COG-UK consortium, 1475 samples from Scottish hospitalised and community cases collected between 1st November 2020 and 30th January 2021 were sequenced. We matched sequence data to clinical outcomes as the Alpha variant became dominant in Scotland and modelled the association between Alpha variant infection and severe disease using a 4-point scale of maximum severity by 28 days: 1. no respiratory support, 2. supplemental oxygen, 3. ventilation and 4. death.

RESULTS

Our cumulative generalised linear mixed model analyses found evidence (cumulative odds ratio: 1.40, 95% CI: 1.02, 1.93) of a positive association between increased clinical severity and lineage (Alpha variant versus pre-Alpha variants).

CONCLUSIONS

The Alpha variant was associated with more severe clinical disease in the Scottish population than co-circulating lineages.

Exploring the implementation of child life services with facility dogs

Many children's hospitals around the United States have programs in which a trained facility dog goes to work daily with a psychosocial healthcare worker, typically a Certified Child Life Specialist (CCLS). CCLSs help children and their families cope with the stress of a healthcare experience by utilizing evidence-based, developmentally appropriate interventions. The purpose of this study was to explore how CCLSs incorporate facility dogs into their treatments and gain their perspectives on handling a facility dog. Participants, four CCLSs, completed a checklist, which assessed patients seen by facility dogs for 10 workdays, and a semi-structured interview. Participants primarily saw patients of ages three to five years and aided with general anxiety and coping support. Findings indicated the dog's specific training, therapeutic value, and ability to bond with patients allowed these interactions to be successful and impactful. This study provides information about the benefits of facility dogs for child life programs and presents data for programs that are considering incorporating this therapeutic modality into their services offered.

Simultaneous identification of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis ‒ multicenter evaluation of the Alinity m STI assay

Objectives

Accurate and rapid diagnosis of sexually transmitted infections (STIs) is essential for timely administration of appropriate treatment and reducing the spread of the disease. We examined the performance of the new Alinity m STI assay, a qualitative real-time multiplex PCR test for simultaneous identification of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG), and Trichomonas vaginalis (TV) run on the fully automated Alinity m platform.

Methods

This international, multicenter study evaluated the accuracy, reproducibility, and clinical performance of the Alinity m STI assay compared to commonly used STI assays in a large series of patient samples encountered in clinical practice.

Results

The Alinity m STI assay identified accurately and precisely single and mixed pathogens from an analytical panel of specimens. The Alinity m STI assay demonstrated high overall agreement rates with comparator STI assays (99.6% for CT [n=2,127], 99.2% for NG [n=2,160], 97.1% for MG [n=491], and 99.4% for TV [n=313]).

Conclusions

The newly developed Alinity m STI assay accurately detects the 4 sexually transmitted target pathogens in various collection devices across clinically relevant specimen types, regardless of single or mixed infection status.

Improved molecular laboratory productivity by consolidation of testing on the new random-access analyzer Alinity m

Objectives

Automated molecular analyzers have accelerated diagnosis, allowing earlier intervention and better patient follow-up. A recently developed completely automated molecular analyzer, Alinity™ m (Abbott), offers consolidated, continuous, and random-access testing that may improve molecular laboratory workflow.

Methods

An international, multicenter study compared laboratory workflow metrics across various routine analyzers and Alinity m utilizing assays for human immunodeficiency virus type 1 (HIV-1), hepatitis C virus (HCV), hepatitis B virus (HBV), high-risk human papillomavirus (HR HPV), and sexually transmitted infection (STI) (Chlamydia trachomatis [CT]/Neisseria gonorrhoeae [NG]/Trichomonas vaginalis [TV]/Mycoplasma genitalium [MG]). Three turnaround times (TATs) were assessed: total TAT (sample arrival to result), sample onboard TAT (sample loading and test starting to result), and processing TAT (sample aspiration to result).

Results

Total TAT was reduced from days with routine analyzers to hours with Alinity m, independent of requested assays. Sample onboard TATs for standard workflow using routine analyzers ranged from 7 to 32.5 h compared to 2.75–6 h for Alinity m. The mean sample onboard TAT for STAT samples on Alinity m was 2.36 h (±0.19 h). Processing TATs for Alinity m were independent of the combination of assays, with 100% of results reported within 117 min.

Conclusions

The consolidated, continuous, random-access workflow of Alinity m reduces TATs across various assays and is expected to improve both laboratory operational efficiency and patient care.

Lockdown measures and relative changes in the age-specific incidence of SARS-CoV-2 in Spain

During the first months of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) epidemic in 2020, Spain implemented an initial lockdown period on 15 March followed by a strengthened lockdown period on 30 March when only essential workers continued to commute to work. However, little is known about the epidemic dynamics in different age groups during these periods.We used the daily number of coronavirus 2019 cases (by date of symptom onset) reported to the National Epidemiological Surveillance Network among individuals aged 15-19 years through 65-69 years. For each age group g, we computed the proportion PrE(g) of individuals in age group g among all reported cases aged 15-69 years during the pre-lockdown period (1-10 March 2020) and the corresponding proportion PrL(g) during two lockdown periods (initial: 25 March-3 April; strengthened: 8-17 April 2020). For each lockdown period, we computed the proportion ratios PR(g) = PrL(g)/PrE(g). For each pair of age groups g1, g2, PR(g1)>PR(g2) implies a relative increase in the incidence of detected SARS-CoV-2 infection in the age group g1 compared with g2 for the lockdown period vs. the pre-lockdown period.For the initial lockdown period, the highest PR values were in age groups 50-54 years (PR = 1.21; 95% CI: 1.12,1.30) and 55-59 years (PR = 1.19; 1.11,1.27). For the second lockdown period, the highest PR values were in age groups 15-19 years (PR = 1.26; 0.95,1.68) and 50-54 years (PR = 1.20; 1.09,1.31).Our results suggest that different outbreak control measures led to different changes in the relative incidence by age group. During the initial lockdown period, when non-essential work was allowed, individuals aged 40-64 years, particularly those aged 50-59 years, had a higher relative incidence compared with the pre-lockdown period. Younger adults/older adolescents had an increased relative incidence during the later, strengthened lockdown. The role of different age groups during the epidemic should be considered when implementing future mitigation efforts.

On the effect of age on the transmission of SARS-CoV-2 in households, schools and the community

BACKGROUND

There is limited information on the effect of age on the transmission of SARS-CoV-2 infection in different settings, including primary, secondary and high schools, households, and the whole community. We undertook a literature review of published studies/data on detection of SARS-CoV-2 infection in contacts of COVID-19 cases, as well as serological studies, and studies of infections in the school setting to examine those issues.

RESULTS

Our literature review presents evidence for significantly lower susceptibility to infection for children aged under 10 years compared to adults given the same exposure, for elevated susceptibility to infection in adults aged over 60y compared to younger/middle aged adults, and for the risk of SARS-CoV-2 infection associated with sleeping close to an infected individual. Published serological studies also suggest that younger adults (particularly those aged under 35y) often have high cumulative rates of SARS-CoV-2 infection in the community. Additionally, there is some evidence of robust spread of SARS-CoV-2 in secondary/high schools, and there appears to be more limited spread in primary schools. Some countries with relatively large class sizes in primary schools (e.g. Chile and Israel) reported sizeable outbreaks in some of those schools, though routes of transmission of infection to both students and staff are not clear from current reports.

CONCLUSIONS

Opening secondary/high schools is likely to contribute to the spread of SARS-CoV-2, and, if implemented, it should require both lower levels of community transmission and greater safeguards to reduce transmission. Compared to secondary/high schools, opening primary schools and daycare facilities may have a more limited effect on the spread of SARS-CoV-2 in the community, particularly under smaller class sizes and in the presence of mitigation measures. Efforts to avoid crowding in the classroom and other mitigation measures should be implemented, to the extent possible, when opening primary schools. Efforts should be undertaken to diminish the mixing in younger adults to mitigate the spread of the epidemic in the whole community.

Multicenter clinical evaluation of alinity m HBV assay performance

BACKGROUND

Accurate molecular methods to detect and quantify hepatitis B virus (HBV) DNA are essential to diagnose chronic infections, guide treatment decisions, assess response to treatment, and determine risk of HBV-related complications. New generations of real-time HBV DNA assay platforms provide results in less than 2-3 h, with continuous loading of specimens and true random-access capability.

OBJECTIVES

We examined the clinical performance of the new Alinity m HBV assay, run on the fully automated, continuous, random-access Alinity m platform, to accurately detect and quantify HBV DNA in a large series of patient samples infected with different HBV genotypes frequently encountered in clinical practice.

STUDY DESIGN

This international, multisite study assessed the precision and reproducibility of the Alinity m HBV assay and compared its performance to four HBV assays currently in clinical use.

RESULTS

The Alinity m HBV assay demonstrated linear quantitation of HBV DNA in plasma samples, with high precision (coefficient of variation 4.1 %-8.8 %) and reproducibility. The Alinity m HBV assay showed excellent correlation (correlation coefficients ≥0.947) with comparator HBV assays, with an overall observed bias ranging from -0.07 to 0.17 Log₁₀ IU/mL. 97 % of quantifiable patient results were <1 Log₁₀ IU/mL different than the respective comparator assays, with comparable results across HBV genotypes.

CONCLUSIONS

The newly developed real-time PCR-based Alinity m HBV assay is sensitive, reproducible, and accurately quantifies HBV DNA levels from HBsAg-positive patients across the full dynamic range of quantification.

Multicenter clinical evaluation of alinity m HCV assay performance

BACKGROUND

Nucleic acid testing is essential for the detection and quantification of HCV RNA in the diagnosis of HCV infection and treatment monitoring. The Alinity m HCV assay was recently developed by Abbott Molecular for rapid detection and quantification of HCV RNA on the fully automated, continuous, random-access Alinity m analyzer.

OBJECTIVES

Our study assessed the performance of the new Alinity m HCV assay for detection and quantification of HCV RNA in a large series of patient samples of various genotypes. This international, multicentric study evaluated the linearity, precision, and reproducibility of the Alinity m HCV assay and its performance in comparison to three other HCV assays currently used in clinical practice.

RESULTS

The Alinity m HCV assay demonstrated high linearity (correlation coefficient r = 1.00), precision (coefficients of variation [CV] 6.6-13.5 %) and reproducibility (CV 1.7-4.3 % across three control lots). At a concentration near the lower limit of detection, the Alinity m HCV assay exhibited >98 % detectability. The Alinity m HCV assay showed excellent correlation with comparator HCV assays in serum (n = 406) and plasma (n = 1401) samples (correlation coefficients ≥0.96, bias 0.01 to 0.14 Log₁₀ IU/mL). More than 95 % of the quantified results with the Alinity m HCV assay were less than mean bias ± 1.96 SD different from those of the comparator assays.

CONCLUSIONS

The newly developed Alinity m HCV assay is sensitive, reproducible, and accurately quantifies HCV RNA levels in serum and plasma samples from patients with chronic HCV infection, with no impact of HCV genotype on assay performance.

Depletion-of-susceptibles bias in influenza vaccine waning studies: how to ensure robust results

Vaccine effectiveness studies are subject to biases due to depletion-of-persons at risk of infection, or at especially high risk of infection, at different rates from different groups (depletion-of-susceptibles bias), a problem that can also lead to biased estimates of waning effectiveness, including spurious inference of waning when none exists. An alternative study design to identify waning is to study only vaccinated persons, and compare for each day the incidence in persons with earlier or later dates of vaccination to assess waning in vaccine protection as a function of vaccination time (namely whether earlier vaccination would result in lower subsequent protection compared to later vaccination). Prior studies suggested under what conditions this alternative would yield correct estimates of waning. Here we define the depletion-of-susceptibles process formally and show mathematically that for influenza vaccine waning studies, a randomised trial or corresponding observational study that compares incidence at a specific calendar time among individuals vaccinated at different times before the influenza season begins will not be vulnerable to depletion-of-susceptibles bias in its inference of waning as a function of vaccination time under the null hypothesis that none exists, and will - if waning does actually occur - underestimate the extent of waning. Such a design is thus robust in the sense that a finding of waning in that inference framework reflects actual waning of vaccine-induced immunity. We recommend such a design for future studies of waning, whether observational or randomised.

Prevalence of pre-treatment hepatitis C virus NS5A resistance associated amino-acid substitutions in genotype 1A infected patients in Scotland

BACKGROUND

Hepatitis C (HCV) NS5A resistance associated amino-acid substitutions (RAS) can exist at baseline in treatment naïve individuals and have been shown to be associated with lower rates of sustained virological response (SVR) for patients infected with HCV genotype 1A (G1A) following treatment with NS5A inhibitors.

OBJECTIVES

The aim of this study was to measure the prevalence of baseline NS5A resistance in Scotland.

STUDY DESIGN

The study population consisted of 531 treatment naïve, G1A infected patients. The patient samples were collected between March and September 2017. The NS5A region was amplified and sequenced.

RESULTS

Baseline NS5A resistance in Scotland is high (16.8%) and is comparable to rates reported by a number of previously published studies. The high rate of baseline RAS, together with the high cost of direct-acting antivirals (DAAs), supports resistance testing to guide current patient treatment. However, given the rate at which new DAAs are currently being licensed with ever broader genotype efficacy and higher SVR rates, baseline resistance testing may not be required in the near future.

CONCLUSIONS

Baseline NS5A inhibitor resistance is high. The results of the present study support performing resistance testing at baseline for current regimens.

In Vitro Activity of Eravacycline and Comparator Antimicrobials Against 143 Strains of Bacteroides Species

Background

Eravacycline (ERV is the first fully synthetic fluorocycline with activity against tetracycline (TET)-resistant organisms. In addition, it is 2–8 times more potent than tigecycline (TGC). Like other tetracyclines, it inhibits protein synthesis by binding to the 30S ribosomal subunit exhibiting a broad spectrum of activity. To further explore its activity, we tested 143 clinical isolates of Bacteroides and included TET, TGC and other drugs frequently used to treat serious infections.

Methods

Clinical isolates recovered during the past 3 years from patients in southern California were saved as pure cultures in 20% skim milk at −70°C. Prior to testing, they were transferred at least twice to ensure purity and good growth. Antimicrobials included ERV, TET, TGC, piperacillin-tazobactam (P-T), meropenem (MER), clindamycin (CLI), and metronidazole (MET). The method was agar dilution as described in the CLSI M11-A8 document for testing anaerobes using Brucella agar and incubation in the anaerobic chamber at 36°C for 44h. The MIC was defined as the lowest dilution that completely inhibited growth or resulted in a marked reduction compared with a drug-free growth control.

Results

The MIC₉₀ values (µg/ml) for Bacteroides and Parabacteroides are presented in the table:

Conclusion

This study confirmed the improved activity of ERV over TGC against Bacteroides and suggests that ERV may be an appropriate choice for infections involving these organisms.

Disclosures

E. Goldstein, Tetraphase Pharmaceuticals: Research Contractor, Research grant

Vaccine allocation in a declining epidemic

Sizeable quantities of 2009 pandemic influenza A/H1N1 (H1N1pdm) vaccine in the USA became available at the end of 2009 when the autumn wave of the epidemic was declining. At that point, risk factors for H1N1-related mortality for some of the high-risk groups, particularly adults with underlying health conditions, could be estimated. Although those high-risk groups are natural candidates for being in the top priority tier for vaccine allocation, another candidate group is school-aged children through their role as vectors for transmission affecting the whole community. In this paper, we investigate the question of prioritization for vaccine allocation in a declining epidemic between two groups-a group with a high risk of mortality versus a 'core' group with a relatively low risk of mortality but fuelling transmission in the community. We show that epidemic data can be used, under certain assumptions on future decline, seasonality and vaccine efficacy in different population groups, to give a criterion when initial prioritization of a population group with a sufficiently high risk of epidemic-associated mortality is advisable over the policy of prioritizing the core group.

Distribution of vaccine/antivirals and the 'least spread line' in a stratified population

We describe a prioritization scheme for an allocation of a sizeable quantity of vaccine or antivirals in a stratified population. The scheme builds on an optimal strategy for reducing the epidemic's initial growth rate in a stratified mass-action model. The strategy is tested on the EpiSims network describing interactions and influenza dynamics in the population of Utah, where the stratification we have chosen is by age (0-6, 7-13, 14-18, adults). No prior immunity information is available, thus everyone is assumed to be susceptible-this may be relevant, possibly with the exception of persons over 50, to the 2009 H1N1 influenza outbreak. We have found that the top priority in an allocation of a sizeable quantity of seasonal influenza vaccinations goes to young children (0-6), followed by teens (14-18), then children (7-13), with the adult share being quite low. These results, which rely on the structure of the EpiSims network, are compared with the current influenza vaccination coverage levels in the US population.

Pharmacokinetic and pharmacodynamic modelling of the novel human granulocyte colony-stimulating factor derivative Maxy-G34 and pegfilgrastim in rats

OBJECTIVES

This study aims to compare pharmacokinetics and pharmacodynamics of pegfilgrastim, a pharmaceutical recombinant human granulocyte colony-stimulating factor (rhG-CSF), with that of a newly developed reagent, Maxy-G34. This comparison was performed using rat experiments and biomathematical modelling of granulopoiesis.

METHODS

Healthy rats and those with cyclophosphamide-induced neutropenia were treated with either pegfilgrastim or Maxy-G34 under various schedules. Time courses of absolute neutrophil count (ANC) and G-CSF serum level were measured and we constructed a combined pharmacokinetic/pharmacodynamic model of both drugs. Neutropenic episodes were assessed by experimental data and model simulations.

RESULTS

Both Pegfilgrastim and Maxy-G34 showed strong dose-dependent efficacy in reducing neutropenic episodes. However, time courses of ANC and G-CSF serum levels were markedly different. The biomathematical model showed good agreement with these data. We estimated that differences between the two drugs could be explained by lower bioavailability and reduced elimination of Maxy-G34. Based on the data and model interpolations, we estimated that Maxy-G34 is superior in reducing neutropenic episodes. Also, we predicted that G-CSF administration 48 h after cyclophosphamide would be superior to its administration after 2 or 24 h, for both derivatives.

CONCLUSION

Maxy-G34 is a highly potent drug for stimulation of neutrophil production in rats. By our modelling approach, we quantified differences between Maxy-G34 and pegfilgrastim, related to pharmacokinetic parameters. Model simulations can be used to estimate optimal dosing and timing options in the present preclinical rat model.

An open-label, dose-escalating study of Maxy-G34, a novel potent, long-acting Pegylated G-CSF, compared with pegfilgrastim (PF) for the treatment of chemotherapy induced neutropenia (CIN)

e14500

Background: rhG-CSF reduces the incidence and duration of CIN in patients (pts) receiving myelosuppressive chemotherapy. Maxy-G34 is a recombinant, modified human G-CSF, containing three 5 kD PEG groups. These modifications alter both renal and receptor mediated clearance, leading to a longer half-life and the potential for enhanced activity. Phase I studies demonstrated safety of Maxy-G34 in normal volunteers with a dose dependent rapidly reversible increase in the absolute neutrophil count (ANC). The effect of Maxy-G34 on CIN was evaluated in an open-label, active-comparator controlled, dose-ranging study. Methods: The primary efficacy endpoint was duration of severe, Grade 4 neutropenia (G4N) in treatment cycle 1. Adults with high-risk Stage I-IIIa breast cancer eligible for TAC chemotherapy received Maxy-G34 at 10, 30, 45, 60 or 100 μg/kg or the active control PF 6 mg, given sub- cutaneously 24-hours after each dose of TAC for 6 cycles. Blood samples were collected daily and analyzed at a central laboratory throughout each of the 21-day chemotherapy cycles to determine ANC and evaluate PK profile of Maxy-G34. Results: All dose groups of Maxy-G34 enrolled 6 pts each, except the 100 μg/kg group (3 pts), and the PF group (8 pts). The mean durations of G4N in cycle 1 were 2.2 days for 10 μg/kg, 1.8 days for 30 μg/kg, 0.8 days for 45 μg/kg, 2.2 days for 60 μg/kg, and 1.7 days for 100 μg/kg Maxy-G34 groups vs. 2.0 days for PF. The rate of FN was 2.6% across all Maxy-G34 doses vs. 4.2% for PF. CD34+ cell counts increased across Maxy-G34 groups following recovery from nadir with maximum concentration in treatment cycle 1 ranging from 25.8 to 133.3 cells/mL versus 49.6 cells/mL for PF. The average half-life and Cmax obtained after Maxy-G34 were approximately 2-fold higher than PF. Adverse events were consistent with those reported for G-CSF and TAC with no serious unexpected adverse events. Grade 3/4 AEs for Maxy-G34 was 9.5% vs. 8.5% for PF. No neutralizing antibodies related to Maxy-G34 were observed. Conclusion: Once-per-cycle Maxy-G34 appears to be effective in reducing CIN with no new safety signals. Further Phase II studies are planned.

[Table: see text]

Genetic variation in the CHRNA5 gene affects mRNA levels and is associated with risk for alcohol dependence

Alcohol dependence frequently co-occurs with cigarette smoking, another common addictive behavior. Evidence from genetic studies demonstrates that alcohol dependence and smoking cluster in families and have shared genetic vulnerability. Recently a candidate gene study in nicotine dependent cases and nondependent smoking controls reported strong associations between a missense mutation (rs16969968) in exon 5 of the CHRNA5 gene and a variant in the 3'-UTR of the CHRNA3 gene and nicotine dependence. In this study we performed a comprehensive association analysis of the CHRNA5-CHRNA3-CHRNB4 gene cluster in the Collaborative Study on the Genetics of Alcoholism (COGA) families to investigate the role of genetic variants in risk for alcohol dependence. Using the family-based association test, we observed that a different group of polymorphisms, spanning CHRNA5-CHRNA3, demonstrate association with alcohol dependence defined by Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) criteria. Using logistic regression we replicated this finding in an independent case-control series from the family study of cocaine dependence. These variants show low linkage disequilibrium with the SNPs previously reported to be associated with nicotine dependence and therefore represent an independent observation. Functional studies in human brain reveal that the variants associated with alcohol dependence are also associated with altered steady-state levels of CHRNA5 mRNA.

Poor facial affect recognition among boys with duchenne muscular dystrophy

Children with Duchenne or Becker muscular dystrophy (MD) have delayed language and poor social skills and some meet criteria for Pervasive Developmental Disorder, yet they are identified by molecular, rather than behavioral, characteristics. To determine whether comprehension of facial affect is compromised in boys with MD, children were given a matching-to-sample test with four types of visual recognition (Object, Face, Affect, and Situation matching) developed by Lucci and Fein. Within-group analyses on 50 boys with MD found decreased Affect matching relative to the other matching conditions. Between-group comparisons on 20 sibling pairs found the boys with Duchenne performed more poorly only on the Affect-matching condition. Thus, mildly impaired facial affect recognition may be part of the phenotype associated with Duchenne or Becker MD.

The experience of long-term diagnosis with human immunodeficiency virus: a stimulus to clinical eupraxia and person-centred medicine

The biopsychosocial challenges of living with human immunodeficiency virus (HIV) have changed over time and they dictate the need for relevant medical services. The meaning of an HIV diagnosis has moved from a terminal to a manageable condition with the development of antiretrovirals, bringing profound changes to the experience of living with HIV and the meaning and use of diagnostic labels. Six biological stage-related categories in the literature of psychological medicine of HIV are critiqued. Long-term HIV highlights the inadequacy of physician-centred, acute-care medicine in chronic illness and its exclusion of preventive, psychological and rehabilitative modalities. 'Eupraxia' is presented as a conceptual framework for chronic care medicine, referring to best practice, wellbeing, best interests, and (public) welfare, through facilitated but collaborative approaches. A public-centred service model is proposed, using idiographic assessment and treatment by clinicians as patient delegates (proxies), monitoring joined-up care, providing group-based biopsychosocial treatment, facilitating autonomous and self-managing behaviour by the public, removing professional and practice hierarchies, and implementing real-time clinical and managerial accountability with public ownership and involvement. This model is superior in its health-and cost-effectiveness but can only work within a nationalized system that focuses equally on standardized outcomes and evidential and personalized health outcomes.

Investigation of Poor Academic Achievement in Children with Duchenne Muscular Dystrophy

Duchenne Muscular Dystrophy (DMD) is a neurogenetic developmental disorder that presents with progressive muscular weakness. It is caused by a mutation in a gene that results in the absence of specific products that normally localize to muscle cells and the central nervous system (CNS). The majority of affected individuals have IQs within the normal range, generally with lower verbal than performance IQ scores. Prior work has demonstrated selective deficits on tests of verbal span and immediate memory. For the current study, 26 boys with DMD (and normal intellectual function) and their unaffected siblings were evaluated. Paired comparisons demonstrated that the children with DMD had significantly poorer academic achievement scores than their siblings, even though their vocabulary levels and home and educational environments were comparable. Children with DMD also had more behavioral concerns, physical disabilities, and poorer verbal memory spans. Linear regression indicated that behavioral concerns, executive function, and physical disability did not contribute substantially to academic performance, whereas performance on verbal span did. DMD presents with a selective developmental aberration in verbal span that has wide-ranging consequences on learning skills.

A cornucopia of cycloadducts: theoretical predictions of the mechanisms and products of the reactions of cyclopentadiene with cycloheptatriene

The potential cycloaddition reactions between cyclopentadiene and cycloheptatriene have been explored theoretically. B3LYP/6-31G was used to locate the transition states, intermediates, and products for concerted pathways and stepwise pathways passing through diradical intermediates. Interconversions of various cycloadducts through sigmatropic shifts were also explored. CASPT2/6-31G single point calculations were employed to obtain independent activation energy estimates. MM3 was also used to compute reaction energetics. Several bispericyclic cycloadditions in which two cycloadducts are linked by a sigmatropic shift have been identified. B3LYP predicts, in line with frontier molecular orbital predictions, that the [6+4] cycloaddition is the favored concerted pathway, but an alternative [4+2] pathway is very close in energy. By contrast, CASPT2 predicts that a [4+2] cycloaddition is the preferred pathway. B3LYP predicts that the lowest energy path to many of the cycloadducts will involve diradical intermediates, whereas CASPT2 predicts that each of the products of orbital symmetry allowed reactions will be reached most readily by closed shell processes-concerted cycloadditions and sigmatropic shift rearrangements of cycloadducts.

Application of comparative genomic hybridization in search for genetic aberrations in fibroadenomas of the breast

We applied a comparative genomic hybridization (CGH) technique to paraffin-embedded tissue samples taken from fibroadenomas, benign breast tumors, to detect possible numerical and unbalanced genetic changes. We compared the results to those from previous cytogenetic studies of fibroadenomas. In concurrence with previous cytogenetic studies of fibroadenomas, we detected genetic aberrations in chromosomes 4-6, 8-13, 16, 18, 19, 20, and 22. In addition, with the CGH technique we were able to find two new aberrations, 15q+ and 16p-. Because these aberrations have also been reported to be present in breast cancer, the importance of this finding is yet to be determined.

In vitro activities of newer quinolones against bacteroides group organisms

The activities of BMS-284576, clinafloxacin, moxifloxacin, sitafloxacin, trovafloxacin, imipenem, cefoxitin, and clindamycin against 589 Bacteroides fragilis group isolates were determined. The activity of BMS-284576 was comparable to that of trovafloxacin. Sitafloxacin and clinafloxacin were the most active quinolones, and moxifloxacin was the least active. B. fragilis was the most susceptible of the species, and Bacteroides vulgatus was the most resistant. Association of specific antibiotic resistance with Bacteroides species was noted for all quinolones.

Reporting of CAHPS quality information to medicare beneficiaries

OBJECTIVES

To assess which Consumer Assessment of Health Plans (CAHPS) survey measures Medicare beneficiaries find the most meaningful, how beneficiaries and information intermediaries interpret different formats for presenting CAHPS information, and how beneficiaries have reacted to the CAHPS information included in the annual mailing to beneficiaries called Medicare & You 2000.

DATA SOURCES

Fourteen focus groups of beneficiaries and State Health Insurance Assistance Program counselors, more than 200 cognitive interviews, and 122 mall-intercept interviews with beneficiaries were conducted from spring 1998 through winter 2000.

STUDY DESIGN

In 1998 focus groups and cognitive interviews were conducted with Medicare beneficiaries and State Health Insurance Assistance Program counselors to determine which CAHPS measures to report to Medicare beneficiaries and how to report this information. In 1999 additional focus groups and mall-intercept interviews were conducted to determine which measures to include in Medicare & You 2000. To obtain feedback on the CAHPS information in Medicare & You 2000 additional focus groups were conducted in winter 2000.

PRINCIPAL FINDINGS

Focus group participants indicated that getting the care they need quickly, having access to specialists, and communicating well with doctors were more important to them than nonmedical characteristics of plans. Most beneficiaries had problems interpreting quality information. Many misinterpreted star charts, and while bar charts appear easier to read, many beneficiaries still had trouble interpreting the information on these charts. Most beneficiaries did not consider quality information important to them and most were unaware of the availability of CAHPS information.

CONCLUSIONS

Many challenges lie ahead in making quality information meaningful to Medicare beneficiaries. These challenges include increasing awareness of the existence of this information, educating beneficiaries about how this information can help in choosing a health plan, continuing to simplify reporting formats, assuring beneficiaries that this information comes from a credible source, and providing guidance to beneficiaries about how quality information can help with health care decisions.

Use of Medicaid 1915(c) home- and community-based care waivers to reconfigure state long-term care systems

Since Congressional authorization in 1981, Medicaid 1915(c) home- and community-based care waivers have influenced states' efforts to transform their long-term care systems. In 1997, every state participated in the 1915(c) waiver program, while waiver expenditures, at $8.1 billion, represented 59.6 percent of all Medicaid community-based care expenditures. To explore state-level factors that appear related to these expenditures, the authors turn to a body of work on Medicaid resource allocation. They compare the influence of five factors--sociodemographic, supply, economic, programmatic, and political environment--on states' allocations to long-term care expenditures and 1915(c) waiver expenditures. The state economic environment was an important influence on total, as well as waiver expenditures. State regulation of long-term care supply demonstrated the most substantive relationship, increasing the share of dollars supporting 1915(c) waivers from 11.6 to 20.0 over the study period, all else equal.

Screening and surveillance colonoscopy in chronic Crohn's colitis

BACKGROUND & AIMS

Unlike ulcerative colitis, there are few reports on the efficacy of surveillance colonoscopy in patients with chronic Crohn's colitis and therefore little agreement as to whether routine surveillance is indicated. We report on 259 patients with chronic Crohn's colitis who underwent screening and subsequent surveillance colonoscopy and biopsy since 1980.

METHODS

Biopsies were performed at 10-cm intervals and from strictures and polypoid masses. Pathology was classified as normal, dysplasia (indefinite, low-grade, high-grade), or carcinoma.

RESULTS

A total of 663 examinations were performed on 259 patients. The median interval between examinations was 24 months; examinations were performed more frequently (1-6 months) in patients with dysplasia on biopsy. A thinner-caliber colonoscope was required to complete 12% of screening examinations and 23% of surveillance examinations. The pediatric colonoscope helped increase our yield of neoplasia by 19%. The screening and surveillance program detected dysplasia or cancer in 16% (10 indefinite, 23 low-grade, and 4 high-grade dysplasias and 5 cancers). A finding of definite dysplasia or cancer was associated with age >45 years and increased symptoms. By life table analysis, the probability of detecting dysplasia or cancer after a negative screening colonoscopy was 22% by the fourth surveillance examination.

CONCLUSIONS

Colonoscopic surveillance should be strongly considered in chronic extensive Crohn's colitis.

Lessons learned from the National Medicare & You Education Program

In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH).

Selective deficits in verbal working memory associated with a known genetic etiology: the neuropsychological profile of duchenne muscular dystrophy

Forty-one boys diagnosed with Duchenne muscular dystrophy (DMD) were each compared to an unaffected sibling on a battery of neuropsychological tests. Verbal. visuospatial, attention/memory, abstract thinking, and academic achievement skills were tested. Results indicated the boys with DMD performed similarly to their siblings on the majority of measures, indicating intact verbal, visuospatial, long-term memory, and abstract skills. However, the DMD group did significantly more poorly than their siblings on specific measures of story recall, digit span, and auditory comprehension, as well as in all areas of academic achievement (reading, writing, and math). This profile indicates that verbal working memory skills are selectively impaired in DMD, and that that likely contributes to limited academic achievement. The association between the known impact of the genetic mutation on the development of the central nervous system and boys' cognitive profile is discussed.

Poor verbal working memory across intellectual level in boys with Duchenne dystrophy

OBJECTIVE

To determine whether all boys with Duchenne muscular dystrophy (DMD) have a similar verbal and memory profile of skills, or whether only a subset is affected, and to determine whether the weak areas in their profile are substantially different from a control group.

METHODS

Performance of patients with DMD on neuropsychological tests of verbal and memory skills was examined in two ways. Standardized test scores for 80 boys with DMD (estimated IQ range, 70 to 160) were ranked individually from worst to best, and the individual rankings were compared across the group using Friedman rank analysis. Additionally, performance of 41 boys with DMD was compared with that of their sibling control subjects of similar age and estimated IQ using multivariate analysis of variance.

RESULTS

Individual cognitive profiles were significantly similar among the subjects with DMD, such that for most subjects digit span, story recall, and comprehension were the tests on which each performed most poorly. This finding remained true regardless of whether they were of high or low intellectual function. In contrast, no significant cognitive profile was found among their sibling control subjects, and when compared with their siblings, the DMD group scored significantly more poorly on digit span, comprehension, and story recall, but not on other verbal and memory measures.

CONCLUSIONS

Boys with DMD have a specific cognitive profile, regardless of their general level of cognitive function. Specifically, boys with DMD performed more poorly on tests requiring attention to complex verbal information than they did on other verbal or memory measures. The possibility that the missing dystrophin brain products may contribute to selective cognitive processing is considered.

Minimal heparinization in coronary angioplasty--how much heparin is really warranted?

The purpose of the study was to assess the results of percutaneous transluminal coronary angioplasty (PTCA), performed with a single intravenous bolus of 2,500 U of heparin, in a nonemergency PTCA cohort. Three hundred of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the study. They received heparin, 2,500-U intravenous bolus, before PTCA, with intention of no additional heparin administration. Patient and lesion characteristics as well as PTCA results were evaluated independently by 2 physicians. Patients were followed up by structured telephone questionnaires at 1 and 6 months after PTCA. Mean activated clotting time obtained 5 minutes after heparin administration was 185+/-19 seconds (range 157 to 238). There were 3 (1%) in-hospital major adverse cardiovascular events: 2 deaths (0.66%), 1 (0.33%) Q-wave myocardial infarction. Emergency coronary surgery and stroke were not reported. Six patients (2%) experienced abrupt coronary occlusion within 14 days after PTCA, warranting repeat target vessel revascularization. Angiographic and clinical success were achieved in 96% and 93.3%, respectively. No bleeding or vascular complications were recorded. Six-month follow-up (184 patients) revealed 3 cardiac deaths (1 arrhythmic, 2 after cardiac surgery), 1 Q-wave myocardial infarction, and 9.7% repeat target vessel revascularization. This study suggests that very low doses of heparin and reduced activated clotting time target values are safe in non-emergency PTCA, and can reduce bleeding complications, hospital stay, and costs. Larger, randomized, double-blind heparin dose optimization studies need to confirm this notion.

Colonoscopic polypectomy in chronic colitis: conservative management after endoscopic resection of dysplastic polyps

BACKGROUND & AIMS

Adenomatous polyps are by definition dysplastic and pathologically indistinguishable from the dysplasia-associated lesion or mass (DALM) described in 1981. Yet, adenomatous polyps in noncolitic colons are usually removed definitively endoscopically, whereas DALMs are regarded as harbingers of colon cancer, mandating colectomy.

METHODS

Since 1988, all of our patients with chronic ulcerative or Crohn's colitis and dysplastic polyps and no coexistent dysplasia in flat mucosa underwent colonoscopic polypectomy. Biopsy specimens were obtained also adjacent to polypectomy sites, from strictures, and throughout the colon at 10-cm intervals. Follow-up colonoscopies and biopsies were performed within 6 months after polypectomy and yearly thereafter.

RESULTS

Colonoscopy in 48 patients with chronic colitis (mean duration, 25.4 years) resected 70 polyps (60 in colitic and 10 in noncolitic mucosa). Polyps were detected on screening colonoscopies (29%) and on surveillance (71%). Pathology was tubular adenoma in all polyps from noncolitic mucosa and low-grade dysplasia (57), high-grade dysplasia (2), or carcinoma (1) in polyps from colitic mucosa. Subsequent colonoscopies (mean follow-up, 4.1 years) revealed additional polyps in 48% but no carcinomas. Surgical resection (6 patients) for recurrent polyps confirmed colonoscopic findings. No dysplasia or cancers in flat mucosa were found at surgery or on follow-up colonoscopies.

CONCLUSIONS

In patients with chronic colitis who have no dysplasia in flat mucosa, colonoscopic resection of dysplastic polyps can be performed effectively, just as in noncolitic colons.

Comparison of human sera reactivities in immunoblots with recombinant human herpesvirus (HHV)-8 proteins associated with the latent (ORF73) and lytic (ORFs 65, K8.1A, and K8.1B) replicative cycles and in immunofluorescence assays with HHV-8-infected BCBL-1 cells

The development of reliable, sensitive, and specific serological methods for the detection of human herpesvirus-8 (HHV-8) antibodies is critical for a thorough understanding of HHV-8 prevalence and pathogenesis. To evaluate the potential usefulness of HHV-8 proteins in measuring the responses against both latent and lytic antigens, we selected 1 latent [open reading frame (ORF) 73] antigen and 3 HHV-8 lytic antigens (ORFs 65, K8.1A, and K8.1B) previously identified as immunogenic [Virology (1998) 243, 208-217]. Full-length genomic ORF 73 and full-length ORFs 65, K8.1A, and K8.1B from the cDNA clones were cloned, expressed in bacterial and baculovirus-insect cell expression systems, and purified as GST fusion proteins. These recombinant proteins were used in Western blot reactions to test sera from 104 human immunodeficiency virus (HIV)+/Kaposi's sarcoma (KS)+ homosexual men, 77 HIV+/KS- homosexual men, and 84 age-matched HIV-/KS- men. These sera were also tested in immunofluorescence assays (IFAs) with uninduced and 12-O-tetradecanoylphorbol-13-acetate-induced B cell lymphoma-1 cells to detect antibodies against latency-associated nuclear antigens (LANA) and antibodies against lytic antigens (cytoplasmic fluorescence). These sera exhibited differential reactivities reflecting different titers of antibodies against HHV-8 proteins, and variable reactivities were seen more commonly with the sera from HIV-/KS- adult men. In the Western blot assay, 89% (93 of 104) of HIV+/KS + sera, 60% (46 of 77) of HIV+/KS- sera, and 7% (6 of 84) HIV+/KS- sera were reactive with both latent and lytic recombinant antigens. Western blot reactions with ORF 73 protein were more sensitive than LANA-IFA results. The lytic IFA and lytic Western blot (ORFs 65 and K8.1A) assays were more sensitive than the ORF 73 Western blots and LANA-IFA. With an exception of 2 sera from the HIV-/KS- group, all sera positive for lytic IFA antibodies and ORF 65 and K8.1A antibodies were also positive for latent antibodies. With few exceptions, sera positive for ORF 65 antibodies were also positive for K8.1A antibodies, and sera recognized the K8.1A protein more often than the K8.1B protein. There is a high degree of concordance between IFA and Western blot reactions, suggesting that this panel of HHV-8 recombinant proteins could detect a majority of the HHV-8-seropositive individuals. These results suggest that IFA followed by confirmation with the Western blot reactions with a panel of latent and lytic immunogenic antigens would provide a reliable, sensitive, and specific method for the detection of HHV-8 antibodies.

Collaborative community research consortium: a model for HIV prevention

In 1991, the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco, set out to develop a model of community collaborative research that would bring the skills of science to the service of HIV prevention and the knowledge of service providers into the domain of research. Essential elements of the model were training for community-based organizations (CBOs) in research protocol writing, partnership between CBOs and CAPS researchers, program research funding, support to implement studies and analyze results, and a program manager to oversee the effort and foster the relationships between CBOs and researchers. In this article, the authors describe the CAPS model of consortium-based community collaborative research. They also introduce a set of papers, written by researchers and service providers, that describes collaborative research projects conducted by research institutions and CBOs and illustrates how collaboration can change both HIV prevention research and service.