Nurse-led immunotreatment DEcision Coaching In people with Multiple Sclerosis (DECIMS) - A cluster- randomised controlled trial and mixed methods process evaluation

OBJECTIVE

To evaluate a nurse-led decision coaching programme aiming to redistribute health professionals' tasks to support immunotherapy decision-making in people with multiple sclerosis (MS).

METHODS

Cluster-randomised controlled trial with an accompanying mixed methods process evaluation (2014 - 2018). We planned to recruit 300 people with clinically isolated syndrome or relapsing-remitting MS facing immunotherapy decisions in 15 clusters across Germany. Participants in the intervention clusters received up to three decision coaching sessions by a trained nurse and access to an evidence-based online information platform. In the control clusters, participants also had access to the information platform. The primary outcome was informed choice after six months, defined as good risk knowledge and congruent attitude and uptake.

RESULTS

Twelve nurses from eight clusters participated in the decision coaching training. Due to insufficient recruitment, the randomised controlled trial was terminated prematurely with 125 participants (n = 42 intervention clusters, n = 83 control clusters). We found a non-significant difference between groups for informed choice favouring decision coaching: odds ratio 1.64 (95% CI 0.49-5.53).

CONCLUSIONS

Results indicate that decision coaching might facilitate informed decision-making in MS compared to providing patient information alone.

PRACTICE IMPLICATIONS

Barriers have to be overcome to achieve structural change and successful implementation.

Safety, Efficacy, and Biomarker Analyses of Dostarlimab in Patients with Endometrial Cancer: Interim Results of the Phase I GARNET Study

PURPOSE

This interim report of the GARNET phase I trial presents efficacy and safety of dostarlimab in patients with advanced or recurrent endometrial cancer (EC), with an analysis of tumor biomarkers as prognostic indicators.

PATIENTS AND METHODS

A total of 153 patients with mismatch repair deficient (dMMR)/microsatellite instability-high (MSI-H) and 161 patients with mismatch repair proficient (MMRp)/microsatellite stable (MSS) EC were enrolled and dosed. Patients received 500 mg dostarlimab every 3 weeks for four cycles, then 1,000 mg every 6 weeks until progression. Primary endpoints were objective response rate (ORR) and duration of response (DOR).

RESULTS

A total of 143 patients with dMMR/MSI-H EC and 156 patients with MMRp/MSS EC were evaluated for efficacy. ORR was 45.5% (n = 65) and 15.4% (n = 24) for dMMR/MSI-H EC and MMRp/MSS EC, respectively. Median DOR for dMMR/MSI-H EC was not met (median follow-up, 27.6 months); median DOR for MMRp/MSS EC was 19.4 months. The ORRs by combined positive score (CPS) ≥1 status were 54.9% and 21.7% for dMMR/MSI-H EC and MMRp/MSS EC, respectively. ORRs by high tumor mutational burden (≥10 mutations/Mb) were 47.8% (43/90) and 45.5% (5/11) for dMMR/MSI-H EC and MMRp/MSS EC, respectively. ORR in TP53mut or POLεmut molecular subgroups was 18.1% (17/94) and 40.0% (2/5), respectively. The safety profile of dostarlimab was consistent with previous reports.

CONCLUSIONS

Dostarlimab demonstrated durable antitumor activity and safety in patients with dMMR/MSI-H EC. Biomarkers associated with EC may identify patients likely to respond to dostarlimab. See related commentary by Jangra and Dhani, p. 4521.

Antitumor Activity and Safety of Dostarlimab Monotherapy in Patients With Mismatch Repair Deficient Solid Tumors: A Nonrandomized Controlled Trial

Importance

Mismatch repair deficiency (dMMR) occurs in various cancers, and these tumors are attractive candidates for anti-programmed cell death 1 therapies, such as dostarlimab, a recently approved immune checkpoint inhibitor.

Objective

To assess the antitumor activity and safety of dostarlimab in patients with advanced or recurrent dMMR solid tumors.

Design, Setting, And Participants

The GARNET trial was a phase 1, open-label, single-group, multicenter study that began enrolling May 8, 2017. Participants had advanced or recurrent dMMR and microsatellite instability-high (MSI-H) or polymerase epsilon (POLE)-altered solid tumors. The data cut for this interim analysis was from November 1, 2021, with median follow-up of 27.7 months.

Interventions

Patients received 500 mg of dostarlimab intravenously every 3 weeks for 4 doses, then 1000 mg every 6 weeks until disease progression, discontinuation, or withdrawal.

Main Outcomes and Measures

The primary objective was to evaluate objective response rate and duration of response in patients with dMMR solid tumors by blinded independent central review using Response Evaluation Criteria in Solid Tumors, version 1.1.

Results

The efficacy population included 327 patients (median [range] age, 63 [24-85] years; 235 [71.9%] female; 7 [2.1%] Asian, 6 [1.8%] Black, and 206 [63.0%] White patients), with 141 patients (43.1%) with dMMR endometrial cancer, 105 patients (32.1%) with dMMR colorectal cancer, and 81 patients (24.8%) with other dMMR tumor types. All patients had at least 1 previous line of therapy. Objective response rate assessed per blinded independent central review for dMMR solid tumors was 44.0% (95% CI, 38.6% to 49.6%). Median duration of response was not reached (range, ≥1.18 to ≥47.21 months); 72.2% of responders (104 of 144) had a response lasting 12 or more months. Median progression-free survival was 6.9 months (95% CI, 4.2 to 13.6 months); probability of progression-free survival at 24 months was 40.6% (95% CI, 35.0% to 46.1%). Median overall survival was not reached (95% CI, 31.6 months to not reached). The most frequent immune-related adverse events were hypothyroidism (25 [6.9%]), alanine aminotransferase increase (21 [5.8%]), and arthralgia (17 [4.7%]). No new safety concerns were identified.

Conclusions And Relevance

In this nonrandomized controlled trial, dostarlimab was a well-tolerated treatment option with rapid, robust, and durable antitumor activity in patients with diverse dMMR solid tumors. These findings suggest that dostarlimab provides meaningful long-term benefit in a population with high unmet need.

Trial Registration

ClinicalTrials.gov Identifier: NCT02715284.

Time to Cure for Childhood and Young Adult Acute Lymphoblastic Leukemia Is Independent of Early Risk Factors: Long-Term Follow-Up of the UKALL2003 Trial

PURPOSE

The aim of the randomized trial, UKALL2003, was to adjust treatment intensity on the basis of minimal residual disease (MRD) stratification for children and young adults with acute lymphoblastic leukemia. We analyzed the 10-year randomized outcomes and the time for patients to be considered cured (ClinicalTrials.gov identifier: NCT00222612).

METHODS

A total of 3,113 patients were analyzed including 1,054 patients who underwent random assignment (521 MRD low-risk and 533 MRD high-risk patients). Time to cure was defined as the point at which the chance of relapse was < 1%. The median follow-up time was 10.98 (interquartile range, 9.19-13.02) years, and survival rates are quoted at 10 years.

RESULTS

In the low-risk group, the event-free survival was 91.7% (95% CI, 87.4 to 94.6) with one course of delayed intensification versus 93.7% (95% CI, 89.9 to 96.1) with two delayed intensifications (adjusted hazard ratio, 0.73; 95% CI, 0.38 to 1.40; P = .3). In the high-risk group, the event-free survival was 82.1% (95% CI, 76.9 to 86.2) with standard therapy versus 87.1% (95% CI, 82.4 to 90.6) with augmented therapy (adjusted hazard ratio, 0.68; 95% CI, 0.44 to 1.06; P = .09). Cytogenetic high-risk patients treated on augmented therapy had a lower relapse risk (22.1%; 95% CI, 15.1 to 31.6) versus standard therapy (52.4%; 95% CI, 28.9 to 80.1; P = .016). The initial risk of relapse differed significantly by sex, age, MRD, and genetics, but the risk of relapse for all subgroups quickly coalesced at around 6 years after diagnosis.

CONCLUSION

Long-term outcomes of the UKALL2003 trial confirm that low-risk patients can safely de-escalate therapy, while intensified therapy benefits patients with high-risk cytogenetics. Regardless of prognosis, the time to cure is similar across risk groups. This will facilitate communication to patients and families who pose the question "When am I/is my child cured?"

Safety and Efficacy of Dostarlimab in Patients With Recurrent/Advanced Non-small Cell Lung Cancer: Results from Cohort E of the Phase I GARNET Trial

BACKGROUND

Dostarlimab is an anti-programmed cell death protein-1 antibody being evaluated in recurrent/advanced solid tumors, including non-small cell lung cancer (NSCLC), in the ongoing Phase I, multi-center, open-label, 2-part (dose escalation and cohort expansion) GARNET study (NCT02715284).

MATERIALS AND METHODS

Here, we report an interim analysis of patients with recurrent/advanced NSCLC who progressed following platinum-based chemotherapy. Patients received dostarlimab (500 mg IV every 3 weeks [Q3W] for Cycles 1-4, then 1000 mg Q6W) until disease progression or unacceptable toxicity for > 2 years. The primary endpoints were immune-related objective response rate (irORR) per investigator-assessed irRECIST and safety.

RESULTS

As of 8, July 2019, 67 patients with recurrent/advanced NSCLC were enrolled and treated with dostarlimab; the majority had programmed death ligand 1 (PD-L1) tumor proportion score (TPS) < 1% (35.8% of patients) or PD-L1 TPS 1%-49% (29.9% of patients); 7.5% had PD-L1 TPS ≥ 50%, and 26.9% had unknown PD-L1 TPS status. Median follow-up was 13.8 months (range: 0.0-22.6). irORR was 26.9%, including 2 complete and 16 partial responses. The median duration of response of 11.6 months (range: 2.8-19.4). Responses were observed in 2 of 24 (16.7%) patients with PD-L1 TPS < 1%, 4 of 20 (20.0%) patients with PD-L1 TPS 1%-49% and 2 of 5 (40.0%) patients with PD-L1 TPS ≥ 50%. Fatigue (4.5%) was the most common Grade ≥ 3 treatment-related treatment-emergent adverse event (TRAE). Immune-related TRAEs (any grade) were observed in 28.4% of patients.

CONCLUSION

Dostarlimab demonstrated promising antitumor activity in advanced/recurrent NSCLC that progressed following platinum-based chemotherapy, including across all PD-L1 subgroups, and has an acceptable safety profile.

Continuous up skilling of teaching faculty for competency building: during and post pandemic

It is always a proven statement that the education industry keeps growing and it has been witnessed a reflectivetransformation in the meadow of edification. Swiftprogress and skill augmentation for teachers are the need of the hour. Chalk and Talk Method, so called conventional teaching have distorted into smart boards, interactive teaching and virtual reality and augmented reality mode of teaching. Access to innovative tools and technology has made education expedienttransversely in all platforms. This study has envisaged the real impact of Covid’19 towards the continuous up skilling of the teaching faculty irrespective of their disciplines. A sample size of 182 teaching professionals of Engineering and Arts and Science in growing institutions of Coimbatore City has been included for the study. A well structured questionnaire was framed and distributed among the teaching community and the data is analyzed through descriptive statistics. The pandemic has made a drastic change in all the fields, especially education as the teachers perception towards teaching mode has transformed from conventional to contemporary in most of the prominent cases.

Abstract 5135: Antitumor activity of dostarlimab by PD-L1 and tumor mutation burden (TMB) in patients (pts) with mismatch repair deficient and proficient (dMMR and MMRp) tumors in the GARNET trial

Background: Dostarlimab is a programmed death 1 (PD-1) inhibitor approved as monotherapy in pts with dMMR recurrent/advanced endometrial cancer (EC) that has progressed on or following treatment with a platinum-containing regimen or solid tumors that have progressed on or following prior treatment, with no satisfactory alternative treatment options. Here we report on a post-hoc analysis of antitumor activity by PDL1 expression and TMB in pts with dMMR and MMRp solid tumors in the GARNET trial.

Methods: GARNET (NCT02715284) is a phase 1, multicenter, open-label, single-arm study of dostarlimab in pts with advanced/recurrent solid tumors. Three expansion cohorts enrolled pts based on MMR status: dMMR (A1) and MMRp (A2) advanced/recurrent EC, and dMMR non-EC solid tumors (F). Pts received dostarlimab 500 mg IV Q3W for 4 cycles, then 1000 mg IV Q6W until progression or discontinuation. TMB and PDL1 were exploratory biomarkers. TMB status was determined by Foundation One test; TMB-high (TMB-H) was defined as ≥10 mutations/Mb. PDL1 expression was determined by combined positive score (CPS) by Ventana assay; PDL1-high (PDL1-H) was defined as CPS ≥1. The study was not powered to assess antitumor activity within subgroups.

Results: TMB-H and PDL1-H were common in dMMR solid tumors; PDL1-H was observed in 39.4% of MMRp EC tumors (Table). Objective response rate (ORR) was higher in pts with TMB-H/PDL1-H tumors (55.6% for all cohorts, combined; Table). Safety for each cohort was previously reported.1

Conclusions: PDL1-H and TMB-H were frequently observed in the dMMR EC and non-EC cohorts, regardless of tumor type; PDL1-H was also prevalent in MMRp EC tumors. Although not powered to assess antitumor activity, ORR by BICR per RECIST v1.1 was higher in pts with TMB-H and PDL1-H solid tumors. Across cohorts, dMMR status was predictive of response.

1.Andre T, et al. Ann Oncol 2021;32(suppl 5):S829-S866. 991P.

Table A1(dMMR EC)N=103 F(dMMR non-EC)N=106 A1+F(dMMR combined)N=209 A2(MMRp EC)N=142 A1+A2+F (Total)N=351 Biomarker distribution, n (%) TMB High 85 (82.5) 79 (74.5) 164 (78.5) 9 (6.3) 173 (49.3) Low 13 (12.6) 9 (8.5) 22 (10.5) 129 (90.8) 151 (43.0) Unknown 5 (4.9) 18 (17.0) 23 (11.0) 4 (2.8) 27 (7.7) PD-L1 High 56 (54.4) 52 (49.1) 108 (51.7) 56 (39.4) 164 (46.7) Low 23 (22.3) 17 (16.0) 40 (19.1) 45 (31.7) 85 (24.2) Unknown 24 (23.3) 37 (34.9) 61 (29.2) 41 (28.9) 102 (29.1) ORR by BICR per RECIST v1.1, n/N (%, 95% CI)a Overall 46/103(44.7, 34.9–54.8) 41/106(38.7, 29.4–48.6) 87/209(41.6, 34.9–48.6) 19/142(13.4, 8.3–20.1) — TMB-L/PDL1-L (L/L) 1/5(20.0, 0.5–71.6) 1/3 (33.3, 0.8–90.6) 2/8(25.0, 3.2–65.1) 2/43(4.7, 0.6–15.8) 4/51(7.8, 2.2–18.9) TMB-L/PDL1-H (L/H) 2/5(40.0, 5.3–85.3) 1/2(50.0, 1.3–98.7) 3/7(42.9, 9.9–81.6) 7/50(14.0, 5.8–26.7) 10/57(17.5, 8.7–29.9) TMB-H/PDL1-L (H/L) 5/17(29.4, 10.3–56.0) 3/14(21.4, 4.7–50.8) 8/31(25.8, 11.9–44.6) 0/1(0, 0–97.5) 8/32(25.0, 11.5–43.4) TMB-H/PDL1-H (H/H) 29/50(58.0, 43.2–71.8) 22/43(51.2, 35.5–66.7) 51/93(54.8, 44.2–65.2) 4/6(66.7, 22.3–95.7) 55/99(55.6, 45.2–65.5) aOnly those pts with both known TMB status and known CPS were included in ORR calculations

Citation Format: Thierry André, Susana Banerjee, Dominique Berton, Susan L. Ellard, Begoña Jimenez, Vanessa Samouëlian, Lucy Gilbert, Valentina Boni, Xinwei Han, Grace Antony, Jennifer Veneris, Ana Oaknin. Antitumor activity of dostarlimab by PD-L1 and tumor mutation burden (TMB) in patients (pts) with mismatch repair deficient and proficient (dMMR and MMRp) tumors in the GARNET trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5135.

Genetic characterisation of childhood B-other-acute lymphoblastic leukaemia in UK patients by fluorescence in situ hybridisation and Multiplex Ligation-dependent Probe Amplification

While next-generation sequencing technologies provide excellent strategies to screen for newly defined genetic abnormalities of prognostic or therapeutic significance in patients with B-other-acute lymphoblastic leukaemia (ALL), they are not widely available. We used a dual screening approach, incorporating fluorescence in situ hybridisation (FISH) and Multiplex Ligation-dependent Probe Amplification (MLPA), to establish the frequency and long-term outcome of a representative cohort of specific subgroups of B-other-ALL recruited to the childhood ALL trial, UKALL2003. We focussed on abnormalities of known prognostic significance, including ABL-class fusions and ERG deletions, as a surrogate marker for DUX4-rearranged ALL. ABL-class fusions accounted for ~4% of B-other-ALL and were associated with high levels of minimal residual disease (MRD; 14/23 with MRD >5%) and a high relapse rate (55·7%) following treatment without tyrosine kinase inhibitor (TKI), confirming the importance of prospective screening with a view to incorporating TKI into therapy. Patients with deletions of ERG (~10% of B-other-ALL) had a 10-year event-free-survival of 97·2%, validating previous reports of their excellent outcome. Rearrangements of ZNF384, MEF2D and NUTM1 were observed at low frequencies. Here, we estimate that approximately one third of B-other-ALL patients can be reliably classified into one of the known genetic subgroups using our dual screening method. This approach is rapid, accurate and readily incorporated into routine testing.

HIA on lockdown and social distancing to contain the COVID-19 pandemic in Austria – results and lessons learned

The COVID-19 pandemic and the measures taken created opportunities in various areas of life, but also created new challenges or increased existing ones, which can also have a (direct or indirect) impact on health and well-being of the population or certain population groups. This health impact assessment (HIA) was commissioned to provide an overview of these effects. The foundation of gathering information for the impact assessment was a national literature research and analysis combined with an online survey. In addition, a search of international literature was conducted by the European Observatory on Health Systems and Policies. The impact assessment and an initial collection of recommendations for action were carried out together with relevant stakeholders in the context of several thematically merged online assessment workshops. Positive and negative - direct as well as indirect - impacts on health in different areas of life could be identified, with the negative impacts predominating in proportion. In addition to identifying the impacts, the HIA also identified groups that were particularly affected by the pandemic. In the course of this HIA, it became clear that the direct in indirect health impacts in many areas of life are interrelated (e. g., job loss, family climate, social inclusion, and psychological well-being) and that a separate discussion often fell short. This HIA provides an overview of various impacts and allows first impressions on actions for future measures in regard to the pandemic in various areas of life, according to the HiAP approach.

Assessing the health impact of staying at home, social distancing and lockdown measures during the Covid-19 epidemic

Objectives

To systematically review the evidence published in systematic reviews on the health impact of staying at home, social distancing and lockdown measures.

Study design

We followed a systematic review approach, in line with PRISMA guidelines.

Methods

In October 2020, we searched the databases Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase, and Web of Science, using a pre-defined search strategy.

Results

The literature search yielded an initial list of 2172 records. After screening of titles and abstracts, followed by full-text screening, 51 articles were retained and included in the analysis. All of them referred to the first wave of the COVID-19 pandemic. The direct health impact that was covered in the greatest number (25) of systematic reviews related to mental health, followed by 13 systematic reviews on healthcare delivery(1-13)(1-13)(1-13), and 12 on infection control. The predominant areas of indirect health impacts covered by the included studies relate to the economic and social impacts (15 and 7 articles respectively. Only 3 articles mentioned the negative impact on education.

Conclusions

The focus of systematic reviews so far has been uneven, with mental health receiving the most attention. The impact of measures to contain the spread of the virus can be direct and indirect, having both intended and unintended consequences.

Outcome monitoring of the Austrian health targets

Background

The ten Austrian Health Targets, developed in a Health-in-All-Policies process and adopted in 2012 with a time horizon until 2032, are monitored by a series of indicators. The (interim) results are reported regularly.

Methods

Indicators were discussed intensively with experts and defined in advance. The outcome monitoring enables to observe developments over time, to analyse differences by gender, education and region, and comparisons with other EU-countries. For each indicator an overall qualitative assessment is done. This makes monitoring very comprehensive. The challenge is to communicate the monitoring results in an easily understandable way. Therefore, besides reports and presentations further in depth-discussions about communication formats with decision makers were required.

Results

The outcome monitoring shows that there is potential for development in all areas: Between 2006 and 2014 only 25 % of the outcome-indicators developed positively. As far as equal opportunities are concerned, the most improvements were seen in gender differences, significantly less for educational differences and hardly any positive developments in regional differences. In an EU comparison, Austria performs well concerning 15 out of 35 indicators (43 %). However, for some indicators - contrary to the EU trend - no improvements can be observed.

Conclusions

The results confirm the relevance of the ten health targets and identify whole-of-society areas for action. The monitoring provides steering impulses and information enabling decision-making for politics, administration, the health target plenary, and the intersectoral working groups.

Key messages

The monitoring contributes to strategic steering, helps optimising strategy and action plans and enhancing the overall process. Stakeholder involvement is important for development of a format to communicate the results in the best comprehensible way.

The SCottish Alcoholic Liver disease Evaluation: A Population-Level Matched Cohort Study of Hospital-Based Costs, 1991-2011

Studies assessing the costs of alcoholic liver disease are lacking. We aimed to calculate the costs of hospitalisations before and after diagnosis compared to population controls matched by age, sex and socio-economic deprivation. We aimed to use population level data to identify a cohort of individuals hospitalised for the first time with alcoholic liver disease in Scotland between 1991 and 2011.Incident cases were classified by disease severity, sex, age group, socio-economic deprivation and year of index admission. 5 matched controls for every incident case were identified from the Scottish population level primary care database. Hospital costs were calculated for both cases and controls using length of stay from morbidity records and hospital-specific daily rates by specialty. Remaining lifetime costs were estimated using parametric survival models and predicted annual costs. 35,208 incident alcoholic liver disease hospitalisations were identified. Mean annual hospital costs for cases were 2.3 times that of controls pre diagnosis (£804 higher) and 10.2 times (£12,774 higher) post diagnosis. Mean incident admission cost was £6,663. Remaining lifetime cost for a male, 50–59 years old, living in the most deprived area diagnosed with acoholic liver disease was estimated to be £65,999 higher than the matched controls (£12,474 for 7.43 years remaining life compared to £1,224 for 21.8 years). In Scotland, alcoholic liver disease diagnosis is associated with significant increases in admissions to hospital both before and after diagnosis. Our results provide robust population level estimates of costs of alcoholic liver disease for the purposes of health-care delivery, planning and future cost-effectiveness analyses.

Scottish Keep Well health check programme: an interrupted time series analysis

BACKGROUND

Effective interventions are available to reduce cardiovascular risk. Recently, health check programmes have been implemented to target those at high risk of cardiovascular disease (CVD), but there is much debate whether these are likely to be effective at population level. This paper evaluates the impact of wave 1 of Keep Well, a Scottish health check programme, on cardiovascular outcomes.

METHODS

Interrupted time series analyses were employed, comparing trends in outcomes in participating and non-participating practices before and after the introduction of health checks. Health outcomes are defined as CVD mortality, incident hospitalisations and prescribing of cardiovascular drugs.

RESULTS

After accounting for secular trends and seasonal variation, coronary heart disease mortality and hospitalisations changed by 0.4% (95% CI -5.2% to 6.3%) and -1.1% (-3.4% to 1.3%) in Keep Well practices and by -0.3% (-2.7% to 2.2%) and -0.1% (-1.8% to 1.7%) in non-Keep Well practices, respectively, following the intervention. Adjusted changes in prescribing in Keep Well and non-Keep Well practices were 0.4% (-10.4% to 12.5%) and -1.5% (-9.4% to 7.2%) for statins; -2.5% (-12.3% to 8.4%) and -1.6% (-7.1% to 4.3%) for antihypertensive drugs; and -0.9% (-6.5% to 5.0%) and -2.4% (-10.1% to 6.0%) for antiplatelet drugs.

CONCLUSIONS

Any impact of the Keep Well health check intervention on CVD outcomes and prescribing in Scotland was very small. Findings do not support the use of the screening approach used by current health check programmes to address CVD. We used an interrupted time series method, but evaluation methods based on randomisation are feasible and preferable and would have allowed more reliable conclusions. These should be considered more often by policymakers at an early stage in programme design when there is uncertainty regarding programme effectiveness.

Brief intervention to reduce risky drinking in pregnancy: study protocol for a randomized controlled trial

Background

Risky drinking in pregnancy by UK women is likely to result in many alcohol-exposed pregnancies. Studies from the USA suggest that brief intervention has promise for alcohol risk reduction in antenatal care. However, further research is needed to establish whether this evidence from the USA is applicable to the UK. This pilot study aims to investigate whether pregnant women can be recruited and retained in a randomized controlled trial of brief intervention aimed at reducing risky drinking in women receiving antenatal care.

Methods

The trial will rehearse the parallel-group, non-blinded design and procedures of a subsequent definitive trial. Over 8 months, women aged 18 years and over (target number 2,742) attending their booking appointment with a community midwife (n = 31) in north-east England will be screened for alcohol consumption using the consumption questions of the Alcohol Use Disorders Identification Test (AUDIT-C). Those screening positive, without a history of substance use or alcohol dependence, with no pregnancy complication, and able to give informed consent, will be invited to participate in the trial (target number 120). Midwives will be randomized in a 1:1 ratio to deliver either treatment as usual (control) or structured brief advice and referral for a 20-minute motivational interviewing session with an alcohol health worker (intervention). As well as demographic and health information, baseline measures will include two 7-day time line follow-back questionnaires and the EuroQoL EQ-5D-3 L questionnaire. Measures will be repeated in telephone follow-ups in the third trimester and at 6 months post-partum, when a questionnaire on use of National Health Service and social care resources will also be completed. Information on pregnancy outcomes and stillbirths will be accessed from central health service records before the follow-ups. Primary outcomes will be rates of eligibility, recruitment, intervention delivery, and retention in the study population, to inform power calculations for a definitive trial. The health-economics component will establish how cost-effectiveness will be assessed, and examine which data on health service resource use should be collected in a main trial. Participants’ views on instruments and procedures will be sought to confirm their acceptability.

Discussion

The study will produce a full trial protocol with robust sample-size calculations to extend evidence on effectiveness of screening and brief intervention.

Trial Registration

Current Controlled Trials ISRCTN43218782

Excinier Laser Radiation Induced Rapid-Solidification of Alunjinumi and Aluminumi Alloys

A study of the effects of high intensity excimer laser radiation (249nm.) of aluminum and an Al-Si alloy reveals a variety of intriguing surface topographical features. Important parameters determining these include the energy-density and the number of short-duration (≈22ns.) pulses. Specific attention has been devoted to determining the condition for the onset of surface melting, and the physical effects of further increasing the energy density. A study of the frozen-in surface wave structure has been used to determine the approximate solidification time and the solidification-front velocity. As well as overall surface melting, an interesting phenomenon is the localized melting occurring at precipitates which preferentially absorb the incident radiation. This phenomenon has been studied in an Al-Si alloy subjected to single and multiple pulses; the effect of the latter has been found to have a striking effect.

Registers for Networked Medical Research in Germany: Situation and prospects

BACKGROUND

Several disease specific registers are operated by members of the 'TMF - Technology, Methods, and Infrastructure for Networked Medical Research', an umbrella organization of research networks in Germany.

OBJECTIVE

To describe the coverage and the current state as well as financial and organizational issues of registers operated by member networks of the TMF, to identify their requirements and needs, and to recommend best practice models.

METHODS

A survey with a self-completion questionnaire including all 55 TMF member networks was carried out in winter 2007/2008. Interviews focusing on technological issues were conducted and analyzed in summer 2009 with a convenience sample of 10 registers.

RESULTS

From 55 TMF member networks, 11 provided information about 14 registers. Six registers address diseases of the circulatory system with more than 150,000 registered patients. The interviews revealed a typical setting of "research registers". Research registers are an important mean to generate hypotheses for clinical research, to identify eligible patients, and to share data with clinical trials. Concerning technical solutions, we found a remarkable heterogeneity. The analysis of the most efficient registers revealed a structure with five levels as best practice model of register management: executive, operations, IT-management, software, hardware.

CONCLUSION

In the last ten years, the TMF member networks established disease specific registers in Germany mainly to support clinical research. The heterogeneity of organizational and technical solutions as well as deficits in register planning motivated the development of respective recommendations. The TMF will continue to assist the registers in quality improvement.

Features of probable multiple system atrophy patients identified among 4770 patients with parkinsonism enrolled in the multicentre registry of the German Competence Network on Parkinson’s disease

We identified 221 patients with probable multiple system atrophy (MSA) among 4770 patients enrolled in the multicentre registry of the German Competence Network on Parkinson's disease (PD) according to the established consensus criteria to characterize their clinical presentation. Analyses of more than 100 recorded clinical items revealed several specifics: I) 50% of patients with probable MSA had asymmetry of symptoms at disease onset and tremor at rest was present in 25%; II) a positive response to levodopa was recorded in 51% of patients identified initially with severe autonomic failure and cerebellar ataxia; III) a positive family history was recorded in 11% (n = 23), two of these patients were identified with spinocerebellar ataxia type 3 (SCA3). Thus asymmetry of symptoms, tremor at rest and a positive response to levodopa are not as specific for idiopathic PD as believed previously. Patients with SCA3 may present with the clinical features of MSA.

Phenotypic switching and its influence on expression of virulence factors by Candida albicans causing candidiasis in human immunodeficiency virus-infected patients

PURPOSE

The purpose of the present study was to determine the degree of expression of virulence factors such as adherence, cell surface hydrophobicity (CSH) and production of proteinase by different morphological forms of Candida albicans causing oral candidiasis in human immunodeficiency virus (HIV)-infected individuals.

METHODS

C. albicans 3153A and two strains isolated from oral thrush in HIV infected individuals were induced to undergo phenotypic switching by exposure to UV light and the degree of expression of virulence factors by the different morphological forms was studied.

RESULTS

Three different morphological forms of C. albicans were obtained namely, star (S), wrinkled (W) and ring (R) types from the original smooth (O) variety. It was found that proteinase production was greatest with the W type followed by the R type and O type. The S type produced the least proteinase. Expression of cell surface hydrophobicity and adherence was greatest in the O type followed by the R and then the W type and finally the S type.

CONCLUSIONS

The differential expression of virulence factors occurs with different phenotypic forms of C. albicans and this may provide a particular morphological type with a distinct advantage over other types in causing candidiasis.

Value of superficial cultures in diagnosing neonatal sepsis

This study was conducted to determine the value of superficial cultures in the diagnosis of neonatal sepsis in our hospital. Sixty three babies, younger than 2 weeks who were admitted with suspected sepsis were investigated. A total of 369 cultures were obtained from these babies--252 (68.29%) superficial and 171 (31.70%) deep cultures. External ear canal swab, umbilical cord swab and throat swab culture accounted for the superficial cultures. Blood culture, cerebrospinal fluid culture and i.v. catheter culture accounted for deep cultures. Of the 369 cultures, 225 (60.97%) were positive for pathogens, which included Staphylococcus aureus, Klebsiella sp, Escherichia coli, Group B streptococcus and Enterococcus fecalis. The yield of pathogenic organisms was higher for superficial cultures (53.84%). All superficial cultures obtained during the study on each patient were simultaneously compared with the deep cultures by antimicrobial sensitivity method. The overall comparison showed that the practice of superficial cultures could be useful to predict the pathogenic organisms causing invasive disease.

Synthesis of some new biologically active thiadiazolotriazinones--Part II

4-Amino-6-phenyl/methyl-3-mercapto-1,2,4-triazin-5(4H)-ones (1) are condensed with an aromatic carboxylic acid, aryloxyacetic acid or anilinoacetic acid (2), to yield 7-substituted-3-phenyl/methyl-4H-1,3,4-thiadiazolo-[2,3-c]-1,2,4-+ ++triazin-4- ones (3). Phosphorus oxychloride is used as a cyclizing agent. All the synthesized compounds are screened for their antibacterial activities against S. aureus, E. coli, P. aeruginosa and G. bacillus.

Studies on arylfuran derivatives. Part VII. Synthesis and characterization of some Mannich bases carrying halophenylfuryl moieties as promising antibacterial agents

A series of 4-[5-(halophenyl)-2-furfurylidene)] amino-3-mercapto-5-substituted-1,2,4-triazoles (3) were synthesized. Aminomethylation of 3 with formaldehyde and a secondary amine furnished Mannich bases, 4. Both Schiff bases and Mannich bases were characterized on the basis of IR, NMR, mass spectral data and elemental analysis. All the newly synthesized compounds were tested for their antibacterial activities. Some of them carrying morpholino and N-methylpiperazino residues were found to be promising antibacterial agents.

Studies on arylfuran derivatives- Part VIII. Synthesis, characterization and antibacterial activities of some 1-aminomethyl-3-substituted-4-[5-(4-nitrophenyl-2-furfurylidene)] amino-1,2,4-triazole-5-thiones

A series of 4-[5-(4-nitrophenyl-2-furfurylidene)]amino-5- mercapto-3-substituted-s-triazoles (3) and their Mannich bases (4) are synthesized. The structures of these compounds are established on the basis of elemental analysis, IR, NMR and mass spectral data. The newly synthesized compounds are screened for their antibacterial activities.

Giardiasis in the adult population of Dakshina Kannada district of south India

A 10-year study of Giardia intestinalis infections in adults was conducted in the Dakshina Kannada District of Karnataka State, South India. Coproparasitological investigations were made on 10,000 stool specimens collected from selected patients. The infection rate was 37.1% with a male disease rate of 91.4%. The highest incidence rate was recorded in the age group 15-26 years. A possible reason for this preponderance of giardiasis in these males, is discussed. The optimum time for transmission appeared to be during the warmer months of the year (May to October) which coincided with the greatest amount of rainfall. The most common symptoms were abdominal discomfort, flatulence, diarrhoea, weight loss and anorexia. The predominating symptoms in our series varied with socio-economic level. There appeared to be some correlation between the clinical manifestations and the immune status of the individual.

Intravenous immunoglobulin therapy for autoimmune diabetes mellitus

OBJECTIVE

A variety of immune therapies have been used in an attempt to reduce the immune destruction of the insulin secreting beta cells which results in insulin dependent diabetes mellitus (IDDM). This study investigated the use of intravenous gammaglobulin therapy (IVIG) in children and adults with IDDM who participated in a two-year randomised controlled trial which also examined the effect of transfer factor in altering the natural course of IDDM.

METHODS

Treatment was administered every two months for the duration of the study. IVIG was given in a dose of 2 g/ kg body weight in divided doses over two days. The other two groups received an intramuscular injection-the control group received normal saline and the transfer factor group received 1 i.u. of transfer factor. Remission rates, beta cell function and treatment side effects were assessed.

RESULTS

Compared with the control group, IVIG therapy given every 2 months for 2 years, did not result in an increased number of complete remissions or differences in insulin dose, diabetes control or endogenous insulin secretion assessed as fasting and stimulated C-peptide responses to glucagon and a meal. IVIG therapy was associated with significant side effects.

CONCLUSION

It is unlikely that IVIG therapy will be a viable option for immunotherapy in IDDM.

Continuous subcutaneous insulin infusion (CSII) and insulin antibodies in rabbits

Using prepubertal male New Zealand White rabbits, continuous subcutaneous insulin infusion (CSII), delivered by either an external or an implantable infusion device, resulted in significantly higher insulin antibody (I-Ab) production than bolus injection (BII). We tested the influence during CSII of (1) the insulin species, (2) the insulin diluent, (3) the materials of which the infusion devices were made and (4) the incubation of insulin in a syringe on the backs of rabbits ('sham-infusion'), with the following results: (1) beef and sulphated beef insulins produced high levels of I-Abs, while porcine and human insulins produced moderate levels; (2) with all insulins used, 0.9% NaCl and 0.9% NaCl with 24-26 mmol NaHCO3 added, produced high levels of I-Ab. A buffer containing 0.7% NaCl, 0.136% sodium acetate trihydrate and 0.1% methyl-p-hydroxybenzoate and a buffer containing 16 mg/ml glycerol and 2 mg/ml phenol, produced highly significantly lower I-Abs (P less than 0.001); (3) insulin glass syringes produced much lower I-Ab levels than in standard polypropylene syringes and (4) polypropylene syringes in a 'sham-infusion' technique, resulted in intermediate levels of insulin antibodies [(P less than 0.02) vs CSII; (P less than 0.005) vs BII]. Our data suggest that insulin immunogenicity is influenced by all four factors tested. We suggest that benefits of CSII therapy may be attenuated unless a best possible control of these factors is achieved.

Luteinizing hormone-releasing hormone analogue (Buserelin) treatment for central precocious puberty: a multi-centre trial

A multi-centre open trial of Buserelin, a luteinizing hormone-releasing hormone (LHRH) analogue, was conducted in 13 children with central precocious puberty. Eleven children (eight girls and three boys), aged 3.4-10.2 years at commencement, completed the required 12 month period of treatment. Initially all patients received the drug by intranasal spray in a dose of 1200 micrograms/day, but by the end of the 12 month period two were having daily subcutaneous injections and three were receiving an increased dose intranasally. The first month of treatment was associated in one boy with increased aggression and masturbation, and in the girls with an increase in the prevalence of vaginal bleeding. Thereafter, however, both behavioural abnormalities and menstruation were suppressed. Median bone age increased significantly during the study, but without any significant change in the ratio of height age to bone age. The median predicted adult height for the group therefore did not alter significantly over the twelve months of the study. Buserelin treatment caused a reduction in the peak luteinizing hormone and follicle-stimulating hormone (FSH) responses to LHRH, mostly to prepubertal levels, and also suppressed basal FSH. In the first weeks of treatment, the girls' serum oestradiol levels rose significantly and then fell to prepubertal or early pubertal levels. A similar pattern was seen for serum testosterone levels. Serum somatomedin-C levels, however, showed little fluctuation over the course of the study. Buserelin treatment was safe and well accepted, and offers the promise of improved linear growth potential in precocious puberty.

A comparison of the effects of plasma exchange and immunoadsorption on anti-insulin antibody synthesis in rabbits

Plasma exchange (PE) and ex vivo immunoadsorption (IA) may be applicable to the removal of anti-insulin antibodies (AI-Ab) from diabetic patients. However, the removal of antibodies may prompt an increase in their rate of synthesis and an overshoot of antibody levels which may be deleterious to the patient. The effects of both PE and IA on AI-Ab synthesis were studied in a rabbit model. Rabbits were immunized with insulin and the resulting AI-Abs removed by both plasma exchange and specific immunoadsorption. Following AI-Ab removal by PE no increase in AI-Ab synthesis or antibody overshoot occurred. However a large increase in AI-Ab synthesis and overshoot occurred following specific AI-Ab removal by immunoadsorption. Despite similar reductions in AI-Ab levels by PE and IA, no increase in antibody synthesis occurred due solely to antibody removal. It is likely that antigen released from the immunoadsorbent stimulated the increase in antibody synthesis following immunoadsorption. These findings are relevant to the clinical application of both PE and IA.

The effect of immediate polyethylene glycol precipitation on free insulin measurements in diabetic patients with insulin antibodies

Free insulin (FI) measurements obtained by polyethylene glycol (PEG) precipitation within 3 min of drawing the blood sample (FI3) from four insulin-treated diabetic subjects with a wide range of insulin antibodies were compared with published methods of FI estimation. Comparison of FI values obtained by PEG precipitation in assays of replicate samples of the same specimens (N = 9) stored at 4 degrees C for 24 h (EFI) and FI3 were 4.76 +/- 1.5 microU/ml (mean +/- SEM) and 17.13 +/- 4.7 microU/ml, respectively (P less than 0.005). Comparison of FI values obtained in six groups of replicate samples (N = 12, 18 per group, a total of 91 specimens) from these four patients assayed immediately after thawing to 18 degrees C, and incubated at 37 degrees C for 30, 60, and 120 min, and FI3 showed a significant difference in at least one of these four comparisons (mean +/- SEM) in each of these six sample groups. In 18 of 24 comparisons there was a loss of FI when stored samples were used with or without incubation (12 of these were significant at the P less than 0.05-0.001 level), but in 6 of the 24 comparisons there was an increase in the FI against FI3 (3 of these 6 significant at the P less than 0.05-0.01 level). There was a trend toward a greater loss of FI in stored samples with higher FI3 content. Loss of FI during incubation occurred in all groups irrespective of the FI3 content.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous nasogastric phosphorus infusion in hypophosphatemic rickets of prematurity

Radiologic and biochemical abnormalities associated with nutritional hypophosphatemic rickets were discovered in a 945-g preterm infant despite daily supplementation with 800 to 1,600 IU of ergocalciferol (vitamin D2) and an elevated serum 25-hydroxyvitamin D concentration. Vitamin D supplementation was stopped, and the rickets was corrected by phosphorus supplement alone with the use of a unique technique of long-term, continuous nasogastric phosphorus infusion. Normophosphatemia was rapidly achieved and effectively maintained. Hypocalcemia did not occur at rates of infusion of 100 mg of elemental phosphorus per day. The data are consistent with specific phosphorus deficiency as the cause of rickets in this infant, rather than insufficient vitamin D intake or disturbed vitamin D metabolism. We speculated that continuous phosphorus infusion prevents the intermittent hyperphosphatemia of bolus phosphorus supplement and that continuous phosphorus infusion may be useful in the treatment of other hypophosphatemic states of infancy.

Metabolism of D- and L-glyceraldehyde in adipose tissue: a stereochemical probe for glycerokinase activity

Distributions of (14)C have been determined in free glycerol, in glycerol from triglycerides, in glucose from glycogen, and in lactate after incubation of d-glyceraldehyde-3-(14)C and l-glyceraldehyde-3-(14)C with rat adipose tissue. The distributions are interpreted in terms of presently accepted possible reactions for the initial metabolism of glyceraldehyde. Formation of glycerol-1-(14)C from d-glyceraldehyde-3-(14)C indicates that in adipose tissue glyceraldehyde is reduced to glycerol. Incorporation of (14)C from d-glyceraldehyde-3-(14)C into carbon 3 of the glycerol of triglyceride indicates that d-glyceraldehyde is either phosphorylated or oxidized to d-glyceric acid, or both, in its initial metabolism. Incorporation of (14)C from l-glyceraldehyde-3-(14)C into carbon 3 of glycerol indicates that l-glyceraldehyde is reduced to glycerol, which is phosphorylated and (or) converted to d-glyceric acid via l-glyceric acid. Some (14)C from l-glyceraldehyde-3-(14)C is incorporated into carbon 1 of glycerol of triglycerides and carbon 4 of glycogen; the explanation for this incorporation is uncertain.