Dyad and group-based interventions in physical activity, diet, and weight loss: a systematic review of the evidence

Studies show that interpersonal relations impact behavior change. Yet, a comprehensive review of their efficacy remains unclear. This systematic review examines the efficacy of dyadic and group-based studies that intervened on primary endpoints: diet, PA, and weight loss in adults and their networks. We searched five databases for eligible articles published from 1980 to present. Final inclusion and risk of bias were independently determined and agreed upon by two of the paper's co-authors. Nine dyads and twelve group-based studies were eligible. Of the studies, 36% (4/11) of PA studies, 60% (3/5) of diet studies and 57% (8/14) of studies with weight loss as primary outcomes, reported significant findings. Compared to dyadic interventions, a greater proportion of group-based interventions demonstrated efficacy in PA gain and weight loss as outcomes. Approximately 43% of studies demonstrated low to moderate methodological quality. This systematic review synthesized the evidence of dyadic and group studies that intervened on PA, diet, and weight in adults from the same network. Moderately-high risk of bias and lack of diverse representation restricts inferences around efficacy. High-quality rigorous research is needed to understand the efficacy of dyadic and group-based interventions in addressing these co-occurring endpoints of interest.

AAV9:PKP2 improves heart function and survival in a Pkp2-deficient mouse model of arrhythmogenic right ventricular cardiomyopathy

BACKGROUND

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a familial cardiac disease associated with ventricular arrhythmias and an increased risk of sudden cardiac death. Currently, there are no approved treatments that address the underlying genetic cause of this disease, representing a significant unmet need. Mutations in Plakophilin-2 (PKP2), encoding a desmosomal protein, account for approximately 40% of ARVC cases and result in reduced gene expression.

METHODS

Our goal is to examine the feasibility and the efficacy of adeno-associated virus 9 (AAV9)-mediated restoration of PKP2 expression in a cardiac specific knock-out mouse model of Pkp2.

RESULTS

We show that a single dose of AAV9:PKP2 gene delivery prevents disease development before the onset of cardiomyopathy and attenuates disease progression after overt cardiomyopathy. Restoration of PKP2 expression leads to a significant extension of lifespan by restoring cellular structures of desmosomes and gap junctions, preventing or halting decline in left ventricular ejection fraction, preventing or reversing dilation of the right ventricle, ameliorating ventricular arrhythmia event frequency and severity, and preventing adverse fibrotic remodeling. RNA sequencing analyses show that restoration of PKP2 expression leads to highly coordinated and durable correction of PKP2-associated transcriptional networks beyond desmosomes, revealing a broad spectrum of biological perturbances behind ARVC disease etiology.

CONCLUSIONS

We identify fundamental mechanisms of PKP2-associated ARVC beyond disruption of desmosome function. The observed PKP2 dose-function relationship indicates that cardiac-selective AAV9:PKP2 gene therapy may be a promising therapeutic approach to treat ARVC patients with PKP2 mutations.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

A multi-centre retrospective study of Nocardia speciation and antimicrobial susceptibility in Queensland, Australia

The study aims to characterise the species identification and antimicrobial susceptibility testing (AST) results of Nocardial isolates from adult patients across major public hospitals in Queensland, Australia, over a 15-year period. A multi-centre retrospective observational study of Nocardia sp. isolates was conducted from 7 major public hospitals in Queensland, Australia, over a 15-year period. Clinical samples from patients aged ≥ 18 years that isolated Nocardia sp. were included. Demographic and clinical data were collected, along with species identification and AST results. Overall, 484 Nocardia sp. were isolated. Most patients were male (297, 61%) with a mean (IQR) age of 60 (51-75) and a median (IQR) Charlson Comorbidity Index of 4 (2-6). Of these, 239 (49%) patients were immunosuppressed. Organisms were most frequently isolated from sputum (174, 36%), and superficial swabs (102, 21%). Patients presented with pulmonary infections (165, 35%) and superficial skin and soft tissue infections (87, 18%) most commonly. One hundred (21%) isolates were deemed pulmonary colonisation and were not treated. Of the speciated organisms, N. nova complex was the most common (93, 19%), followed by N. farcinica complex (79, 16%). Organisms were reliably susceptible to linezolid (240/245, 98%), amikacin (455/470, 97%), and trimethoprim/sulfamethoxazole (459/476, 96%), but less so to imipenem (243/472, 51%) and ceftriaxone (261/448, 58%). This is the largest Australian description of Nocardia sp. to date. Given antimicrobials are often commenced prior to AST results and sometimes even speciation, characterisation of local species and antibiogram data is important to guide empiric choices and local guidelines.

Sodium nitrite poisoning: A series of 20 fatalities in which post-mortem blood nitrite and nitrate concentrations are reported

Sodium nitrite has several industrial applications however its accidental or intentional ingestion has been associated with severe toxicity and death. We present a series of 20 cases over 2 years in which evidence of sodium nitrite ingestion was found at the scene and supported by biochemical analysis of post-mortem blood nitrite and nitrate levels. Routine toxicological screening was performed on post-mortem blood samples received at University Hospitals of Leicester (UHL) NHS Trust, including ethanol analysis by headspace gas chromatography-flame ionisation detection (HS GC-FID), drug screening by high resolution accurate mass-mass spectrometry (HRAM-MS) and confirmatory drug quantitation by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cases in which the history indicated the possibility of nitrite salts present at the scene, purchase of a suicide kit or a dusky-ash appearance of skin on post-mortem were referred to a specialist laboratory for nitrite and nitrate analysis. Analysis was based upon the gas-phase chemiluminescent reaction between nitric oxide (NO) and ozone; NO levels were determined using an NOA 280A, Sievers NO analyser. Twenty post-mortem cases in which sodium nitrite ingestion was the most probable cause of death were reported between January 2020 and February 2022; mean age was 31 years (range 14-49) with 9/20 (45%) female. 16/20 (80%) of cases had a history of depression and / or mental health issues. In half of the cases, anti-depressant / anti-psychotic drugs were prescribed; these drugs were detected in 8/20 (40%) cases. Ethanol was detected in 4/20 (20%) cases and anti-emetic drugs in 7/20 (35%) cases; anti-emetic drugs may be used to aid retention of sodium nitrite. Illicit drugs (amphetamine, cannabis and cocaine) were present in 3/20 cases (15%). Nitrite was found to be elevated in all but one case (95%), and nitrate was elevated in 17/20 (85%) cases. This paper highlights a surge in numbers of deaths across England and Wales due to sodium nitrite toxicity. Although, nitrite poisoning remains a rare cause of death, it is worthwhile considering its use in individuals with suicidal ideation given its unregulated availability online. The detection and quantitation of nitrite and nitrate requires specialised, highly reliable methodology currently only available in research laboratories. Implication of sodium nitrite ingestion also relies heavily upon circumstantial evidence combined with quantification. The provision of a quantitative nitrite / nitrate analytical service greatly assists in determining the cause of death in these cases.

The effect of building-level socioeconomic status on bystander cardiopulmonary resuscitation: a retrospective cohort study

Background/Introduction

In out-of-hospital cardiac arrest (OHCA), bystander cardiopulmonary resuscitation (BCPR) increases survival [1]. Understanding the social determinants of BCPR receipt can inform the design of public health interventions to increase BCPR. The association of socioeconomic status (SES) with BCPR is generally poorly understood.

Purpose

We aimed to evaluate the effect of SES on BCPR in OHCA using a building-level SES marker.

Methods

This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry, an ongoing long-term prospective registry for OHCA in the Asia-Pacific region, between 2010 to 2018. We categorized patients into low, medium and high Singapore Housing Index (SHI) levels. The SHI, which appraises a residential property value on an ordinal scale of 1 to 7 (low to high), is a building-level marker that has a robust association with income and residence value [2]. The primary outcome was receipt of BCPR. The secondary outcomes were pre-hospital return of spontaneous circulation (ROSC) and survival – defined as survival to 30 days or hospital discharge, whichever occurred first.

Results

A total of 12,730 OHCA cases were included (Figure 1), the median age was 71 years and 58.9% were male. BCPR rate was 56.7%. OHCA patients in the low SHI tier were the youngest, most likely male, and least likely to have any medical co-morbidities (Table 1). Compared the low SHI category, those in the medium and high SHI categories were more likely to receive BCPR (medium SHI: adjusted odds ratio [aOR] 1.483, 95% CI 1.301–1.691, p<0.01; high SHI: aOR 1.933, 95% CI 1.669–2.240, p<0.01). As a continuous variable, every unit increase in SHI was associated with increased BCPR (aOR 1.142, 95% CI 1.110–1.174, p<0.001). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.789, 95% CI 1.080–2.964) but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). There were no significant differences in the proportion of ROSC across three categories of SHI (p=0.426). When comparing high with low SHI, females had larger increases in BCPR rates compared to males (ratio of OR 1.370, 95% CI 1.012–1.853). There were no significant associations between SHI and BCPR in the subgroups age ≥65 years, witnessed arrest, daytime arrest, and arrests after 2014, and no interaction effects were observed.

Conclusions

Lower building-level SES was independently associated with lower rate of BCPR. Higher SES was associated with higher 30-day survival on unadjusted analysis but not adjusted analysis, and this study may be under-powered for this outcome. Females were more susceptible to the effect of low SES on lower rate of BCPR, and community CPR training should focus on recognizing OHCA and performing BCPR in women in low SES communities.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council, Clinician Scientist Awards, Singapore (NMRC/CSA/024/2010, NMRC/CSA/0049/2013 and NMRC/CSA-SI/0014/2017) and Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012).

QTc interval in anorexia nervosa: a systematic review and meta-analysis

Background

Patients with anorexia nervosa (AN) are at higher risk of sudden cardiac death. Although the underlying aetiology for this association remains unclear. It may be related to prolongation of the QT interval, which can degenerate into fatal ventricular arrhythmias. However, the presence of prolonged heart rate-corrected QT interval (QTc) in AN remains controversial, and two previous meta-analyses on AN and QTc showed contradictory findings [1,2].

Purpose

In this systematic review and meta-analysis, we aimed to evaluate if AN was associated with changes in the QTc interval and dispersion.

Methods

MEDLINE, EMBASE and COCHRANE databases were systematically searched from inception to January 2021. Random-effects meta-analysis and meta-regression were used. The inclusion criteria were (i) confirmed diagnosis of AN, (ii) measurement of QTc on electrocardiogram and (iii) peer-reviewed articles. The primary endpoint of the study was the duration of the QTc interval calculated using the Bazett (QTcB), Hodges (QTcH), Fridericia (QTcF) and Framingham (QTcFr) formulae. The secondary endpoints were QT dispersion (QTd) and QTc dispersion (QTcd).

Results

The 25 eligible studies included 5687 patients (1862 AN, 3825 control) (Figure 1: PRISMA diagram). The majority of patients were female (96.3%) with a mean age between 14.3 to 31.0 years and mean duration of disease ranging from 9.1 to 129.6 months. The mean BMI ranged from 13.7 to 18.5 kg/m2. Pooled analysis did not show significant prolongation between AN versus control in QTcB (mean difference (MD) MD 4.9ms, 95% CI −3.2, 13.1ms, p=0.23; I2=95%; n=24/25 studies; Figure 2A), QTcH (MD 1.3ms, 95% CI −8.5, 11.2ms, p=0.79; I2=71%; n=3/25 studies), and QTcF (MD 3.1ms, 95% CI −21.6, 27.7ms, p=0.81; I2=97%; n=3/25 studies). Only two studies reporting QTcFr showed a significant prolongation between AN and control (MD 15.9ms, 95% CI 0.0, 31.8ms, p=0.05, I2=65%; n=2/25 studies; Figure 2B). However, QTd and QTcd were significantly greater in AN than control (MD 21.3ms, 95% CI 10.4, 32.3ms, p=0.0001, I2=94%; Figure 2C and MD 16.9ms, 95% CI 4.5, 29.3ms, p=0.007 I2=93%; Figure 2D, respectively).

Conclusion

To the best of our knowledge, this is the largest meta-analysis of QTc in AN and the first meta-analysis exploring the significance of QTd and QTcd in AN. AN was not found to be associated with prolongation of QTc calculated using the Bazett, Fridericia and Hodges formulae. However, an association of AN with prolonged QTc was observed in the studies using the Framingham formula. More pronounced dispersion (QTd and QTcd) was also observed in patients with AN.

Funding Acknowledgement

Type of funding sources: None.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Phenotypic screening with deep learning identifies HDAC6 inhibitors as cardioprotective in a BAG3 mouse model of dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is characterized by reduced cardiac output, as well as thinning and enlargement of left ventricular chambers. These characteristics eventually lead to heart failure. Current standards of care do not target the underlying molecular mechanisms associated with genetic forms of heart failure, driving a need to develop novel therapeutics for DCM. To identify candidate therapeutics, we developed an in vitro DCM model using induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) deficient in B-cell lymphoma 2 (BCL2)-associated athanogene 3 (BAG3). With these BAG3-deficient iPSC-CMs, we identified cardioprotective drugs using a phenotypic screen and deep learning. From a library of 5500 bioactive compounds and siRNA validation, we found that inhibiting histone deacetylase 6 (HDAC6) was cardioprotective at the sarcomere level. We translated this finding to a BAG3 cardiomyocyte-knockout (BAG3^cKO) mouse model of DCM, showing that inhibiting HDAC6 with two isoform-selective inhibitors (tubastatin A and a novel inhibitor TYA-018) protected heart function. In BAG3^cKO and BAG3^E455K mice, HDAC6 inhibitors improved left ventricular ejection fraction and reduced left ventricular diameter at diastole and systole. In BAG3^cKO mice, TYA-018 protected against sarcomere damage and reduced Nppb expression. Based on integrated transcriptomics and proteomics and mitochondrial function analysis, TYA-018 also enhanced energetics in these mice by increasing expression of targets associated with fatty acid metabolism, protein metabolism, and oxidative phosphorylation. Our results demonstrate the power of combining iPSC-CMs with phenotypic screening and deep learning to accelerate drug discovery, and they support developing novel therapies that address underlying mechanisms associated with heart disease.

P-696 Serum androgen levels and risk of endometrial hyperplasia and malignancy in patients with polycystic ovarian syndrome: a cross-sectional analysis

Study question

In patients with polycystic ovarian syndrome (PCOS), are serum androgen levels (total and free testosterone) associated with the risk of endometrial hyperplasia or cancer?

Summary answer

Patients with PCOS diagnosed with endometrial hyperplasia or cancer had statistically significantly lower serum levels of androgens compared to PCOS patients with a normal endometrium.

What is known already

PCOS affects as many as 12% of women of reproductive age. Women with PCOS are almost three times as likely to develop endometrial cancer as women without PCOS, and endometrial hyperplasia precedes cancer in 36% of cases. Known risk factors of endometrial hyperplasia include anovulation, obesity, and resultant unopposed estrogen stimulation of the endometrium. A hallmark of PCOS is hyperandrogenism, however the effect of androgens on the endometrium is unclear.

Study design, size, duration

This was a cross-sectional, retrospective study of patients aged 18-40, being evaluated for oligomenorrhea and/or PCOS in the Reproductive Endocrinology Clinic at Los Angeles County Hospital, California, USA. All patients underwent an endometrial biopsy and serum measurement of free and total testosterone, estradiol, and hemoglobin A1c. Patients diagnosed with PCOS and with an endometrial biopsy diagnosis were included in the study. Patients on any hormonal therapy were excluded.

Participants/materials, setting, methods

In all patients included in the study, serum androgen levels (free and total testosterone) were measured by mass spectrometry. All endometrial biopsies were analyzed by an experienced histopathology, and all diagnoses of endometrial hyperplasia or cancer were confirmed by histologic studies.

Main results and the role of chance

Using the Rotterdam criteria, a total of 232 patients were diagnosed with PCOS during the study period. Of these patients, 161 patients (70%) had a normal endometrium, 19 (8%) were diagnosed with endometrial hyperplasia (EH) without atypia, 38 (16%) were diagnosed with EH with atypia, and 14 (6%) were diagnosed with endometrial cancer. Patients with a normal endometrium had a mean total testosterone of 60.9 ng/dL and mean free testosterone of 9.3 ng/dL. Relatively, patients with EH without atypia, EH with atypia, and endometrial cancer had lower mean total testosterone levels of 50.1 ng/dL, 45.5 ng/dL, and 30.1 ng/dL, respectively (p-values 0.04, 0.02, 0.001, respectively), as well as lower mean free testosterone levels of 8.2 pg/mL, 6.7 pg/mL, and 5.5 pg/mL, respectively (p-values 0.04, 0.03, and 0.01, respectively). There was no significant difference in age, parity, BMI, estradiol levels, or hemoglobin A1c between the four groups.

Limitations, reasons for caution

Limitations of our study include its retrospective nature. Furthermore, hormone levels were only measured in the serum, and not in the endometrial tissue directly, which would give the most insight into their actions on the endometrium.

Wider implications of the findings

Our findings suggest that androgens have a protective effect on the endometrium against endometrial hyperplasia and cancer. Further studies are needed to evaluate the therapeutic potential role of androgens in the prevention or treatment of these conditions.

Trial registration number

not applicable

162 A Closed Loop Audit Assessing and Improving the Quality of Electronic Discharge Documents in a Neurosurgical Ward for Patient Safety and Continuity of Care

Aim

To assess the quality of neurosurgical electronic discharge documents (EDDs) as per the Scottish Intercollegiate Guidelines Network's (SIGN) discharge document guidelines, and to implement interventions to ensure patient safety and continuity of care.

Method

We performed a closed loop audit on the quality of EDDs at the neurosurgical unit at Ninewells Hospital. We collected six sets of two-weeks’ worth of EDDs from the Tayside EDD system coinciding with foundation trainee changeover times for a representative sample of pre- and intra-COVID-19 EDDs. We analysed our findings and developed interventions in collaboration with the MDT. These included a copy-paste template, educational poster, and presentation, and more. We implemented the interventions and reassessed EDDs after three months.

Results

A total of 207 EDDs were included. Pre-interventions, 88% of the EDDs were inadequate in quality when compared to SIGN’s guidelines. This had 33% reduction post-interventions. The percentage of EDDs adequate in quality doubled post-interventions, from 22% to 43%. The most commonly mistaken or missed criterion pre- and post-intervention was the neurological status on admission and discharge. Others were mistaking presenting complaint for diagnosis and vice versa, and not mentioning follow-up or new medications.

Conclusions

Accurate records of care, including discharge documents, are central to the principles of good medical practice outlined by the GMC. This study showed that EDD quality is compromised due to time pressures, lack of information and constant changeover due to COVID-19. We alleviated this by creating accessible interventions that assure safe patient care despite the challenges of changeover and COVID-19.

Delgocitinib in atopic dermatitis

Delgocitinib ointment is a newly approved topical medication for the treatment of atopic dermatitis (AD). AD usually has onset in early childhood and is a common, often chronic relapsing inflammatory skin condition that affects all age groups. AD has a large impact on patients' quality of life including physical health and emotional impacts. Conventional management of AD consists of phototherapy and treatments that comprise corticosteroids (both topically and systemically), topical calcineurin inhibitors (tacrolimus and pimecrolimus) or systemic immunosuppressants like ciclosporin. New targeted therapies for AD, including interleukin (IL)-4/13 inhibitors, Janus kinase (JAK) inhibitors and IL-13 inhibitors have been introduced for both topical and systemic use. In this review, we give an overview of the use of delgocitinib, the first topical JAK inhibitor to be approved for AD, including its preclinical pharmacology, pharmacokinetics and metabolism, safety, existing clinical trials and future directions.

Deep learning detects cardiotoxicity in a high-content screen with induced pluripotent stem cell-derived cardiomyocytes

Drug-induced cardiotoxicity and hepatotoxicity are major causes of drug attrition. To decrease late-stage drug attrition, pharmaceutical and biotechnology industries need to establish biologically relevant models that use phenotypic screening to detect drug-induced toxicity in vitro. In this study, we sought to rapidly detect patterns of cardiotoxicity using high-content image analysis with deep learning and induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs). We screened a library of 1280 bioactive compounds and identified those with potential cardiotoxic liabilities in iPSC-CMs using a single-parameter score based on deep learning. Compounds demonstrating cardiotoxicity in iPSC-CMs included DNA intercalators, ion channel blockers, epidermal growth factor receptor, cyclin-dependent kinase, and multi-kinase inhibitors. We also screened a diverse library of molecules with unknown targets and identified chemical frameworks that show cardiotoxic signal in iPSC-CMs. By using this screening approach during target discovery and lead optimization, we can de-risk early-stage drug discovery. We show that the broad applicability of combining deep learning with iPSC technology is an effective way to interrogate cellular phenotypes and identify drugs that may protect against diseased phenotypes and deleterious mutations.

Systemic medication requirement in post-surgical patients with eosinophilic chronic rhinosinusitis

BACKGROUND

Eosinophilic chronic rhinosinusitis (eCRS) is contemporarily managed by surgical creation of a 'neo-sinus' cavity and corticosteroid irrigations. While most patients gain control of their disease with this approach, similar to preventive inhaler therapy in asthma, some patients need systemic therapies. This study aimed to define those patients needing ongoing systemic therapy for eCRS.

METHODS

Consecutive adult patients (>18 years) who were seen at a tertiary referral clinic, diagnosed as eCRS and underwent endoscopic sinus surgery were included. Patients were followed up for a minimum of 12 months. All patients had a simple neo- sinus cavity surgically created and used initially a once daily topical corticosteroid irrigation maintenance therapy. Patients who re- quired long term systemic oral corticosteroids and/or biologic therapy were compared to those who remained on topical control.

RESULTS

222 patients with eCRS were assessed (follow-up 2.76 years). Long term systemic therapy was required in 5.4% of pa- tients. Receiver operating curve analysis predicted local treatment failure at an eosinophil count cut-off level 0.455x109/L. Asthma, atopy and aspirin sensitivity also predicted long term systemic therapy. There were no associations with nasal polyposis or revi- sion surgery. Multivariate logistic regression showed elevated blood eosinophil count >0.455 x109/L was 9.27 times more likely to require for systemic medication.

CONCLUSION

Pre-operative blood eosinophil count >0.45 x109/L was associated with failure of local therapy following contem- porary management of eCRS. The quantitative value of serum eosinophilia may be a useful predictor of disease progression and those patients in need of systemic therapies, such as biologic agents.

Adverse cardiovascular ageing among older women and cardiometabolic ageing

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): National Medical Research Council (NMRC)

Background

Despite longer life expectancies, women may experience reduced ‘health-span’ (period of life spent in good health) due to accumulation of risks over their longer life spans. Metabolic factors present in diet and lifestyle may provide modifiable solutions to tackle burdens of cardiovascular (CV) ageing in women.

Objective

We aim to study gender differences in CV structure and function among community older adults without clinical CV disease, as well as metabolic perturbations in their study samples.

Methods

We examined a prospective cohort study of older adults, obtaining their medical history, serum sampling, echocardiography and cardiac magnetic resonance (CMR) imaging on a single day visit. Echo E/A ratio was computed as a ratio of peak velocity flow in early diastole E (m/s) to peak velocity flow in late diastole by atrial contraction A (m/s) mitral inflow velocities. Longitudinal strain (ε) at any time point (t) in the cardiac cycle from end-diastole (time 0) was calculated as: ε(t)=(L(t)-L0)/L0, obtaining left atrial (LA) reservoir strain (εs), conduit strain (εe) and booster strain (εa) by CMR. Metabolomics profiling was performed by standard mass spectrometry techniques.

Results

Among n = 492 (49.6%, n = 244 women, mean age 73 ± 4 years) participants, women had lower prevalence of hypertension (52% vs 58%, p < 0.0001), smoking (4% vs 35%, p < 0.0001), but higher prevalence of dyslipidemia (52% vs 50%, p = 0.001) compared to men. Women had lower left ventricular mass index (69 vs 71 g/m2, p < 0.0001) compared to men. However, women had more adverse CV function, such as lower E/A ratio (0.78 vs 0.85, p < 0.0001), lower LA booster (εa) (16.5 vs 17.8, p = 0.027) and lower LA reservoir (εs) strain rate (1.5 vs 1.6, p = 0.012), compared to men. Amino acids such as alanine, arginine, aspartate, citrulline, glycine, phenylalanine and valine were similar between gender. However, women had higher levels of tyrosine (76 vs 68 μM, p = 0.015). On multivariate adjustment, apart from age, tyrosine was independently associated with E/A ratio (β=0.002, 95%CI 0.00-0.004, p = 0.044) and εs (β=0.004, 95%CI 0.00-0.009, p = 0.048) among women. 

Conclusion

Utilizing conventional and sensitive CV imaging, women appeared to have more adverse CV functions with ageing. As a branched chain amino acid linked to future risk of CV disease, tyrosine may be linked to adverse CV function. Factors that contribute to these cardiometabolic profiles, such as menopause, diet or lifestyle warrant further research.

Ototoxicity among multidrug-resistant TB patients: a systematic review and meta-analysis

BACKGROUND: The use of injectable antibiotics to treat multidrug-resistant TB (MDR-TB) is associated with substantial morbidity due to long-term hearing loss. This systematic review evaluates the incidence of ototoxicity among patients treated for MDR-TB, and the evidence for routine audiometric monitoring to mitigate its severity.METHODS: Studies of ototoxicity among patients with MDR-TB were identified from six databases: PubMed, MEDLINE, Web of Science, Embase, SCOPUS and the Cochrane Library. Meta-analyses were performed to determine the overall incidence of hearing loss, tinnitus and vertigo. The incidence of hearing loss was further stratified by country income status and the injectable agent used during treatment.RESULTS: Among 64 studies from 25 countries including 12 793 patients, 28.3% (95%CI 23.4–33.1) of patients treated with injectables reported hearing loss. Tinnitus and vertigo were experienced by respectively 14.5% (95%CI 10.3–18.7) and 8.1% (95%CI 4.7–11.6) of patients. The incidence of hearing loss was highest among patients treated with amikacin (33.4%, 95%CI 18.2–48.6), and lowest among those treated with capreomycin (2.0%, 95%CI 0–5.5). We found that audiometry was widely used as a method of evaluating hearing loss, and was feasible in a wide range of settings.CONCLUSION: Injectable antibiotics contribute to significant morbidity in patients with MDR-TB. In settings where they are used, routine audiometric monitoring is recommended to prevent irreversible damage.

Dermanyssus gallinae and chicken egg production: impact, management, and a predicted compatibility matrix for integrated approaches

The poultry red mite, Dermanyssus gallinae, is a worldwide threat to egg production and animal and human welfare. This mite is also a potential vector for several significant diseases. EU regulation that forbids the use of conventional cages for egg-laying hens may favour the growth of D. gallinae, a species known to thrive in more complex housing systems. Current control measures emphasize the use of chemical acaricides, which may have limited efficacy on D. gallinae considering its temporary blood-feeding behaviour. In integrated pest management (IPM), two or more compatible measures targeting physical, environmental, and/or biological aspects could be judiciously combined to enhance the effectiveness against D. gallinae infestation. To inform current and future IPM for D. gallinae, a compatibility matrix is proposed to guide the selection of control measures for field application.

Association of premature menopause with incident pulmonary hypertension

Background

Several forms of pulmonary hypertension (PH) disproportionately affect women. Prior animal and human studies suggest that oestradiol exerts mixed effects on the pulmonary vasculature. Whether premature menopause represents a risk factor for PH is currently unknown.

Purpose

To test the independent association of premature menopause with incident PH.

Methods

We included women in the UK Biobank who were 40–69 years old and postmenopausal at enrolment and underwent pulmonary function testing at the baseline study visit. Women with missing menopause data, prevalent PH, extreme pulmonary function test outliers (Z>5 or Z<−5), and those with congenital heart disease were excluded. Premature menopause was defined as occurring before age 40 years. Reproductive history, including age at menopause and use of menopausal hormone therapy (MHT), was ascertained by participant self-report at enrolment. PH risk factors and relevant co-morbidities were captured by participant self-report and by ICD code. Incident PH was ascertained by the appearance of a qualifying ICD code (ICD-9 4160; ICD-10 I27.0, I27.2). Follow-up began at study enrolment, with time to censoring determined by date of PH diagnosis or last encounter in the medical record. Multivariable Cox proportional hazard models tested the association between premature menopause and incident PH, with adjustment for age, race, ever-smoking, body-mass index, systolic blood pressure, antihypertensive medication use, non-high-density lipoprotein cholesterol, cholesterol-lowering medication use, C-reactive protein, prevalent type 2 diabetes, obstructive sleep apnoea, heart failure, venous thromboembolism, mitral regurgitation, aortic stenosis, forced vital capacity (FVC), the forced expiratory volume in 1 second (FEV1)/FVC ratio, and ever-use of MHT.

Results

Among 138,518 postmenopausal women (mean [SD] age at enrolment 60.0 [5.4] years), 5,440 women (3.9%) had a history of premature menopause. Incident PH was diagnosed in 253 women over a median 8.1 (interquartile range 7.4–8.8) years of follow-up. Mean age at menopause was 48.3 (6.4) years among women with incident PH vs. 49.7 (5.1) years among those without PH (P<0.001). Crude cumulative incidence of PH was 0.40% among women premature menopause vs. 0.17% among those without (Figure 1). After multivariable adjustment, premature menopause remained independently associated with PH (hazard ratio [HR] 1.91, 95% CI 1.15–3.16, P=0.01). Ever-use of MHT was not significantly associated with incident PH (HR 0.93, 95% CI 0.68–1.26, P=0.62). In sensitivity analysis excluding 4,461 women with prevalent heart failure, venous thromboembolism, mitral regurgitation, or aortic stenosis, the HR for PH associated with premature menopause was 2.19 (95% CI 1.28–3.74, P=0.004).

Conclusions

Premature menopause is an independent risk factor for PH in women.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): U.S. National Heart, Lung, and Blood Institute

Prevalence of antibiotic resistance and virulence genes in the biofilms from an aquifer recharged with stormwater

An improved understanding of the diversity and composition of microbial communities carrying antibiotic resistance genes (ARGs) and virulence genes (VGs) in aquifers recharged with stormwater is essential to comprehend potential human health risks from water reuse. A high-throughput functional gene array was used to study the prevalence of ARGs and VGs in aquifer biofilms (n = 27) taken from three boreholes over three months. Bacterial genera annotated as opportunistic pathogens such as Aeromonas, Burkholderia, Pseudomonas, Shewanella, and Vibrio were ubiquitous and abundant in all biofilms. Bacteria from clinically relevant genera, Campylobacter, Enterobacter, Klebsiella, Mycobacterium, Mycoplasma, and Salmonella were detected in biofilms. The mean travel time of stormwater from the injection well to P1 and P3 boreholes was 260 and 360 days respectively. The presence of ARGs and VGs in the biofilms from these boreholes suggest a high spatial movement of ARGs and VGs in the aquifer. The ARGs with the highest abundance were small multidrug resistance efflux pumps (SMR) and multidrug efflux (Mex) followed by β-lactamase C genes. β- lactamase C encoding genes were primarily detected in Enterobacteriaceae, Pseudomonadaceae, Bacillaceae, and Rhodobacteraceae families. The VGs encoding siderophores, including aerobactin (iro and iuc genes), followed by pilin, hemolysin, and type III secretion were ubiquitous. Canonical correspondence analysis suggested that Total Organic Carbon (TOC), Dissolved Organic Carbon (DOC), turbidity, and Fe concentration has a significant impact on the microbial community structure of bacteria carrying ARGs and VGs. Post abstraction treatment of groundwater may be prudent to improve water security and reduce potential health risks.

Post-treatment Mortality Among Patients With Tuberculosis: A Prospective Cohort Study of 10 964 Patients in Vietnam

BACKGROUND

Tuberculosis is the leading infectious cause of death. Steep reductions in tuberculosis-related mortality are required to realize the World Health Organization's "End Tuberculosis Strategy." However, accurate mortality estimates are lacking in many countries, particularly following discharge from care. This study aimed to establish the mortality rate among patients with pulmonary tuberculosis in Vietnam and to quantify the excess mortality in this population.

METHODS

We conducted a prospective cohort study among adult patients treated for smear-positive pulmonary tuberculosis in 70 clinics across Vietnam. People living in the same households were recruited as controls. Participants were re-interviewed and their survival was established at least 2 years after their treatment with an 8-month standardized regimen. The presence of relapse was established by linking identifying data on patients and controls to clinic registries. Verbal autopsies were performed. The cumulative mortality among patients was compared to that among a control population, adjusting for age and gender.

RESULTS

We enrolled 10964 patients and 25707 household controls. Among enrolled tuberculosis patients, 9% of patients died within a median follow-up period of 2.9 years: 342 (3.1%) during treatment and 637 (5.8%) after discharge. The standardized mortality ratio was 4.0 (95% confidence interval 3.7-4.2) among patients with tuberculosis, compared to the control population. Tuberculosis was the likely cause of death for 44.7% of these deceased patients.

CONCLUSIONS

Patients treated for tuberculosis had a markedly elevated risk of death, particularly in the post-treatment period. Interventions to reduce tuberculosis mortality must enhance the early detection of drug-resistance, improve treatment effectiveness, and address non-communicable diseases.

Ovulation rates in a stair-step protocol with Letrozole vs clomiphene citrate in patients with polycystic ovarian syndrome

Purpose

To compare ovulation rates between Letrozole and Clomiphene Citrate (CC) using a stair-step protocol to achieve ovulation induction in women with Polycystic Ovarian Syndrome (PCOS).

Methods

This is a retrospective cohort of predominantly Hispanic PCOS women of reproductive age who completed ovulation induction (OI) comparing women who underwent Letrozole stair-step protocol to those who underwent OI with CC stair-step. All women had a diagnosis of PCOS based on the 2003 Rotterdam criteria. For both protocols, sequentially higher doses of Letrozole or CC were given 7 days after the last dose if no dominant follicles were seen on ultrasonography. The primary outcome was ovulation rate (determined by presence of a dominant follicle) between the two treatment groups. Secondary outcomes included time to ovulation, clinical pregnancy rates and side effects.

Results

49 PCOS patients completed a Letrozole stair-step cycle and 43 completed a CC stair-step cycle for OI. Overall, demographics were comparable between both groups. Ovulation rates with the Letrozole stair-step protocol were equivalent to CC stair-step protocol (96% vs 88%, p = 0.17). Although the mean time (days) to ovulation was shorter in the Letrozole group (19.5 vs 23.1, p = 0.027), the pregnancy rates were similar for both groups.

Conclusions

This is the first study to date that has compared the efficacy of the stair-step protocol in PCOS patients using Letrozole and CC. Both Letrozole and CC can be prescribed in a stair-step fashion. Letrozole stair-step was as efficacious as CC stair-step; patients achieved comparable rates of ovulation and clinical pregnancy. Time to ovulation was shorter in the Letrozole protocol.

P5014The NPAC score for predicting survival after incident acute myocardial infarction

Background

Risk stratification in acute myocardial infarction (AMI) is important for guiding clinical management. Current risk scores are mostly derived from clinical trials with stringent patient selection. We aimed to establish and evaluate a composite scoring system to predict short-term mortality after index episodes of AMI, independent of electrocardiography (ECG) pattern, in a large real-world cohort.

Methods

Using electronic health records, patients admitted to our regional teaching hospital (derivation cohort, n=2127) and an independent tertiary care center (validation cohort, n=1276) with index acute myocardial infarction between January 2013 and December 2017 as confirmed by principal diagnosis and laboratory findings, were identified retrospectively.

Results

Univariate logistic regression was used as the primary model to identify potential contributors to mortality. Stepwise forward likelihood ratio logistic regression revealed that neutrophil-to-lymphocyte ratio, peripheral vascular disease, age, and serum creatinine (NPAC) were significant predictors for 90-day mortality (Hosmer-Lemeshow test, P=0.21). Each component of the NPAC score was weighted by beta-coefficients in multivariate analysis. The C-statistic of the NPAC score was 0.75, which was higher than the conventional Charlson's score (C-statistic=0.63). Application of a deep learning model to our dataset improved the accuracy of classification with a C-statistic of 0.81.

Multivariate binary logistic regression Variable β Adjusted Odds ratio (95% CI) P-value Points Age ≥65 years 1.304 3.68 (2.63–5.17) <0.001 2 Peripheral vascular disease 1.109 3.03 (1.52–6.04) 0.002 2 NLRt ≥9.51 1.100 2.73 (2.12–3.51) <0.001 1 Creatinine≥109 μmol/L 1.003 3.00 (2.35–3.85) <0.001 2

NPAC deep learning model

Conclusions

The NPAC score comprised of four items from routine laboratory parameters and basic clinical information and can facilitate early identification of cases at risk of short-term mortality following index myocardial infarction. Deep learning model can serve as a gate-keeper to provide more accurate prediction to facilitate clinical decision making.

P2838The impact of anesthesia depth on catheter ablation for atrial fibrillation: a systematic review and meta-analysis of observational studies

Objectives

This meta-analysis and systematic review seeks to compare both characteristic parameters and procedural outcomes of catheter ablation in patients under GA/deep sedation and mild/moderate sedation.

Background

Catheter ablation has become a widely applied intervention for treating symptomatic AF and arrhythmias that are refractory to medical therapy. It can be conducted through from mild sedation to general anesthesia.

Methods

PubMed and Embase were searched up to July 2018 for randomized controlled trials, cohort and observational studies that assessed the outcomes of catheter ablation under GA/deep sedation or mild/moderate sedation. 12 studies were included in this meta-analysis after screening with the inclusion and exclusion criteria. Heterogeneity between studies and publication bias was evaluated by I2 index and Egger's regression, respectively.

Results

Our meta-analysis found catheter AF ablation with GA/deep sedation to be associated with reduced risk of recurrence (RR: 0.79, 95% CI: 0.56 to 1.13, P=0.20) and complications (RR: 0.95, 95% CI: 0.64 to 1.42, P=0.82), though statistically insignificant. In terms of procedural parameters, there was non-significant difference between the two groups when both procedural time (SMD: −0.13, 95% CI: −0.90 to 0.63, P=0.74) and fluoroscopy time (SMD: −0.41, 95% CI: −1.40 to 0.58, P=0.41) were considered. Multivariate meta-regression demonstrated hypertension as an independent moderating factor for complication risk.

Complications Comparison

Conclusion

Apart from an increased likelihood of procedural success, ablation by GA/deep sedation was found to be non-significantly different from the mild/moderate sedation approach in both procedural parameters and outcome measures.

Impact of an empiric therapy guide on antibiotic prescribing in the emergency department

This quasi-experimental study compared the appropriate prescribing of antibiotics in the emergency department over a 3-month period before and after implementation of an empiric therapy guide (ETG). Overall appropriateness of antibiotic prescribing per Infectious Diseases Society of America (IDSA) guidelines increased significantly by 20.5% after implementation of the ETG (P<0.001). Prescribing for community-acquired pneumonia and cellulitis improved by 33.1% (P<0.001) and 35.5% (P=0.002), respectively. The rate of broad-spectrum antibiotic use decreased by 13.6% (P<0.001). Following the intervention, 90.5% of prescribers achieved at least 75% appropriate prescribing per IDSA guidelines (P<0.001). Appropriate antibiotic prescribing and rates of broad-spectrum antibiotic use were significantly improved following implementation of the ETG.

Utility of a chemotherapy toxicity prediction tool for older patients in a community setting

Background

Expert groups have recommended incorporation of a geriatric assessment into clinical practice for older patients starting oncologic therapy. However, that practice is not standard primarily because of resource limitations. In the present study, we evaluated the effect on treatment decisions by oncologists in the community oncology setting of a brief geriatric assessment tool that estimates risk of toxicity.

Methods

This prospective longitudinal study in 5 community oncology practices in British Columbia involved patients 70 years of age and older starting a new cytotoxic chemotherapy regimen. Clinical personnel completed a brief validated geriatric assessment tool-the Cancer and Aging Research Group chemotherapy toxicity tool (carg-tt)-that estimates the risk of grade 3 or greater toxicity in older patients. Physicians were asked if the carg-tt changed their treatment plan or prompted extra supports. Patients were followed to assess the incidence of toxicity during treatment.

Results

The study enrolled 199 patients between July 2016 and February 2018. Mean age was 77 years. Treatment was palliative in 61.4% of the group. Compared with physician judgment, the carg-tt predicted higher rates of toxicity. In 5 patients, treatment was changed based on the carg-tt. In 38.5% of the patients, data from the tool prompted extra supports. Within the first 3 cycles of treatment, 21.3% of patients had experienced grade 3 or greater toxicity.

Conclusions

This study demonstrates that use of a brief geriatric assessment tool is possible in a broad community oncology practice. The tool modified the oncologist's supportive care plan for a significant number of older patients undertaking cytotoxic chemotherapy.

Respiratory virus infection among hospitalized adult patients with or without clinically apparent respiratory infection: a prospective cohort study

Objectives

To determine the viral epidemiology and clinical characteristics of patients with and without clinically apparent respiratory tract infection.

Methods

This prospective cohort study was conducted during the 2018 winter influenza season. Adult patients with fever/respiratory symptoms (fever/RS group) were age- and sex-matched with patients without fever/RS (non-fever/RS group) in a 1:1 ratio. Respiratory viruses were tested using NxTAG™ Respiratory Pathogen Panel IVD, a commercially-available multiplex PCR panel.

Results

A total of 214 acutely hospitalized patients were included in the final analysis, consisting of 107 with fever/RS (fever/RS group), and 107 age- and sex-matched patients without fever/RS (non-fever/RS group). Respiratory viruses were detected in 34.1% (73/214) of patients, and co-infection occurred in 7.9% (17/214) of patients. The incidence of respiratory virus was higher in the fever/RS group than in the non-fever/RS group (44.9% (48/107) versus 23.4% (25/107), p 0.001). Influenza B virus, enterovirus/rhinovirus and coronaviruses were detected more frequently in the fever/RS group, whereas parainfluenza virus 4B and adenovirus were detected more frequently in the non-fever/RS group. Among the non-fever/RS group, chest discomfort was more common among patients tested positive for respiratory viruses than those without respiratory virus detected (44% (11/25) versus 22% (18/82), p 0.04).

Conclusions

Respiratory viruses can be frequently detected among hospitalized patients without typical features of respiratory tract infection. These patients may be a source of nosocomial outbreaks.

Recommendations on prevention and screening for colorectal cancer in Hong Kong

Colorectal cancer is the commonest cancer in Hong Kong. The Cancer Expert Working Group on Cancer Prevention and Screening was established in 2002 under the Cancer Coordinating Committee to review local and international scientific evidence, assess and formulate local recommendations on cancer prevention and screening. At present, the Cancer Expert Working Group recommends that average-risk individuals aged 50 to 75 years and without significant family history consult their doctors to consider screening by: (1) annual or biennial faecal occult blood test, (2) sigmoidoscopy every 5 years, or (3) colonoscopy every 10 years. Increased-risk individuals with significant family history such as those with a first-degree relative diagnosed with colorectal cancer at age ≤60 years; those who have more than one first-degree relative diagnosed with colorectal cancer irrespective of age at diagnosis; or carriers of genetic mutations associated with familial adenomatous polyposis or Lynch syndrome should start colonoscopy screening earlier in life and repeat it at shorter intervals.

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong

The demand for blood products continues to grow in an unsustainable manner in Hong Kong. While anaemia associated with gastrointestinal bleeding (GIB) is the leading indication for transfusion, there is no local recommendation regarding best practices for transfusion. We aimed to provide evidence-based recommendations regarding management of anaemia in patients with acute and chronic GIB. We reviewed all original papers, meta-analyses, systematic reviews, or guidelines that were available in PubMed. For acute GIB, a restrictive transfusion strategy, targeting a haemoglobin threshold of 7 to 8 g/dL, should be adopted because overtransfusion is associated with significantly higher all-cause mortality and re-bleeding. A liberal transfusion strategy should only be considered in patients with co-existing symptomatic coronary artery disease, targeting a haemoglobin threshold of 9 to 10 g/dL. When acute GIB settles, patients should be prescribed iron supplements if iron deficiency is present. For chronic GIB, iron stores should be replenished aggressively via iron supplementation before consideration of blood transfusion, except in patients with symptoms of severe anaemia. Oral iron replacement is the preferred first-line therapy, while intravenous iron is indicated for patients with inflammatory bowel disease, poor response or poor tolerability to oral iron, and in whom a rapid correction of iron deficit is preferred. Intravenous iron is underutilised and the risk of anaphylactic reaction to current preparations is extremely low. These recommendations are provided to local clinicians to facilitate judicious and appropriate use of red cell products and iron replacement therapy in patients with GIB.

Recommendations on prevention and screening for breast cancer in Hong Kong

In Hong Kong, breast cancer is the most common cancer among women and poses a significant health care burden. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) was set up in 2002 by the Cancer Coordinating Committee to review and assess local and international scientific evidence, and to formulate recommendations for cancer prevention and screening. After considering the local epidemiology, emerging scientific evidence, and local and overseas screening practices, the CEWG concluded that it was unclear whether population-based breast cancer screening did more harm than good in local asymptomatic women at average risk. The CEWG considers that there is insufficient evidence to recommend for or against population-based mammography screening for such individuals. Women who consider breast cancer screening should be adequately informed about the benefits and harms. The CEWG recommends that all women adopt primary preventive measures, be breast aware, and seek timely medical attention for suspicious symptoms. For women at high risk of breast cancer, such as carriers of confirmed BRCA1/2 deleterious mutations and those with a family history of breast cancer, the CEWG recommends that they seek doctor's advice for annual mammography screening and the age at which the process should commence. Additional annual screening by magnetic resonance imaging is recommended for confirmed BRCA1/2 mutation carriers or women who have undergone radiation therapy to the chest between the age of 10 and 30 years. Women at moderate risk of breast cancer should discuss with doctors the pros and cons of breast cancer screening before making an informed decision about mammography screening every 2 to 3 years.

Acute Cellular Rejection and Infection Rates in Alemtuzumab vs Traditional Induction Therapy Agents for Lung and Heart Transplantation: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Heart and lung transplantation is a high-risk procedure requiring intensive immunosuppressive therapy for preventing organ rejection. Alemtuzumab, a CD52-specific monoclonal antibody, is increasingly used for induction therapy compared with conventional agents. However, there has been no systematic review comparing its efficacy with traditional therapeutic drugs.

METHODS

PubMed and EMBASE were searched to October 1, 2017, for articles on alemtuzumab in cardiothoracic transplant surgery. Of the 433 studies retrieved, 8 were included in the final meta-analysis.

RESULTS

In lung transplantation, alemtuzumab use was associated with lower odds of acute cellular rejection compared with antithymocyte globulin (odds ratio [OR], 0.21; 95% CI, 0.11-0.40; P < .001), lower acute rejection rates (OR, 0.12; 95% CI, 0.03-0.55; P < .01), and infection rates (OR, 0.69; 95% CI, 0.35-1.36; P = .33) when compared with basiliximab. Multivariate meta-regression analysis found that mean age, male sex, single lung transplant, double lung transplant, cytomegalovirus or Epstein-Barr virus status, idiopathic pulmonary fibrosis, cystic fibrosis, and mean ischemic time did not significantly influence acute rejection outcomes. For heart transplantation, alemtuzumab use was associated with lower acute rejection rates when compared with tacrolimus (OR, 0.44; 95% CI, 0.30-0.66; P < .001).

CONCLUSIONS

Alemtuzumab use was associated with lower rejection rates when compared with conventional induction therapy agents (antithymocyte globulin, basiliximab, and tacrolimus) in heart and lung transplantation. However, this was based on observational studies. Randomized controlled trials are needed to verify its clinical use.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.