What Can State Medical Boards Do to Effectively Address Serious Ethical Violations?

State Medical Boards (SMBs) can take severe disciplinary actions (e.g., license revocation or suspension) against physicians who commit egregious wrongdoing in order to protect the public. However, there is noteworthy variability in the extent to which SMBs impose severe disciplinary action. In this manuscript, we present and synthesize a subset of 11 recommendations based on findings from our team's larger consensus-building project that identified a list of 56 policies and legal provisions SMBs can use to better protect patients from egregious wrongdoing by physicians.

Promoting multidisciplinary care for patients with unresectable hepatocellular carcinoma (HCC): Findings from a quality improvement initiative across two community cancer centers

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Background: Evolving treatment paradigms in HCC are increasing the need for multidisciplinary coordination and a focus on patient-centered care. Identifying real-world challenges HCC care teams face in implementing these critical practices is necessary to inform educational interventions and optimize patient outcomes. Methods: In March–April 2021, 22 health care professionals (HCPs) who treat HCC at 2 US community oncology clinics completed surveys assessing practice patterns, challenges, and confidence related to multidisciplinary and patient-centered care in HCC and participated in interdisciplinary audit and feedback sessions. Patient charts evaluated pre- and post-intervention assessed changes in clinical practice. Inclusion criteria included confirmed HCC diagnosis, age ≥ 18 years, and ≥ 2 visits in the one-year chart abstraction period. Results: Participants represented the interprofessional HCC care team: medical oncologists (38%), gastroenterologists (8%), hepatologists (4%), internal medicine (17%), advanced practice professionals (4%), and nurses (29%). Baseline and follow-up patient charts included 50% and 47% Stage II-III HCC patients and 50% and 53% Stage IV HCC patients, respectively. Top reported barriers to multidisciplinary tumor board use were ineffective interdepartmental coordination/collaboration (43%) and low volume of referrals (38%). HCPs aimed to resolve these gaps through improved collaboration between multidisciplinary teams (33%) and earlier referrals to a medical oncologist (29%). Providing patient-centered supportive care was identified by 33% of HCPs as the top challenge in HCC patient care. Of HCPs surveyed, 77% estimated that ≤ 25% of patients are evaluated for/referred to distress/behavioral health services. Chart audits after educational intervention and action plan implementation showed improvements in supportive care utilization (see table). A critical component of patient-centered care, shared decision-making (SDM) was reported by 24% of HCPs. HCPs reported patient resistance to SDM (33%) and low patient health literacy (29%) as top barriers to SDM. Chart documentation of HCP participation in SDM increased post intervention (see table). Conclusions: In current real-world practice, HCC care teams report challenges in interdisciplinary collaboration and referrals, providing supportive care, and involving patients in SDM. These identified gaps represent key opportunities for future interventions to improve HCC care. [Table: see text]

Multisite Quality Improvement Initiative to Identify and Address Racial Disparities and Deficiencies in Delivering Equitable, Patient-Centered Care for Multiple Myeloma-Exploring the Differences between Academic and Community Oncology Centers

Treatment of multiple myeloma (MM) is complex; however, with equal access to care, clinical outcomes for Black patients match those in other patient groups. To reveal and begin to address clinical practice barriers to equitable, patient-centered MM care, this quality improvement (QI) initiative assessed patient electronic medical records (EMRs) and surveyed patients and providers at two large hospital systems and four community-based practices. For the educational intervention, providers participated in feedback-focused grand rounds sessions to reflect on system barriers and develop action plans to improve MM care. EMR reviews revealed infrequent documentation of cytogenetics and disease staging at community-based practices compared to large hospital systems. In surveys, providers from each care setting reported different challenges in MM care. Notably, the goals of treatment for patients and providers aligned at community clinics while providers and patients from large hospital systems had discordant perspectives. However, providers in community settings underreported race-associated barriers to care and identified different factors impacting treatment decision-making than Black patients. Relative to pre-session responses, providers were more likely to report high confidence after the educational sessions in aligning treatment decisions with guidelines and clinical evidence and shared decision-making (SDM). This QI study identified discordant perceptions among providers at large hospital systems and community-based practices in providing quality MM care. Provider education yielded increased confidence in and commitment to patient-centered care.

1956. Impact of an Implementation Science-Based Project to Address COVID-19 Vaccine Hesitancy

Background

COVID-19 vaccine uptake remains suboptimal. This project aimed to identify and mitigate reasons for vaccine hesitancy.

Baseline patient knowledge and attitudes about COVID-19 vaccination

Methods

Between 9/2021 and 1/2022, 16 live in-person and/or virtual patient education programs were held in community centers/clinics in NC and GA. Surveys were administered before/after each session, and longitudinal outcomes 3 weeks later.

Results

Surveys were conducted amongst the 1381 participating patients. 64% were already fully vaccinated against COVID-19, 19% had received 1 of 2 doses, and 17% were either unvaccinated (14%) or unsure of their status (3%). Baseline vaccine knowledge was higher among fully vaccinated patients, with patient attitudes varied per vaccination status (Figure). Patients not planning to get vaccinated cited concern for long-term (21%) and short-term (18%) side effects, thinking the vaccines were developed too quickly (16%), not feeling the vaccine would protect them (10%), and not feeling at risk for serious illness (10%). When asked what they thought would increase patient interest in vaccination, providers (n = 28) identified a strong recommendation (39%) or more information (36%) from a patient’s own doctor, while patients prioritized transportation (28%) , vaccine availability in their doctor’s office (23%), and information from their doctor (23%). Provider confidence in counseling patients improved after the program; more providers felt confident discussing vaccine safety (69%) and efficacy (69%) after the program than at baseline (33% and 41%, respectively). More patients felt confident sharing COVID-19 vaccine information with family and friends after the program (73%) than before (53%). Gains in patient views about COVID-19 vaccination were greatest among those who were unvaccinated/unsure; among this group, more patients agreed that vaccines are safe (72%), effective (76%), and important (78%) after the education, compared to 42%, 46%, and 52% at baseline, respectively. In the longitudinal patient follow-up survey 86% of unvaccinated patients got vaccinated after completing the education session.

Conclusion

Patient knowledge and attitudes varied based on vaccine experience, as did patient and provider perceptions about improving vaccine acceptance. Vaccine uptake was high following the program.

Disclosures

Scott C. Ratzan, MD, MPA, Abbvie: Stocks/Bonds|Astra Zeneca: Stocks/Bonds|baxter: Stocks/Bonds|Bristol Myers Squibb: Stocks/Bonds|Merck: Grant/Research Support|Quest Diagnostics: Stocks/Bonds|United Health Group: Stocks/Bonds|Usana Health. Services: Stocks/Bonds|vertex: Stocks/Bonds.

2201. Impact of Educational Sessions on Knowledge and Attitudes About RSV Infection and Prevention Among Residents of Long-Term Care Facilities

Background

Older adults are at risk for severe disease following respiratory syncytial virus (RSV) infection. We assessed knowledge and attitudes regarding RSV infection and prevention among residents of long-term care facilities (LTCFs).

Methods

Between October and December of 2021, surveys were administered to residents of LTCFs before and after 1.25-hour educational sessions led by health care professionals (HCPs) at 5 centers.

Results

Surveys were completed by 167 residents (76% female, average age 67 years). Residents reported low levels of knowledge of RSV-related topics, which increased significantly after the sessions (Figure 1). Before the sessions, 43% used family/friends and social media to obtain information about RSV and other infectious diseases, while only one-fourth consulted an HCP to learn about these topics. After the sessions, residents were more likely to confer with their HCP (P < .001) and less likely to utilize unreliable sources.

Although most residents indicated that they would get tested as soon as possible if they came down with symptoms suggestive of RSV or other infections, only 64% reported high confidence in preventing spread. Although most residents believed that it was important to get vaccinated against respiratory viruses and that FDA-approved vaccines are safe, only 48% would be very willing to get an RSV vaccine if available. This proportion increased to 74% after the educational sessions (Figure 2). Less than one-half were very comfortable sharing questions and concerns about vaccines with HCPs, which increased to 62% after the sessions (P = .016). After attending the sessions, more than 80% reported that they plan to get an RSV vaccine when one is available and be more diligent in taking actions to prevent the spread of infectious diseases.

Conclusion

While residents of LTCFs recognize the importance of RSV testing and prevention, they exhibit low levels of knowledge about RSV-related topics, lack of confidence in reducing the spread of disease, discomfort in raising issues regarding vaccination with their HCP, and unwillingness to get the RSV vaccine once available. Educational sessions can help to narrow knowledge gaps, increasing the potential for changes in behavior related to RSV prevention.

Disclosures

Stefan Gravenstein, MD, MPH, Genentech: Advisor/Consultant|Genentech: Grant/Research Support|Janssen: Advisor/Consultant|Janssen: Honoraria|Longeveron: Honoraria|Merck: Honoraria|Moderna: Advisor/Consultant|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Sanofi: Grant/Research Support|Sanofi: Honoraria|Seqirus: Grant/Research Support|Seqirus: Honoraria.

Quality care for patients with tenosynovial giant cell tumor: A multidisciplinary quality improvement initiative

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Background: Tenosynovial giant cell tumor (TGCT) is a rare soft tissue sarcoma that is difficult to treat due to location, high risk of recurrence, and potential for significant morbidity. Recent approvals of novel systemic therapies provide new options for patients who may not be candidates for surgery. However, clinical teams may encounter challenges that inhibit prompt referral, quality of life assessment, and effective multidisciplinary care coordination between surgeons and oncologists. Methods: In September 2020, we surveyed multidisciplinary oncology health teams (n = 25) to assess gaps in TGCT diagnosis, clinical care, and multidisciplinary care coordination. To address identified gaps, teams participated in audit-feedback sessions to develop action plans for improvement. To better understand identified gaps, surveys and education were extended to a nationwide audience of providers caring for patients with TGCT (n = 553). Results: In the health teams survey, top challenges identified included differentiating among appropriate treatment management strategies (46%), coordinating care/transitions of care for patients with TGCT (25%), and making a proper TGCT diagnosis (13%). Confidence gaps echoed these challenges, with less than half of providers indicating high/very high confidence (5-point Likert scale) in their ability to distinguish between nodular and diffuse types of TGCT (47%), align treatment decisions with evidence-based guidelines (47%), and recognize and manage adverse events associated with novel therapies (47%). During audit-feedback sessions, teams developed action plans to improve collaboration between interprofessional teams, improve adverse event management, increase education for supportive care, and facilitate earlier referrals to medical oncologists. When healthcare providers nationwide were surveyed, only 13% reported high or very high confidence in differentiating available treatment options for TGCT. Additionally, the top challenges in coordination care for patients with TGCT included poor follow-up/monitoring for disease recurrence (23%), ineffective communication between multidisciplinary team members (20%), and lack of time for patient-centered measures (19%). Conclusions: These findings reveal important challenges in diagnosis, treatment, and multidisciplinary care of TGCT patients. The methods and findings from this study offer key opportunities for scalable interventions to improve care for patients with TGCT.

Real-world practice patterns in multidisciplinary squamous cell carcinoma care at community oncology centers

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Background: As the incidence of cutaneous squamous cell carcinoma (cSCC) continues to rise and newer systemic therapies become available, coordination of care between dermatologists and oncologists will be vital to provide quality, patient-centered care. Methods: Between 8/17/2020 and 11/30/2020, we surveyed dermatology team members (n = 50) and oncology team members (n = 54) at 5 community oncology practices to assess current practices, challenges/barriers, and areas for improvement in multidisciplinary care of cSCC. Providers then participated in audit/feedback educational sessions and developed action plans to address identified gaps. Results: A majority of providers (72%) reported “very low” or “low” levels of care coordination between oncology and dermatology teams (5-point Likert scale). The three main barriers identified by dermatology/oncology teams included lack of relationship to other specialties (36%/47%), lack of multidisciplinary tumor board (30%/36%), and difficulty with patient navigation to follow-up and monitoring (44%/29%). In addition, lack of administrative support (30%/47%), lack of time (54%/42%), and high case load (32%/16%) hindered multidisciplinary tumor board meetings. Overall, dermatology teams reported lower confidence in making treatment decisions for patients with advanced cSCC compared to oncology teams. Specific strategies were identified to bridge these gaps and improve cSCC care including improving electronic communication, coordinating treatment plans with multidisciplinary teams, integrating educational seminars between oncologists and dermatologists, and finding better multimodality therapeutic options. Conclusions: These findings reveal important challenges in multidisciplinary care of cSCC in community oncology clinics. The identified gaps may inform future implementation science initiatives, and represent key opportunities for improvement in cSCC patient care.[Table: see text]

Interprofessional care team practices and perspectives on immuno-oncology (IO) therapies for metastatic non-small cell lung cancer (mNSCLC): Insights from a nationwide survey

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Background: Appropriate molecular testing, biomarker-directed treatment selection, and management of immune-related adverse events (irAEs) are essential best practices for managing patients with mNSCLC who are eligible for IO therapies. Identifying real-world challenges among mNSCLC care teams is necessary to inform educational interventions that support optimal care. Methods: From 10/2020 to 01/2021, 75 health care professionals (HCPs) who treat mNSCLC completed surveys assessing practice patterns, challenges, and confidence related to the use of IO therapies. To reflect current real-world practice across treatment settings, surveys were administered at 10 clinics nationwide and through a large oncology practice network. Results: Participants represented the interprofessional mNSCLC care team: oncologists (50%), primary care physicians (23%), advanced practice professionals (13%), and nurses (13%). Nearly one-third reported that PD-L1+ mNSCLC presented greater management challenges than other mNSCLC sub-types. Regarding patients who are eligible for IO therapies, the most commonly reported challenges were applying pathology results to treatment decisions (29%), differentiating IO therapies (19%), and managing irAEs (19%). Case-based questions revealed gaps in care relative to guidelines: 65% incorrectly identified which patients should be tested for PD-L1; 49% failed to identify the most appropriate IO regimen based on case details; and 65% failed to identify an inappropriate strategy for managing mild irAEs (Table). Further, HCPs reported inappropriate reasons to exclude patients from IO therapy and suboptimal use of supportive care measures. Confidence gaps echoed these challenges; most HCPs reported less-than-high confidence in their ability to apply molecular test results to treatment decisions (80%), differentiate IO therapies based on PD-L1 expression (65%), or coordinate irAE care (85%). Conclusions: In current real-world practice, mNSCLC care teams report challenges in biomarker testing and interpretation; differentiation of IO therapies based on patient, disease, and treatment factors; and irAE management. These identified gaps represent key opportunities for future interventions to improve mNSCLC care. [Table: see text]

Alignment and discordances in perceptions and experiences of shared decision making (SDM) among bladder cancer (BC) patients and their care team

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Background: To align BC treatment with patient goals, it is vital that healthcare providers (HCPs) engage their patients (pts) in SDM for treatment planning. We assessed alignment and discordances on aspects of SDM among BC pts and their urology and oncology teams. Methods: Between 05/2020 and 06/2020, surveys were administered to 53 pts with BC (48% female, mean age 68 years) and 23 HCPs, as part of in-clinic and virtual collaborative patient education sessions across 5 US-based practices. Surveys were designed to assess perceptions, preferences, and experiences with regard to SDM during BC care. Results: Survey findings indicated key alignments and discordances in pts’ reported experience and HCPs’ perceptions of the use of SDM in BC care. HCPs and pts identified the same top 2 patient goals for BC care: 1) preventing progression/recurrence (61% pts, 48% HCPs) and 2) maintaining quality of life (35% pts, 78% HCPs). When asked to identify patient’s top challenges for pts in BC care, both pts and HCPs indicated post-treatment aspects as the top challenge, though pts indicated managing side effects/serious worry about side effects from treatment as the top challenge (22%); whereas, HCPs were split evenly between managing side effects from treatment (26%) and managing life changes as a result of urinary diversion (26%). HCPs overestimated the effect that fatigue and worry had on pts capacity for SDM: only 9% of pts indicated worry or fatigue as a barrier to SDM, but 65% of HCPs indicated this as a likely barrier. Furthermore, the patient experience of SDM differed from HCP perception of SDM (Table); for some aspects of SDM, such as explaining different treatment options, explaining pros/cons of treatment options, and overall involvement in treatment decisions, fewer HCPs indicated that these aspects of SDM always or usually occurred as compared to pts. Conclusions: These findings reveal important alignments and discordances between pts and HCPs with regard to BC care and SDM, which may inform future bladder cancer and SDM initiatives. [Table: see text]

Real-world practice patterns in follicular lymphoma (FL) care at community oncology centers

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Background: Though FL generally has good outcomes, patients with high risk FL have poorer outcomes; proper risk stratification for early intervention has been shown to improve overall benefit in some patients. In a quality improvement (QI) initiative conducted in 4 community oncology systems, we assessed practice patterns involving prognostication and the integration of patient-disease-and treatment-related factors to improve decision-making for patients with FL. Methods: Between 10/17/2019 and 3/4/2020, we surveyed hematology/oncology health care professionals (HCP; N=59) to assess challenges, barriers, and self-reported performance of quality FL care. Electronic medical records (EMR) of 100 patients were audited for demographics, disease characteristics, risk stratification, treatment, and patient-centered metrics. To address suboptimal guideline-aligned care, teams participated in audit-feedback sessions to develop action plans for resolving identified gaps. Results: The EMR audit demonstrated low levels of documentation of staging, grade, and criteria required by risk stratification models (Table). Despite 92% of HCP indicating the use of risk stratification or prognostic models to determine treatment choice, only 23% of charts indicated use of a model for risk stratification. 55% of HCP indicated testing for t(14;18), though no patients had documented evidence of t(14;18) testing results. Survey findings indicated low confidence integrating patient-related factors to determine appropriate risk group (24%). Treatment choice was aligned with guidelines. In surveys, providers reported uncertainty about when to initiate treatment (13%), which treatments are most appropriate for each patient (23%), and engaging patients in shared decision-making (28%) as top barriers to care. During audit-feedback sessions, teams created action plans to improve documentation for variables of risk stratification, patient symptoms, molecular results, and shared decision-making. Further, teams identified the need for improved resources and personnel. Conclusions: These findings reveal important challenges to providing individualized FL care in community settings, such as documentation of clinically important metrics, care coordination, and engaging patients in shared decision-making. These gaps may inform future QI and implementation science initiatives. [Table: see text]

Patterns of care in ALK+ or ROS1+ non-small cell lung cancer (NSCLC) in community systems

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Background: For patients who have ALK or ROS1+ NSCLC, targeted therapies have greatly improved treatment options, though challenges personalizing care have hindered effective integration. In a quality improvement (QI) program conducted in 2 community oncology systems, practices involving the use of targeted therapies for NSCLC were assessed. Methods: Between 01-04/2020, retrospective EMR audits of 100 patients with ALK or ROS1+ NSCLC were analyzed for demographics, molecular testing, disease characteristics, treatment history, and shared decision-making (SDM). Surveys were administered to evaluate healthcare professionals’ (HCP; N = 47) challenges and barriers. HCP teams participated in audit-feedback sessions and developed action plans for resolving identified gaps. Results: 64% of HCPs indicated high confidence in utilizing molecular tests to inform treatment and properly sequencing targeted therapies; however, the EMR audit demonstrated challenges efficiently integrating guideline-aligned testing into practice. The mean time from diagnosis to molecular testing results was 22 days and documentation of testing for genetic aberrations other than ALK/ROS1 during work-up were low (Table). Delays in receiving molecular testing results may have presented challenges aligning treatment practices to guidelines as some patients were not receiving frontline targeted therapies (31% ALK+, 24% ROS1+). Additionally, EMR audits suggested sub-optimal use of distress screening (37%), tobacco counseling (38%), quality of life screening (60%), and engagement/documentation of various aspects of SDM (Table) for patient-centered care. Importantly, given the role internalized stigma can play in lung cancer, only 59% of those surveyed indicated that they routinely use tools to identify patients affected by stigma. During audit-feedback sessions, teams identified increased documentation, improved molecular testing/collaboration with pathology team, and provision of patient-centered care, including reduction of smoking-associated stigma as action items. Conclusions: These findings reveal important performance gaps in providing targeted and patient-centered treatment for NSCLC in community settings. These findings may be relevant for future QI programs. [Table: see text]

Real-world practice patterns and barriers to quality care in acute myeloid leukemia (AML)

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Background: For AML patients who are ineligible for intensive induction, novel therapies have greatly improved treatment options, though practice challenges individualizing care have hindered effective integration. In a quality improvement (QI) program conducted in 3 community oncology systems, we assessed practice patterns and barriers involving the use of novel therapies for AML. Methods: We surveyed 15 hematology team members to assess barriers to quality AML care and audited electronic medical records (EMR) of 100 patients across 3 community oncology centers. EMR demographics, disease characteristics, and treatment selection were reviewed. To address suboptimal guideline-aligned care, teams participated in audit-feedback sessions to develop action plans for resolving identified gaps. Results: The EMR audit demonstrated a lack of documentation for clinically important metrics necessary for individualized treatment selection and monitoring, including performance status and testing for targetable biomarkers (Table). Additionally, there was low documented use of novel therapies, such as venetoclax and gemtuzumab ozogamicin (GO), and no documented use of FLT3 or IDH inhibitors. Further, the audit revealed low adherence to guideline recommendations for frontline regimens – notably, 33.3% patients with FLT3 or IDH mutations (n = 15) were receiving low dose cytarabine alone, and 50% patients with a documented performance status of 3+ (n = 2) received intensive induction therapy. Survey findings indicated very low or low confidence in aligning practice with guidelines (20%), identifying patients who are not candidates for intensive induction (27%), and ordering/interpreting molecular tests (33%). Appropriate treatment selection (47%) and integration of molecular testing (27%) were reported as top challenges for individualized AML care. During audit-feedback sessions, teams identified improved collaboration with hematopathologists, assessment of patient mutational status, and patient engagement in treatment planning as actions they plan to integrate. Conclusions: These findings reveal important performance gaps in individualized AML care in community settings, which may inform future QI initiatives. [Table: see text]

Oncology team perception and patient experience discordances in triple-negative breast cancer (TNBC) care

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Background: In TNBC, ensuring patients understand their treatment options and engaging them in shared decision-making (SDM) is vital to patient centered care; however, system-, team-, and individual-level barriers may challenge optimal SDM. As part of a quality improvement, accredited initiative, we identified areas of discordance between oncology healthcare professionals (HCP) perception and actual patient reported experiences. Methods: From 02/2019 – 10/2019, we administered surveys to assess challenges, barriers, attitudes, and experiences of HCP who care for patients with TNBC (N = 77) and their patients with TNBC (N = 65) at 6 community oncology practices. Results: Despite indications of high levels of SDM – 86% of patients indicated that they are always or mostly involved with treatment decisions – survey responses highlight discordances. For example, when asked to identify the most influential factors to patient treatment choice, HCP most commonly indicated side effects (94%), while patients most commonly indicated quality of life (48%). Additionally, when asked to identify the side effect of greatest concern to patients, 61% of patients indicated alopecia, while 45% of HCP indicated gastrointestinal (GI) distress. While both HCP and their patients indicate that the oncology team is the most useful source of patient education, HCP underestimated the extent to which patients rely on their primary care providers (PCPs). Patients and HCP each identified limited time as a barrier to SDM, but patients indicated not knowing what to ask, while HCP indicated that low health literacy was the top barrier to SDM. 31% of patients and their care team identified that improvements in discussions about realistic prognosis were vital to improved care. Conclusions: These survey findings reveal discordances between oncology HCP’s perceptions and patient reported experiences when receiving treatment for TNBC. These findings may highlight areas for improvement in co-productive patient-centered care. [Table: see text]

Real-world data and patient perspectives on quality care and maintenance therapy (MT) decision-making for recurrent ovarian cancer (ROC)

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Background: Despite clinical evidence illustrating the efficacy of MT for ROC, complexities, such as patient-, treatment-, and disease-related factors, and team-based care coordination, limit its optimal use in ROC. In a quality improvement (QI) program, conducted at 2 oncology systems, we evaluated gaps in evidence-based, quality ROC care. Methods: Between 09/2019-02/2020, retrospective EMR audits of 200 patients with ovarian cancer were analyzed for demographics, disease characteristics, treatment history, and shared decision-making (SDM) involving MT. Surveys were administered to evaluate challenges, barriers and experiences of healthcare professionals (HCP; N = 35) and their patients with ROC (N = 21). The HCP teams participated in audit-feedback sessions and developed action plans for resolving identified gaps. Results: EMR audits revealed low utility of MT among patients with ROC (Table), and only 20% of patients reported that MT was discussed as a treatment option. Lack of access to newer therapies was most commonly identified (27%) by HCP as the biggest challenge in treating patients with ROC. Furthermore, survey results revealed that HCP are challenged to correctly integrate guidelines for patient selection for PARP inhibitor MT based on BRCA mutation status (18% of HCP answered correctly), response to previous chemotherapy (49% correct), and line of therapy (46% correct). Data indicated a low level of SDM – none of the patients indicated a high level involvement in treatment decisions and only 20% indicated a high level of agreement that their care team understood their treatment goals. EMR audits also illustrate low documentation of multiple aspects of SDM (Table). Oncology team members formulated plans to develop guidance documents to assist in therapy sequencing and tools to improve patient education. Conclusions: Overall, data from this QI program indicate gaps, challenges, and barriers in evidence-based, MT decision-making and engagement of patients in SDM. These areas for improvement may be relevant for future interventions to improve the provision of quality ROC care. [Table: see text]

Treatment patterns and barriers involving the use of CDK4/6 inhibitors for women with HR+, HER2- breast cancer

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Background: For women with HR+, HER2- breast cancer, cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) can significantly improve outcomes. However, the most effective uses of CDK4/6i may be limited by barriers including a lack of systems-based pathways and education to guide individualized treatment. In a quality improvement program in 2 healthcare systems, we assessed baseline treatment patterns and barriers involving CDK4/6i use. Methods: Participants were 34 oncologists and team members. At baseline, we administered surveys to assess barriers to prescribing CDK4/6i and audited the EMRs of 100 women with HR+, HER2- breast cancer in each system. EMRs were audited for demographics; disease characteristics; and treatment history, monitoring, and shared decision-making (SDM) involving CDK4/6i. The teams participated in an audit-feedback session and developed action plans for resolving gaps. Results: Overall, 31% of the 200 women received a CDK4/6i, and 13% received a CDK4/6i as second-line therapy. More than 30% of women treated with a CDK4/6i had documentation of only Stage I/II disease. EMR audits revealed low rates of recommended electrolyte monitoring and ECGs (0%), liver function tests (LFT; 44%), and SDM (Table). Surveys were completed by 20 participants. Whereas 80% indicated being likely to recommend a CDK4/6i, they reported barriers of identifying eligible patients (35%) and monitoring for disease progression (45%). A moderate proportion of oncologists reported considering menopausal status (60%) and patient preferences (50%) in CDK4/6i decision-making. Participants developed action plans for improving EMR documentation for disease stage and protocols for monitoring progression. Conclusions: These baseline findings reveal gaps that may inform QI initiatives for promoting the appropriate use of CDK4/6i for women with HR+, HER2- breast cancer. Findings from baseline EMR audits (n = 200).

[Table: see text]

Modified aptamers enable quantitative sub-10-nm cellular DNA-PAINT imaging

Although current implementations of super-resolution microscopy are technically approaching true molecular-scale resolution, this has not translated to imaging of biological specimens, because of the large size of conventional affinity reagents. Here we introduce slow off-rate modified aptamers (SOMAmers) as small and specific labeling reagents for use with DNA points accumulation in nanoscale topography (DNA-PAINT). To demonstrate the achievable resolution, specificity, and multiplexing capability of SOMAmers, we labeled and imaged both transmembrane and intracellular targets in fixed and live cells.

Real-world practice patterns in community U.S. oncology practices: A quality improvement approach in HER2-positive breast cancer

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Background: In breast cancer (BC), quality measures related to care coordination (CC), HER2 testing (testing) and use of HER2-targeted therapy (Tx), provide parameters for assessing care quality. We assessed the influence of quality improvement education (QIE) on alignment with BC quality indicators. Methods: 20 community oncologists participated in an IRB-approved QIE program. At baseline, 200 randomly selected charts of women with HER2+ invasive BC were retrospectively reviewed for adherence to quality measures pertaining to testing, Tx and CC. The cohort participated in accredited QIE activities for developing action plans for improvement. Follow-up chart reviews were completed 6 months after the QIE. Results: Patient and disease characteristics were generally similar across the 2 cohorts. At baseline, documentation of cancer staging was 90%, ECOG functional status assessment was 67% and cardiac testing was 33%. Treatment in the adjuvant setting was most common, followed by neoadjuvant, and metastatic. Documentation of CC varied greatly across specialties, and was highest for primary care physicians. At follow-up, randomly selected charts (n=60 to date) revealed increases in documentation of patient assessments and care coordination. A shift towards increased treatment in the neoadjuvant setting was also observed. Conclusions: QIE interventions that engaged oncology teams showed a positive impact on documentation across several parameters. A complete analysis of follow-up charts (n=200) will be presented. [Table: see text]

Abstract 085: Discordance in Patient-Physician Perceptions of Angina Experiences and Delivery of Care

Background: Recent findings from the APPEAR study indicate that physicians under-recognize angina frequency in many patients with coronary artery disease (CAD). We surveyed patients with angina and the physicians who treat them to further explore factors that may contribute to under-recognition and the impact of under-recognition on patients’ experiences.

Methods: Surveys were completed by 29 US physicians and 122 of their patients with stable CAD. Patients reported burden of angina and satisfaction with medication. Physicians estimated the average experience of their patients with stable CAD.

Results: As with prior studies, physicians under-estimated burden of angina as reported by the patients (physician vs. patient report: weekly of more angina: 24% vs 50%, p=0.014; CCS III/IV: 22% vs 43%, p<0.001). Physicians also over-estimated patients’ satisfaction with control of their angina (70% vs 50%, p<0.001). Over 90% of physicians reported routinely asking patients about the frequency of their angina and adherence to antianginal medications (Figure). Most physicians estimate angina using NYHA or CCS class (59% and 24%, respectively) whereas 7% used a patient-reported assessment. While lack of time was reported as the biggest barrier to accurately assessing patients’ burden of angina, most physicians reported having no challenges to conducting these assessments. Conversely, 68% of patients reported that their physicians effectively communicated with them.

Conclusions: Using a detailed survey of patients with stable CAD and their physicians, we found that physicians believe they are communicating effectively and most patients agreed (although to a lesser degree); yet, a substantial discordance between physician and patient perceptions of angina remains. These discordances may contribute to suboptimal treatment decisions, decreased treatment satisfaction, and poor quality of life. The observed discordances may be explained partly by the fact that <10% of physicians reported using a tool to assess angina burden directly from the patients, as physicians appeared to over-estimate their ability to accurately assess angina using traditional interview techniques. Education and use of validated angina assessment tools are essential for aligning perceptions to improve patient care and outcomes.

Continuing Medical Education Improves Gastroenterologists' Compliance with Inflammatory Bowel Disease Quality Measures

BACKGROUND

Low rates of compliance with quality measures for inflammatory bowel disease (IBD) have been reported for US gastroenterologists.

AIMS

We assessed the influence of quality improvement (QI) education on compliance with physician quality reporting system (PQRS) measures for IBD and measures related to National Quality Strategy (NQS) priorities.

METHODS

Forty community-based gastroenterologists participated in the QI study; 20 were assigned to educational intervention and control groups, respectively. At baseline, randomly selected charts of patients with moderate-to-severe ulcerative colitis were retrospectively reviewed for the gastroenterologists' performance of 8 PQRS IBD measures and 4 NQS-related measures. The intervention group participated in a series of accredited continuing medical education (CME) activities focusing on QI. Follow-up chart reviews were conducted 6 months after the CME activities. Independent t tests were conducted to compare between-group differences in baseline-to-follow-up rates of documented compliance with each measure.

RESULTS

The analysis included 299 baseline charts and 300 follow-up charts. The intervention group had significantly greater magnitudes of improvement than the control group for the following measures: assessment of IBD type, location, and activity (+14 %, p = 0.009); influenza vaccination (+13 %, p = 0.025); pneumococcal vaccination (+20 %, p = 0.003); testing for latent tuberculosis before anti-TNF-α therapy (+10 %, p = 0.028); assessment of hepatitis B virus status before anti-TNF-α therapy (+9 %, p = 0.010); assessment of side effects (+17 %, p = 0.048), and counseling patients about cancer risks (+13 %, p = 0.013).

CONCLUSIONS

QI-focused CME improves community-based gastroenterologists' compliance with IBD quality measures and measures aligned with NQS priorities.

Pulsed EPR characterization of HIV-1 protease conformational sampling and inhibitor-induced population shifts

The conformational landscape of HIV-1 protease (PR) can be experimentally characterized by pulsed-EPR double electron-electron resonance (DEER). For this characterization, nitroxide spin labels are attached to an engineered cysteine residue in the flap region of HIV-1 PR. DEER distance measurements from spin-labels contained within each flap of the homodimer provide a detailed description of the conformational sampling of apo-enzyme as well as induced conformational shifts as a function of inhibitor binding. The distance distribution profiles are further interpreted in terms of a conformational ensemble scheme that consists of four unique states termed "curled/tucked", "closed", "semi-open" and "wide-open" conformations. Reported here are the DEER results for a drug-resistant variant clinical isolate sequence, V6, in the presence of FDA approved protease inhibitors (PIs) as well as a non-hydrolyzable substrate mimic, CaP2. Results are interpreted in the context of the current understanding of the relationship between conformational sampling, drug resistance, and kinetic efficiency of HIV-1PR as derived from previous DEER and kinetic data for a series of HIV-1PR constructs that contain drug-pressure selected mutations or natural polymorphisms. Specifically, these collective results support the notion that inhibitor-induced closure of the flaps correlates with inhibitor efficiency and drug resistance. This body of work also suggests DEER as a tool for studying conformational sampling in flexible enzymes as it relates to function.

No change in neuropsychological dysfunction or emotional processing during treatment of major depression with cognitive-behaviour therapy or schema therapy

BACKGROUND

Impaired neuropsychological functioning is a feature of major depression. Previous studies have suggested that at least some aspects of neuropsychological functioning improve with successful treatment of major depression. The extent to which medications may affect the degree of normalization of these functions is unclear. The aim of the current study was to examine the course of neuropsychological functioning during treatment of major depression with cognitive-behaviour therapy (CBT) or schema therapy (ST).

METHOD

A total of 69 out-patients with a primary diagnosis of major depression and 58 healthy controls completed mood ratings, neuropsychological measures, and measures of emotional processing at baseline and after 16 weeks. Participants were randomized after baseline assessment to a year-long course of CBT or ST. Patients reassessed at 16 weeks were medication-free throughout the study.

RESULTS

Significant neuropsychological impairment was evident at baseline in depressed participants compared with healthy controls. After 16 weeks of psychotherapy, mean depression rating scores fell more than 50%. However, no neuropsychological measures showed convincing evidence of significant improvement and emotional processing did not change.

CONCLUSIONS

Persisting impairment in neuropsychological functioning after the first 16 weeks of CBT or ST suggests a need to modify psychological treatments to include components targeting cognitive functioning.

Influence of Continuing Medical Education on Rheumatologists' Performance on National Quality Measures for Rheumatoid Arthritis

Introduction

In recent years researchers have reported deficits in the quality of care provided to patients with rheumatoid arthritis (RA), including low rates of performance on quality measures. We sought to determine the influence of a quality improvement (QI) continuing education program on rheumatologists’ performance on national quality measures for RA, along with other measures aligned with National Quality Strategy priorities. Performance was assessed through baseline and post-education chart audits.

Methods

Twenty community-based rheumatologists across the United States were recruited to participate in the QI education program and chart audits. Charts were retrospectively audited before (n = 160 charts) and after (n = 160 charts) the rheumatologists participated in a series of accredited QI-focused educational activities that included private audit feedback, small-group webinars, and online- and mobile-accessible print and video activities. The charts were audited for patient demographics and the rheumatologists’ documented performance on the 6 quality measures for RA included in the Physician Quality Reporting System (PQRS). In addition, charts were abstracted for documentation of patient counseling about medication benefits/risks and adherence, lifestyle modifications, and quality of life; assessment of RA medication side effects; and assessment of RA medication adherence.

Results

Mean rates of documented performance on 4 of the 6 PQRS measures for RA were significantly higher in the post-education versus baseline charts (absolute increases ranged from 9 to 24% of patient charts). In addition, after the intervention, significantly higher mean rates were observed for patient counseling about medications and quality of life, and for assessments of medication side effects and adherence (absolute increases ranged from 9 to 40% of patient charts).

Conclusion

This pragmatic study provides preliminary evidence for the positive influence of QI-focused education in helping rheumatologists improve performance on national quality measures for RA.

Electronic supplementary material

The online version of this article (doi:10.1007/s40744-015-0018-7) contains supplementary material, which is available to authorized users.

Practical synthesis of cytidine-5-carboxamide-modified nucleotide reagents

Chemically-modified derivatives of cytidine, bearing a 5-(N-substituted-carboxamide) functional group, are new reagents for use in aptamer discovery via the SELEX process (Systematic Evolution of Ligands by EXponential enrichment). Herein, we disclose a practical synthesis of 5-(N-benzylcarboxamide)-2′-deoxycytidine, and the corresponding 5-(N-1-naphthylmethylcarboxamide)- and 5-(N-3-phenylpropylcarboxamide)-2′-deoxycytidine analogs, as both the suitably-protected 3′-O-cyanoethylphosphoramidite reagents (CEP; gram scale) and the 5′-O-triphosphate reagents (TPP; milligram-scale). The key step in the syntheses is a mild, palladium(0)-catalyzed carboxyamidation of an unprotected 5-iodo-cytidine. Use of the CEP reagents for solid-phase oligonucleotide synthesis was demonstrated and incorporation of the TPP reagents by KOD polymerase in a primer extension assay confirmed the utility of these reagents for SELEX. Finally, the carboxyamidation reaction was also used to prepare the nuclease-resistant sugar-variants: 5-(N-benzylcarboxamide)-2′-O-methyl-cytidine and 5-(N-3-phenylpropylcarboxamide)-2′-deoxy-2′-fluoro-cytidine.

Effects of PRE and POST therapy drug-pressure selected mutations on HIV-1 protease conformational sampling

Conformational sampling of pre- and post-therapy subtype B HIV-1 protease sequences derived from a pediatric subject infected via maternal transmission with HIV-1 were characterized by double electron-electron resonance spectroscopy. The conformational ensemble of the PRE construct resembles native-like inhibitor bound states. In contrast, the POST construct, which contains accumulated drug-pressure selected mutations, has a predominantly semi-open conformational ensemble, with increased populations of open-like states. The single point mutant L63P, which is contained in PRE and POST, has decreased dynamics, particularly in the flap region, and also displays a closed-like conformation of inhibitor-bound states. These findings support our hypothesis that secondary mutations accumulate in HIV-1 protease to shift conformational sampling to stabilize open-like conformations, while maintaining the predominant semi-open conformation for activity.

Crystal structure of interleukin-6 in complex with a modified nucleic acid ligand

IL-6 is a secreted cytokine that functions through binding two cell surface receptors, IL-6Rα and gp130. Because of its involvement in the progression of several chronic inflammatory diseases, IL-6 is a target of pharmacologic interest. We have recently identified a novel class of ligands called SOMAmers (S low Off-rate Modified Aptamers) that bind IL-6 and inhibit its biologic activity. SOMAmers exploit the chemical diversity of protein-like side chains assembled on flexible nucleic acid scaffolds, resulting in an expanded repertoire of intra- and intermolecular interactions not achievable with conventional aptamers. Here, we report the co-crystal structure of a high affinity SOMAmer (K_d = 0.20 nm) modified at the 5-position of deoxyuridine in a complex with IL-6. The SOMAmer, comprised of a G-quartet domain and a stem-loop domain, engages IL-6 in a clamp-like manner over an extended surface exhibiting close shape complementarity with the protein. The interface is characterized by substantial hydrophobic interactions overlapping the binding surfaces of the IL-6Rα and gp130 receptors. The G-quartet domain retains considerable binding activity as a disconnected autonomous fragment (K_d = 270 nm). A single substitution from our diversely modified nucleotide library leads to a 37-fold enhancement in binding affinity of the G-quartet fragment (K_d = 7.4 nm). The ability to probe ligand surfaces in this manner is a powerful tool in the development of new therapeutic reagents with improved pharmacologic properties. The SOMAmer·IL-6 structure also expands our understanding of the diverse structural motifs achievable with modified nucleic acid libraries and elucidates the nature with which these unique ligands interact with their protein targets.

Chemically modified DNA aptamers bind interleukin-6 with high affinity and inhibit signaling by blocking its interaction with interleukin-6 receptor

Interleukin-6 (IL-6) is a pleiotropic cytokine that regulates immune and inflammatory responses, and its overproduction is a hallmark of inflammatory diseases. Inhibition of IL-6 signaling with the anti-IL-6 receptor antibody tocilizumab has provided some clinical benefit to patients; however, direct cytokine inhibition may be a more effective option. We used the systematic evolution of ligands by exponential enrichment (SELEX) process to discover slow off-rate modified aptamers (SOMAmers) with hydrophobic base modifications that inhibit IL-6 signaling in vitro. Two classes of IL-6 SOMAmers were isolated from modified DNA libraries containing 40 random positions and either 5-(N-benzylcarboxamide)-2′-deoxyuridine (Bn-dU) or 5-[N-(1-naphthylmethyl)carboxamide]-2′-deoxyuridine (Nap-dU) replacing dT. These modifications facilitate the high affinity binding interaction with IL-6 and provide resistance against degradation by serum endonucleases. Post-SELEX optimization of one Bn-dU and one Nap-dU SOMAmer led to improvements in IL-6 binding (10-fold) and inhibition activity (greater than 20-fold), resulting in lead SOMAmers with sub-nanomolar affinity (K_d = 0.2 nm) and potency (IC₅₀ = 0.2 nm). Although similar in inhibition properties, the two SOMAmers have unique sequences and different ortholog specificities. Furthermore, these SOMAmers were stable in human serum in vitro for more than 48 h. Both SOMAmers prevented IL-6 signaling by blocking the interaction of IL-6 with its receptor and inhibited the proliferation of tumor cells in vitro as effectively as tocilizumab. This new class of IL-6 inhibitor may be an effective therapeutic alternative for patients suffering from inflammatory diseases.

Circulating levels of IL-1B+IL-6 cause ER stress and dysfunction in islets from prediabetic male mice

Elevated levels of circulating proinflammatory cytokines are associated with obesity and increased risk of type 2 diabetes, but the mechanism is unknown. We tested whether proinflammatory cytokines IL-1B+IL-6 at low picogram per milliliter concentrations (consistent with serum levels) could directly trigger pancreatic islet dysfunction. Overnight exposure to IL-1B+IL-6 in islets isolated from normal mice and humans disrupted glucose-stimulated intracellular calcium responses; cytokine-induced effects were more severe among islets from prediabetic db/db mice that otherwise showed no signs of dysfunction. IL-1B+IL-6 exposure reduced endoplasmic reticulum (ER) calcium storage, activated ER stress responses (Nos2, Bip, Atf4, and Ddit3 [CHOP]), impaired glucose-stimulated insulin secretion, and increased cell death only in islets from prediabetic db/db mice. Furthermore, we found increased serum levels of IL-1B and IL-6 in diabetes-prone mice at an age before hyperglycemia was exhibited, suggesting that low-grade systemic inflammation develops early in the disease process. In addition, we implanted normal outbred and inbred mice with subcutaneous osmotic mini-pumps containing IL-1B+IL-6 to mimic the serum increases found in prediabetic db/db mice. Both IL-1B and IL-6 were elevated in serum from cytokine-pump mice, but glucose tolerance and blood glucose levels did not differ from controls. However, when compared with controls, isolated islets from cytokine-pump mice showed deficiencies in calcium handling and insulin secretion that were similar to observations with islets exposed to cytokines in vitro. These findings provide proof of principle that low-grade systemic inflammation is present early in the development of type 2 diabetes and can trigger ER stress-mediated islet dysfunction that can lead to islet failure.

Measures of temperament and character are differentially impacted on by depression severity

BACKGROUND

Cloninger's Temperament and Character Inventory (TCI) is a widely used measure of personality. Two scales of the TCI, harm avoidance (HA) and self directedness (SD), have been shown to be influenced by depressed mood. We examined how the seven TCI scales and their subscales are correlated with depression severity before and after treatment. We also examined whether changes in personality measures could be attributed to changes in depression severity.

METHODS

Two clinical samples of depressed out-patients were recruited for trials to examine predictors of treatment response to antidepressants (N=195) and psychotherapies (N=177). Assessment included the Montgomery-Asberg depression rating scales (MADRS), Hopkins Symptom Checklist (SCL-90) and TCI at baseline and after treatment.

RESULTS

After treatment, in both samples, depression severity correlated significantly with HA and negatively with SD. Multiple regression analysis revealed that changes in SD and HA over treatment were related to improvement in depression. In the psychotherapy trial baseline MADRS scores correlated with low SD and high HA.

LIMITATIONS

The trial results are applicable to mild-moderately depressed out-patients.

CONCLUSIONS

Depression severity influences the total scales and most of the subscale measures of HA and SD. Some personality traits, as measured by the TCI, were not impacted upon by mood. Clinically mood should be taken into account when assessing personality measures of negative affect using the TCI.

Evidence that low-grade systemic inflammation can induce islet dysfunction as measured by impaired calcium handling

In obesity and the early stages of type 2 diabetes (T2D), proinflammatory cytokines are mildly elevated in the systemic circulation. This low-grade systemic inflammation exposes pancreatic islets to these circulating cytokines at much lower levels than seen within the islet during insulitis. These low-dose effects have not been well described. We examined mouse islets treated overnight with a low-dose cytokine combination commonly associated with inflammation (TNF-alpha, IL-1 beta, and IFN-gamma). We then examined islet function primarily using intracellular calcium ([Ca(2+)](i)), a key component of insulin secretion and cytokine signaling. Cytokine-treated islets demonstrated several features that suggested dysfunction including excess [Ca(2+)](i) in low physiological glucose (3mM), reduced responses to glucose stimulation, and disrupted [Ca(2+)](i) oscillations. Interestingly, islets taken from young db/db mice showed similar disruptions in [Ca(2+)](i) dynamics as cytokine-treated islets. Additional studies of control islets showed that the cytokine-induced elevation in basal [Ca(2+)](i) was due to both greater calcium influx through L-type-calcium-channels and reduced endoplasmic reticulum (ER) calcium storage. Many of these cytokine-induced disruptions could be reproduced by SERCA blockade. Our data suggest that chronic low-grade inflammation produces circulating cytokine levels that are sufficient to induce beta-cell dysfunction and may play a contributing role in beta-cell failure in early T2D.

AGI-1067, a novel antioxidant and anti-inflammatory agent, enhances insulin release and protects mouse islets

The antioxidant and anti-inflammatory compound AGI-1067 (succinobucol) has potential as an oral anti-diabetic agent. AGI-1067 reduces H(b)A1c, improves fasting plasma glucose, and reduces new-onset diabetes. We investigated AGI-1067 for possible effects on mouse pancreatic islets in vitro. Pretreatment with 10 microM AGI-1067 increased glucose-stimulated insulin secretion (11 mM) without affecting secretion in basal (3 mM) glucose. AGI-1067 enhanced the intracellular calcium response to glucose stimulation in 7 mM and 11 mM glucose, but had no effect in 28 mM or basal glucose. AGI-1067-pretreated islets also showed enhanced calcium responses to methyl pyruvate and alpha-ketoisocaproate at low doses, but not high doses. The AGI-1067-mediated effects on glucose-stimulated calcium were maintained during continuous diazoxide exposure, suggesting effects on the K(ATP)-channel-independent pathway. AGI-1067 also reduced cytokine-induced islet cell death and expression of iNOS, a key component in cytokine signaling. This is the first report of direct stimulatory and protective effects of a first-in-class potential anti-diabetic agent on pancreatic islets.

Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial

OBJECTIVE

Chlamydia trachomatis and Chlamydophila (Chlamydia) pneumoniae are known triggers of reactive arthritis (ReA) and exist in a persistent metabolically active infection state in the synovium, suggesting that they may be susceptible to antimicrobial agents. The goal of this study was to investigate whether a 6-month course of combination antibiotics is an effective treatment for patients with chronic Chlamydia-induced ReA.

METHODS

This study was a 9-month, prospective, double-blind, triple-placebo trial assessing a 6-month course of combination antibiotics as a treatment for Chlamydia-induced ReA. Eligible patients had to be positive for C trachomatis or C pneumoniae by polymerase chain reaction (PCR). Groups received 1) doxycycline and rifampin plus placebo instead of azithromycin; 2) azithromycin and rifampin plus placebo instead of doxycycline; or 3) placebos instead of azithromycin, doxycycline, and rifampin. The primary end point was the number of patients who improved by 20% or more in at least 4 of 6 variables without worsening in any 1 variable in both combination antibiotic groups combined and in the placebo group at month 6 compared with baseline.

RESULTS

The primary end point was achieved in 17 of 27 patients (63%) receiving combination antibiotics and in 3 of 15 patients (20%) receiving placebo. Secondary efficacy end points showed similar results. Six of 27 patients (22%) randomized to combination antibiotics believed that their disease went into complete remission during the trial, whereas no patient in the placebo arm achieved remission. Significantly more patients in the active treatment group became negative for C trachomatis or C pneumoniae by PCR at month 6. Adverse events were mild, with no significant differences between the groups.

CONCLUSION

These data suggest that a 6-month course of combination antibiotics is an effective treatment for chronic Chlamydia-induced ReA.

Valsartan protects pancreatic islets and adipose tissue from the inflammatory and metabolic consequences of a high-fat diet in mice

Obesity, hypertension, cardiovascular disease, and inflammation are closely associated with the rising incidence of diabetes mellitus. One pharmacological target that may have significant potential to lower the risk of obesity-related diseases is the angiotensin type 1 receptor (AT1R). We examined the hypothesis that the AT1R blocker valsartan reduces the metabolic consequences and inflammatory effects of a high-fat (Western) diet in mice. C57BL/6J mice were treated by oral gavage with 10 mg/kg per day of valsartan or vehicle and placed on either a standard chow or Western diet for 12 weeks. Western diet-fed mice given valsartan had improved glucose tolerance, reduced fasting blood glucose levels, and reduced serum insulin levels compared with mice fed a Western diet alone. Valsartan treatment also blocked Western diet-induced increases in serum levels of the proinflammatory cytokines interferon-gamma and monocyte chemotactic protein 1. In the pancreatic islets, valsartan enhanced mitochondrial function and prevented Western diet-induced decreases in glucose-stimulated insulin secretion. In adipose tissue, valsartan reduced Western diet-induced macrophage infiltration and expression of macrophage-derived monocyte chemotactic protein 1. In isolated adipocytes, valsartan treatment blocked or attenuated Western diet-induced changes in expression of several key inflammatory signals: interleukin 12p40, interleukin 12p35, tumor necrosis factor-alpha, interferon-gamma, adiponectin, platelet 12-lipoxygenase, collagen 6, inducible NO synthase, and AT1R. Our findings indicate that AT1R blockade with valsartan attenuated several deleterious effects of the Western diet at the systemic and local levels in islets and adipose tissue. This study suggests that AT1R blockers provide additional therapeutic benefits in the metabolic syndrome and other obesity-related disorders beyond lowering blood pressure.

Sequential proteolysis and high-field FTICR MS to determine disulfide connectivity and 4-maleimide TEMPO spin-label location in L126C GM2 activator protein

The GM2 activator protein (GM2AP) is an 18 kDa nonenzymatic accessory protein involved in the degradation of neuronal gangliosides. Genetic mutations of GM2AP can disrupt ganglioside catabolism and lead to deadly lysosomal storage disorders. Crystallography of wild-type GM2AP reveals 4 disulfide bonds and multiple conformations of a flexible loop region that is thought to be involved in lipid binding. To extend the crystallography results, a cysteine construct (L126C) was expressed and modified with 4-maleimide TEMPO for electron paramagnetic resonance (EPR) studies. However, because a ninth cysteine has been added by site-directed mutagenesis and the protein was expressed in E. coli in the form of inclusion bodies, the protein could misfold during expression. To verify correct protein folding and labeling, a sequential multiple-protease digestion, nano-liquid chromatograph (LC) electrospray ionization 14.5 T Fourier transform ion cyclotron resonance mass spectrometry assay was developed. High-magnetic field and robust automatic gain control results in subppm mass accuracy for location of the spin-labeled cysteine and verification of proper connectivity of the four disulfide bonds. The sequential multiple protease digestion strategy and ultrahigh mass accuracy provided by FTICR MS allow for rapid and unequivocal assignment of relevant peptides and provide a simple pipeline for analyzing other GM2AP constructs.

A practical guide to rodent islet isolation and assessment

Pancreatic islets of Langerhans secrete hormones that are vital to the regulation of blood glucose and are, therefore, a key focus of diabetes research. Purifying viable and functional islets from the pancreas for study is an intricate process. This review highlights the key elements involved with mouse and rat islet isolation, including choices of collagenase, the collagenase digestion process, purification of islets using a density gradient, and islet culture conditions. In addition, this paper reviews commonly used techniques for assessing islet viability and function, including visual assessment, fluorescent markers of cell death, glucose-stimulated insulin secretion, and intracellular calcium measurements. A detailed protocol is also included that describes a common method for rodent islet isolation that our laboratory uses to obtain viable and functional mouse islets for in vitro study of islet function, beta-cell physiology, and in vivo rodent islet transplantation. The purpose of this review is to serve as a resource and foundation for successfully procuring and purifying high-quality islets for research purposes.

Noninvasive assessment of pancreatic beta-cell function in vivo with manganese-enhanced magnetic resonance imaging

Loss of beta-cell function in type 1 and type 2 diabetes leads to metabolic dysregulation and inability to maintain normoglycemia. Noninvasive imaging of beta-cell function in vivo would therefore provide a valuable diagnostic and research tool for quantifying progression to diabetes and response to therapeutic intervention. Because manganese (Mn(2+)) is a longitudinal relaxation time (T1)-shortening magnetic resonance imaging (MRI) contrast agent that enters cells such as pancreatic beta-cells through voltage-gated calcium channels, we hypothesized that Mn(2+)-enhanced MRI of the pancreas after glucose infusion would allow for noninvasive detection of beta-cell function in vivo. To test this hypothesis, we administered glucose and saline challenges intravenously to normal mice and mice given high or low doses of streptozotocin (STZ) to induce diabetes. Serial inversion recovery MRI was subsequently performed after Mn(2+) injection to probe Mn(2+) accumulation in the pancreas. Time-intensity curves of the pancreas (normalized to the liver) fit to a sigmoid function showed a 51% increase in signal plateau height after glucose stimulation relative to saline (P < 0.01) in normal mice. In diabetic mice given a high dose of STZ, only a 9% increase in plateau signal intensity was observed after glucose challenge (P = not significant); in mice given a low dose of STZ, a 20% increase in plateau signal intensity was seen after glucose challenge (P = 0.02). Consistent with these imaging findings, the pancreatic insulin content of high- and low-dose STZ diabetic mice was reduced about 20-fold and 10-fold, respectively, compared with normal mice. We conclude that Mn(2+)-enhanced MRI demonstrates excellent potential as a means for noninvasively monitoring beta-cell function in vivo and may have the sensitivity to detect progressive decreases in function that occur in the diabetic disease process.

Evidence of diminished glucose stimulation and endoplasmic reticulum function in nonoscillatory pancreatic islets

Pulsatility is a fundamental feature of pancreatic islets and a hallmark of hormone secretion. Isolated pancreatic islets endogenously generate rhythms in secretion, metabolic activity, and intracellular calcium ([Ca(2+)](i)) that are important to normal physiological function. Few studies have directly compared oscillatory and nonoscillatory islets to identify possible differences in function. We investigated the hypothesis that the loss of these oscillations is a leading indicator of islet dysfunction by comparing oscillatory and nonoscillatory mouse islets for multiple parameters of function. Nonoscillatory islets displayed elevated basal [Ca(2+)](i) and diminished [Ca(2+)](i) response and insulin secretory response to 3-28 mm glucose stimulation compared with oscillatory islets, suggesting diminished glucose sensitivity. We investigated several possible mechanisms to explain these differences. No differences were observed in mitochondrial membrane potential, estimated ATP-sensitive potassium channel and L-type calcium channel activity, or cell death rates. Nonoscillatory islets, however, showed a reduced response to the sarco(endo)plasmic reticulum calcium ATPase inhibitor thapsigargin, suggesting a disruption in calcium homeostasis in the endoplasmic reticulum (ER) compared with oscillatory islets. The diminished ER calcium homeostasis among nonoscillatory islets was also consistent with the higher cytosolic calcium levels observed in 3 mm glucose. Inducing mild damage with low-dose proinflammatory cytokines reduced islet oscillatory capacity and produced similar effects on glucose-stimulated [Ca(2+)](i), basal [Ca(2+)](i), and thapsigargin response observed among untreated nonoscillatory islets. Our data suggest the loss of oscillatory capacity may be an early indicator of diminished islet glucose sensitivity and ER dysfunction, suggesting targets to improve islet assessment.

12-Lipoxygenase-knockout mice are resistant to inflammatory effects of obesity induced by Western diet

Inflammation is a key pathological process in the progression of atherosclerosis and type 2 diabetes. 12/15-lipoxygenase (12-LO), an enzyme involved in fatty acid metabolism, may contribute to inflammatory damage triggered by stressors such as obesity and insulin resistance. We hypothesized that mice lacking 12-LO are protected against inflammatory-mediated damage associated with a "western" diet. To test this hypothesis, age-matched male 12-LO knockout (12-LOKO) and wild-type C57BL/6 (B6) mice were fed either a standard chow or western diet and assessed for several inflammatory markers. Western-fed B6 mice showed expected reductions in glucose and insulin tolerance compared with chow-fed mice. In contrast, western-fed 12-LOKO mice maintained glucose and insulin tolerance similar to chow-fed mice. Circulating proinflammatory cytokines, tumor necrosis factor-alpha and interleukin-6, were increased in western B6 mice but not 12-LOKO mice, whereas the reported protective adipokine, adiponectin, was decreased only in western B6 mice. 12-LO activity was significantly elevated by western diet in islets from B6 mice. Islets from 12-LOKO mice did not show western-diet-induced islet hyperplasia or increases in caspase-3 apoptotic staining observed in western-fed B6 mice. Islets from 12-LOKO mice were also protected from reduced glucose-stimulated insulin secretion observed in islets from western-fed B6 mice. In visceral fat, macrophage numbers and monocyte chemoattractant protein-1 expression were elevated in western B6 mice but not 12-LOKO mice. These data suggest that 12-LO activation plays a role in western-diet-induced damage in visceral fat and islets. Inhibiting 12-LO may provide a new therapeutic approach to prevent inflammation-mediated metabolic consequences of excess fat intake.

Nonobese diabetic (NOD) mice congenic for a targeted deletion of 12/15-lipoxygenase are protected from autoimmune diabetes

OBJECTIVE

12/15-lipoxygenase (12/15-LO), one of a family of fatty acid oxidoreductase enzymes, reacts with polyenoic fatty acids to produce proinflammatory lipids. 12/15-LO is expressed in macrophages and pancreatic beta-cells. It enhances interleukin 12 production by macrophages, and several of its products induce apoptosis of beta-cells at nanomolar concentrations in vitro. We had previously demonstrated a role for 12/15-LO in beta-cell damage in the streptozotocin model of diabetes. Since the gene encoding 12/15-LO (gene designation Alox15) lies within the Idd4 diabetes susceptibility interval in NOD mice, we hypothesized that 12/15-LO is also a key regulator of diabetes susceptibility in the NOD mouse.

RESEARCH DESIGN AND METHODS

We developed NOD mice carrying an inactivated 12/15-LO locus (NOD-Alox15(null)) using a "speed congenic" protocol, and the mice were monitored for development of insulitis and diabetes.

RESULTS

NOD mice deficient in 12/15-LO develop diabetes at a markedly reduced rate compared with NOD mice (2.5 vs. >60% in females by 30 weeks). Nondiabetic female NOD-Alox15(null) mice demonstrate improved glucose tolerance, as well as significantly reduced severity of insulitis and improved beta-cell mass, when compared with age-matched nondiabetic NOD females. Disease resistance is associated with decreased numbers of islet-infiltrating activated macrophages at 4 weeks of age in NOD-Alox15(null) mice, preceding the development of insulitis. Subsequently, islet-associated infiltrates are characterized by decreased numbers of CD4(+) T cells and increased Foxp3(+) cells.

CONCLUSIONS

These results suggest an important role for 12/15-LO in conferring susceptibility to autoimmune diabetes in NOD mice through its effects on macrophage recruitment or activation.

Combined treatment with lisofylline and exendin-4 reverses autoimmune diabetes

Type 1 diabetes mellitus (T1DM) is an autoimmune disease leading to near complete pancreatic beta-cell destruction. New evidence suggests that beta-cell regeneration is possible, but ongoing autoimmune damage prevents restoration of beta-cell mass. We tested the hypothesis that simultaneously blocking autoimmune cytokine damage and supplying a growth-promoting stimulus for beta-cells would provide a novel approach to reverse T1DM. Therefore, in this study we combined lisofylline to suppress autoimmunity and exendin-4 to enhance beta-cell proliferation for treating autoimmune-mediated diabetes in the non-obese diabetic (NOD) mouse model. We found that this combined therapy effectively reversed new-onset diabetes within a week of therapy, and even maintained euglycemia up to 145 days after treatment withdrawal. The therapeutic effect of this regimen was associated with improved beta-cell metabolism and insulin secretion, while reducing beta-cell apoptosis. It is possible that such combined therapy could become a new strategy to defeat T1DM in humans.

The effect of a low-carbohydrate diet on bone turnover

INTRODUCTION

Low-carbohydrate diets have become popular as weight loss techniques. These diets are high in protein, saturated fats, and omega-6 fatty acids. They also lead to a ketogenic state. These factors could lead to increased bone turnover. This study was designed to see whether a low-carbohydrate diet would lead to increased bone turnover in humans.

METHODS

Thirty patients (15 study subjects and 15 controls) were recruited for this 3-month study. The 15 patients on the diet were instructed to consume less than 20 g of carbohydrates per day for the 1st month and then less than 40 g per day for months 2 and 3. Control subjects had no restrictions on their diet. The primary end point was urinary N-telopeptide (UNTx) at 3 months. Secondary end points included UNTx at 1 month, bone-specific alkaline phosphatase (BSAP) at 1 month, bone turnover ratio (BSAP/UNTx) at 1 month, and weight loss.

RESULTS

The mean UNTx in the study subjects increased by 1.6 [95% confidence interval (CI) +/-22.8] compared with an increase of 1.9 (95% CI +/-17.6) in the controls at 3 months (p=0.86). The mean UNTx decreased by 2.2 (95% CI +/-27.2) and 3.1 (95% CI +/-17.6) at 1 month in the dieters and controls, respectively (p=0.36). The mean BSAP decreased by 0.53 (95% CI +/-2.96) in the dieters and increased by 0.34 (95% CI +/-2.92) in the controls at 1 month (p=0.27). The bone turnover ratio increased by 0.08 (95% CI +/-0.81) in the dieters and by 0.05 (95% CI +/- 0.27) in the controls at 1 month (p=0.78). The dieters lost 6.39 kg versus 1.05 kg for the controls at 3 months (p=0.0008).

CONCLUSIONS

Although the patients on the low-carbohydrate diet did lose significantly more weight than the controls did, the diet did not increase bone turnover markers compared with controls at any time point. Further, there was no significant change in the bone turnover ratio compared with controls.

Viral IL-10-mediated immune regulation in pancreatic islet transplantation

Protection of transplanted pancreatic islet grafts in recipients with autoimmune diabetes depends on the suppression of autoimmune recurrence and allogeneic rejection. The aim of this study was to investigate the efficiency of viral IL-10 gene delivery in the prevention of autoimmune recurrence following islet transplantation. We evaluated the effectiveness of a systemically delivered adeno-associated viral vector (AAV vIL-10) carrying viral IL-10 in protecting islet engraftment. We observed significant prolongation of graft survival after treatment with AAV vIL-10 when using islets from donors lacking autoimmunity. We found that the mechanism of vIL-10-mediated protection was associated with suppression of T cell activation and that donor immune cells that were simultaneously transferred with the islet grafts could induce autoimmune recurrence. AAV vIL-10 gene transfer suppressed previously activated T cells and protected grafted islets from autoimmune-mediated destruction. We conclude that vIL-10 can regulate autoimmune activity and that transfer of its gene may have potential for therapeutic islet transplantation.

The relationship between performance on the standardised field sobriety tests, driving performance and the level of Δ9-tetrahydrocannabinol (THC) in blood

The consumption of Delta9-tetrahydrocannabinol (THC) as cannabis has been shown to result in impaired and culpable driving. Testing drivers for the presence of THC in blood is problematic as THC and its metabolites may remain in the blood for several days following its consumption, even though the drug may no longer have an influence on driving performance. In the present study, the aim was to assess whether performance on the standardised field sobriety tests (SFSTs) provides a sensitive measure of impaired driving behaviour following the consumption of THC. In a repeated measures design, 40 participants consumed cigarettes that contained either 0% THC (placebo), 1.74% THC (low dose) or 2.93% THC (high dose). For each condition, after smoking a cigarette, participants performed the SFSTs on three occasions (5, 55 and 105 min after the smoking procedure had been completed) as well as a simulated driving test on two occasions (30 and 80 min after the smoking procedure had been completed). The results revealed that driving performance was not significantly impaired 30 min after the consumption of THC but was significantly impaired 80 min after the consumption of THC in both the low and high dose conditions. The percentage of participants whose driving performance was correctly classified as either impaired or not impaired based on the SFSTs ranged between 65.8 and 76.3%, across the two THC conditions. The results suggest that performance on the SFSTs provides a moderate predictor of driving impairment following the consumption of THC and as such, the SFSTs may provide an appropriate screening tool for authorities that wish to assess the driving capabilities of individuals suspected of being under the influence of a drug other than alcohol.

Inflammation blockade improves pancreatic islet function

Pancreatic islet transplantation can replace insulin-secreting beta cells in patients with diabetes mellitus. However, current methodology for isolating islets from a pancreas only retrieves a portion of the total islets. Within these limited number of islets, nearly 50% of beta cells lose biological function before transplantation. Protecting and improving beta-cell viability and function was the goal of this study. Previously we observed that an anti-inflammatory compound, lisofylline (LSF), protects beta cells from cytotoxicity during diabetes development. In this study, we demonstrated that human islets treated in vitro with LSF retained beta-cell glucose responsiveness and insulin secretion in the presence of multiple proinflammatory cytokines. In addition, LSF treatment in vitro enhanced basal insulin production in beta cells, suggesting that LSF can directly improve beta-cell function. LSF reduced beta-cell apoptosis induced by proinflammatory cytokines by 50%. Importantly, 30% fewer LSF-treated islets were sufficient to achieve insulin independence in a murine islet transplantation model. These results demonstrate the ability of LSF-like compounds to protect and enhance beta-cell function, suggesting the potential of using LSF or its analogs in islet transplantation.