Axion Mass from Magnetic Monopole Loops

We show that axions interacting with Abelian gauge fields obtain a potential from loops of magnetic monopoles. This is a consequence of the Witten effect: the axion field causes the monopoles to acquire an electric charge and alters their energy spectrum. The axion potential can also be understood as a type of instanton effect due to a Euclidean monopole worldline winding around its dyon collective coordinate. We calculate this effect, which has features in common with both non-Abelian instantons and Euclidean brane instantons. To provide consistency checks, we argue that this axion potential vanishes in the presence of a massless charged fermion and that it is robust against the presence of higher-derivative corrections in the effective Lagrangian. Finally, as a first step toward connecting with particle phenomenology and cosmology, we discuss the regime in which this potential is important in determining the dark matter relic abundance in a hidden sector containing an Abelian gauge group, monopoles, and axions.

The efficacy of toltrazuril treatment for reducing the infection intensity of Theileria orientalis Ikeda type in dairy calves

The aim of this study was to test the hypothesis that toltrazuril administered at 4 weeks post-turnout reduces the infection intensity of Theileria orientalis Ikeda type in dairy calves and so prevents serious clinical disease in these animals at 2-3 months of age. Two groups of 40 dairy calves on two separate dairy farms in the Waikato were followed for 16 weeks post-turnout onto pasture. On each farm, 20 calves were randomly selected and orally treated with toltrazuril (15 mg/kg) at 4 weeks post-turnout, whilst the remaining 20 calves were left untreated. All 40 calves were blood sampled and weighed at 2, 4, 6, 8, 12, and 16 weeks post-turnout i.e. 6 samplings per calf. A random subset of 10 calves from each treatment group on each farm were faecal sampled at each visit. The blood samples were used to estimate the T. orientalis Ikeda type infection intensity and haematocrit for each calf and the faecal samples were used to estimate the number of coccidia oocysts per gram of faeces. Three linear mixed effects models, to evaluate the effect of toltrazuril treatment on infection intensity, haematocrit (HCT) and weight respectively were fitted to the data. No calves on either farm developed clinical theileriosis or coccidiosis and the three mixed effects linear models, controlling for the effect of farm and days from turnout, showed that there was no effect of treatment on infection intensity (p = 0.81), on HCT (p = 0.99) and on weight gain (p = 0.79). In conclusion, this study showed no evidence supporting the use of toltrazuril to control T. orientalis Ikeda type infection levels and prevent disease.

Ventricular Flow Field Visualization During Mechanical Circulatory Support in the Assisted Isolated Beating Heart

Investigations of ventricular flow patterns during mechanical circulatory support are limited to in vitro flow models or in silico simulations, which cannot fully replicate the complex anatomy and contraction of the heart. Therefore, the feasibility of using echocardiographic particle image velocimetry (Echo-PIV) was evaluated in an isolated working heart setup. Porcine hearts were connected to an isolated, working heart setup and a left ventricular assist device (LVAD) was implanted. During different levels of LVAD support (unsupported, partial support, full support), microbubbles were injected and echocardiographic images were acquired. Iterative PIV algorithms were applied to calculate flow fields. The isolated heart setup allowed different hemodynamic situations. In the unsupported heart, diastolic intra-ventricular blood flow was redirected at the heart’s apex towards the left ventricular outflow tract (LVOT). With increasing pump speed, large vortex formation was suppressed, and blood flow from the mitral valve directly entered the pump cannula. The maximum velocities in the LVOT were significantly reduced with increasing support. For the first time, cardiac blood flow patterns during LVAD support were visualized and quantified in an ex vivo model using Echo-PIV. The results reveal potential regions of stagnation in the LVOT and, in future the methods might be also used in clinical routine to evaluate intraventricular flow fields during LVAD support.

Untargeted metabolic profiling of dogs with a suspected toxic mitochondrial myopathy using liquid chromatography-mass spectrometry

'Go Slow myopathy' (GSM) is a suspected toxic myopathy in dogs that primarily occurs in the North Island of New Zealand, and affected dogs usually have a history of consuming meat, offal or bones from wild pigs (including previously frozen and/or cooked meat). Previous epidemiological and pathological studies on GSM have demonstrated that changes in mitochondrial structure and function are most likely caused by an environmental toxin that dogs are exposed to through the ingestion of wild pig. The disease has clinical, histological and biochemical similarities to poisoning in people and animals from the plant Ageratina altissima (white snakeroot). Aqueous and lipid extracts were prepared from liver samples of 24 clinically normal dogs and 15 dogs with GSM for untargeted liquid chromatography-mass spectrometry. Group-wise comparisons of mass spectral data revealed 38 features that were significantly different (FDR<0.05) between normal dogs and those with GSM in aqueous extracts, and 316 significantly different features in lipid extracts. No definitive cause of the myopathy was identified, but alkaloids derived from several plant species were among the possible identities of features that were more abundant in liver samples from affected dogs compared to normal dogs. Mass spectral data also revealed that dogs with GSM have reduced hepatic phospholipid and sphingolipid concentrations relative to normal dogs. In addition, affected dogs had changes in the abundance of kynurenic acid, various dicarboxylic acids and N-acetylated branch chain amino acids, suggestive of mitochondrial dysfunction.

Patterns of referral and uptake of BReast CAncer (BRCA) gene testing of eligible women with ovarian cancer in New Zealand

AIMS

To determine the proportion of eligible patients with high-grade serous carcinoma of the ovary, fallopian tube or peritoneum discussed at gynaecological oncology multidisciplinary meetings (MDMs) in New Zealand and subsequently referred for genetic counselling and BRCA pathogenic variant testing.

METHODS

Eligible cases were identified from Auckland, Wellington, Christchurch and Dunedin gynaecologic oncology MDM databases between 1 January 2015 to 31 December 2016. Patients who met the eligibility criteria for genetics referral were identified, and cross-referenced against genetic services databases to ascertain the rates of referrals received, the numbers attending appointments, genetic testing offered and range of results.

RESULTS

During the two-year period, 205 patients were eligible for referral. Of these, 143 (70%) patients were referred for genetic counselling with 128 (90%) of this group recommended for BRCA pathogenic variant testing. Of the 126 who undertook the test, results were available for 120 (95%). Nineteen patients (16%) tested positive for a germline BRCA pathogenic variant.

CONCLUSIONS

The New Zealand rate of referral to genetic counselling for women with high-grade serous cancer, (HGSC), of the ovary, fallopian tube or peritoneum diagnosed between 2015-2016 is encouraging when compared with others internationally. The rate of BRCA positive pathogenic variants is comparable to international data.

Abstract B29: Innate immune modulation: The novel immunotherapeutic Imprime PGG triggers the anti-cancer immunity cycle in concert with tumor-targeting, anti-angiogenic and checkpoint inhibitor antibodies

Cancer immunotherapeutics largely focus on awakening T cell mediated recognition and eradication of tumor cells. Indeed, checkpoint inhibitor antibodies (e.g. pembrolizumab) unleash T cells already involved in anti-cancer responses and have shown remarkable clinical activity, though only in ~20-30% of solid tumor patients. Numerous approaches are being explored to enhance the percent of patients who benefit from checkpoint inhibitor therapies. Chief amongst these are the innate immune modulating therapies collectively designated as PAMPs- pathogen- associated molecular patterns. PAMPs operate as the critical non-self signals that, in response to pathogen infection, ignite the function of the innate immune system to trigger the immunity cycle. TLR and STING agonists acts as PAMPs and reflect bacterial and viral danger signals that can drive dendritic cell maturation, enhancing T cell function. These agents are in development in combination with other immunotherapies, including checkpoint inhibitors, but inspire intolerable cytokine storms and are thereby limited to direct intra-tumoral delivery approaches. We therefore sought to discover and develop a novel, systemically administered PAMP- Imprime PGG (Imprime). Ex vivo studies with whole blood from healthy human donors show that Imprime consistently elicits the activation of innate immune cells. M2 state macrophages repolarize, showing increased expression of M1 markers (CD86, PD-L1) with coincident reduction in M2 markers (CD163, CD206). Dendritic cells (DCs) mature, showing enhanced surface expression of CD80, CD86 and MHC class II. Functionally, the antigen presentation capability of these re-polarized macrophages and activated DCs is substantially enhanced and drives the robust expansion of co-cultured CD8 T cells as well as the marked upregulation of the potent anti-tumor cytokine interferon gamma. In preclinical tumor studies, Imprime is administered IV and profoundly enhances the efficacy of numerous antibody therapies. Using the B16 experimental metastasis model, we show that Imprime (administered IV) synergizes with the anti-TRP1 tumor-targeting antibody TA-99, nearly eradicating B16 metastases as measured by visual counts, TRP-1 RT-PCR and in situ immunofluorescence for TRP1. In the H441 and H1299 non-small cell lung cancer xenografts, Imprime synergizes with the anti-VEGFR2 antibody DC101 to flat-line tumor growth. In the MC-38, CT-26 and 4T-1 syngeneic tumor models, Imprime synergizes with both anti-PD-1 and PD-L1 checkpoint inhibitor antibodies to repress tumor growth and/or to eradicate cancer lesions. In situ imaging of these preclinical tumor tissues repeatedly shows that Imprime instigates a re-orientation of the immune microenvironment, promoting an M1 state (e.g. increased iNOS2, decreased Arginase 1), as well as the influx of myeloid cells and, in the syngenic models, CD8 T cells. In clinical trials in &gt; 400 total patients to date, Imprime has been safely administered by IV infusion (4mg/kg over 2 hours) and has repeatedly shown evidence for efficacy in combination with tumor targeting or anti-angiogenic antibodies. Studies with checkpoint inhibitor antibodies are slated to begin summer of 2016. We now provide the first evidence in healthy human volunteers that Imprime (IV- 4mg/kg, 2 hours) drives the same innate immune activation events evident in the preclinical studies (e.g. chemokine and cytokine release, PD-L1 and CD86 upregulation) verifying that the clinical dose activates the innate immune system. Together, these preclinical and clinical studies provide evidence that the novel PAMP, Imprime PGG, can be safely administered systemically and can drive the critical innate immune activation necessary to spark the anti-cancer immunity cycle.

Citation Format: N Bose, K Gorden, A Chan, A Jonas Bykowski, N Ottoson, D Walsh, X Qiu, B Harrison, T Kangas, K Fraser, R Fulton, S Leonardo, M Uhlik, J Graff. Innate immune modulation: The novel immunotherapeutic Imprime PGG triggers the anti-cancer immunity cycle in concert with tumor-targeting, anti-angiogenic and checkpoint inhibitor antibodies. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr B29.

Atypical Anti-Psychotics in the Real World -A Naturalistic Comparative Outcome Study

Background: There are few real life independent comparative studies of atypical antipsychotics. We prospectively examined five commonly used atypical antipychotics in the UK, without support from the pharmaceutical industry. Method: Prospective naturalistic systematic clinical evaluation. Patients being newly prescribed atypical anti-psychotics over a one year period were assessed by psychiatrists at initiation and after six months treatment using five outcome measures: clinical global impression; positive and negative psychotic symptoms; drug related side effects; and quality of life. Results: 373 patients participated in total. Olanzapine and risperidone produced statistically significant reductions in all ratings at stx months. Amisulpride, clozapine, and quetiapine were also studied. There was limited variance between the different drugs, although some sample sizes were small. Conclusion: Atypical anti-psychotics were found to be clinically effective, and produced similar outcomes. Routine monitoring of outcomes in psychiatry is feasible.

Selection for anthelmintic resistant Teladorsagia circumcincta in pre-weaned lambs by treating their dams with long-acting moxidectin injection

Administration of long-acting anthelmintics to pregnant ewes prior to lambing is a common practice in New Zealand. Today, most of these products contain macrocyclic lactone (ML) actives, which because of their lipophilic nature, are detectable in the milk of treated animals and in the plasma of their suckling offspring. This study was conducted to confirm the transfer of ML actives to lambs in the ewe's milk, and to assess whether this could result in selection for ML resistant nematodes in the lamb. Ninety, twin bearing Romney ewes were treated before lambing with a long-acting injectable formulation of moxidectin, a 100-day controlled release capsule (CRC) containing abamectin and albendazole, or remained untreated. After lambing, seven ewes from each treatment group were selected for uniformity of lambing date and, along with their twin lambs, relocated indoors. At intervals, all ewes and lambs were bled, and samples of ewe's milk were collected, for determination of drug concentrations. Commencing 4 weeks after birth all lambs were dosed weekly with 250 infective larvae (L3) of either an ML-susceptible or –resistant isolate of Teladorsagia circumcinta. At 12 weeks of age all lambs were slaughtered and their abomasa recovered for worm counts. Moxidectin was detected in the plasma of moxidectin-treated ewes until about 50 days after treatment and in their lambs until about day 60. Abamectin was detected in the plasma of CRC-treated ewes until the last sample on day 80 and in the plasma of their lambs until about day 60. Both actives were detectable in milk of treated ewes until day 80 after treatment. Establishment of resistant L3 was not different between the treatment groups but treatment of ewes with moxidectin reduced establishment of susceptible L3 by 70%, confirming the potential of drug transfer in milk to screen for ML-resistance in the suckling lamb.

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Long-acting anthelmintics were administered to pregnant ewes.

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Moxidectin and abamectin were detected in ewe's milk for >60 days.

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Moxidectin and abamectin were detected in plasma of lambs for >60 days.

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Abamectin treatment had not effect on establishment of larvae in the lambs.

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Moxidectin treatment reduced establishment of susceptible, but not resistant larvae.

Tobacco dependence, the most important cardiovascular risk factor: treatment in the Czech Republic

Smoking is the most important cardiovascular (CV) risk factor. Stopping smoking halves the CV risk. Every clinician should provide a brief intervention with smokers. Intensive treatment should be available to those who need it. There are 37 Centers for Tobacco Dependence in the Czech Republic, which offer treatment including a psychobehavioral intervention and pharmacotherapy (varenicline, nicotine, bupropion). Czech physicians, pharmacists and nurses are regularly educated about smoking cessation. We describe the results of intensive treatment offered by our centers. Treatment includes screening (1 h), an intervention (2 h), and follow-up visits during the next 12 months. Among 3532 patients, 34.3 % had CO-validated abstinence at 12-months (including 489 patients who attended the screening visit + only the 12-month follow up visit). Among patients who underwent the intervention, the abstinence rate was 38.2 %. The majority of patients who underwent the intervention (N=2470) used some form of pharmacotherapy. After one year, the abstinence rate was 43.4 %, compared to 15.9 % (N=573) without pharmacotherapy. Only 28 % of patients came on the recommendation of a physician. Despite the decrease in CV risk following smoking cessation and the effectiveness of treatment, centers are underutilized.

Public opinion of drug treatment policy: exploring the public's attitudes, knowledge, experience and willingness to pay for drug treatment strategies

BACKGROUND

Research evidence is strong for opiate replacement treatment (ORT). However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between, attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. This is relevant in the current policy arena in which a major shift from harm reduction to, rehabilitation is underway.

METHODS

A cross sectional postal questionnaire survey in Scotland was conducted where the drug, treatment strategy has changed from harm-reduction to recovery-based. A random sample (N=3000), of the general public, >18 years, and on the electoral register was used. The questionnaire was largely structured with tick box format but included two open questions for qualitative responses. Valuation was measured using the economic willingness-to-pay (WTP) method.

RESULTS

The response rate was 38.1% (1067/2803). Less than 10% had personal experience of drug, misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p<0.001), better knowledge of drugs (p=0.001) and higher income (those earning >£50,000 per, annum compared to <£15K; p=0.01). Over half of respondents were not willing to pay anything for drug treatment indicating they did not value these treatments at all. Respondents were willing-to-pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated many strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit.

CONCLUSIONS

There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

Reduced heart rate variability during sleep in long-duration spaceflight

Limited data are available to describe the regulation of heart rate (HR) during sleep in spaceflight. Sleep provides a stable supine baseline during preflight Earth recordings for comparison of heart rate variability (HRV) over a wide range of frequencies using both linear, complexity, and fractal indicators. The current study investigated the effect of long-duration spaceflight on HR and HRV during sleep in seven astronauts aboard the International Space Station up to 6 mo. Measurements included electrocardiographic waveforms from Holter monitors and simultaneous movement records from accelerometers before, during, and after the flights. HR was unchanged inflight and elevated postflight [59.6 ± 8.9 beats per minute (bpm) compared with preflight 53.3 ± 7.3 bpm; P < 0.01]. Compared with preflight data, HRV indicators from both time domain and power spectral analysis methods were diminished inflight from ultralow to high frequencies and partially recovered to preflight levels after landing. During inflight and at postflight, complexity and fractal properties of HR were not different from preflight properties. Slow fluctuations (<0.04 Hz) in HR presented moderate correlations with movements during sleep, partially accounting for the reduction in HRV. In summary, substantial reduction in HRV was observed with linear, but not with complexity and fractal, methods of analysis. These results suggest that periodic elements that influence regulation of HR through reflex mechanisms are altered during sleep in spaceflight but that underlying system complexity and fractal dynamics were not altered.

Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease

INTRODUCTION

Non-invasive ventilation (NIV) has revolutionised the management of hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD). We wished to evaluate factors related to its overall success in the 'real-life' setting.

METHODS

A retrospective analysis of patients receiving NIV for a hypercapnic exacerbation of COPD was performed. Demographics, laboratory data, blood gases and outcomes (hospital discharge or in-patient death) were extracted and subsequently analysed to identify factors relating to its overall success or failure.

RESULTS

Over 6 years, 240 patients (mean age 70 years), received NIV with mean pH and pCO(2) prior to NIV 7.24 and 10.4kPa respectively; of these, 167 survived to hospital discharge with a median age (70 vs. 74; p = 0.02) lower than non-survivors. Absolute values of pH and pCO(2) (higher and lower respectively) prior to NIV and at 1 h were both associated with successful hospital discharge. An improvement (p = 0.02) in pH within an hour of receiving NIV - but not pCO(2) - was associated with surviving to hospital discharge. Of all laboratory data assessed, only baseline urea was significantly (p = 0.021) associated with a successful outcome.

CONCLUSION

Younger patients with a lower urea, higher pH and lower pCO(2) at baseline and who demonstrate an improvement in pH within 1 h, are more likely to have a successful outcome when given NIV for a hypercapnic exacerbation of COPD on an unselected basis. Prospective studies evaluating many other parameters are now required to help identify patients in whom NIV is likely to be successful.

Economic impact of using inhaled corticosteroids without prior exacerbation among elderly patients with chronic obstructive pulmonary disorder

OBJECTIVE

To assess the economic impact of initiating inhaled corticosteroids (ICS) without evidence of prior exacerbation among elderly patients with chronic obstructive pulmonary disease (COPD) in the US.

METHODS

This retrospective study used administrative claims to identify newly diagnosed COPD patients between 1/1/2005 and 6/30/2006 who were dispensed ICS. The dispense date of the first ICS was set as the index date. Patients with prior diagnoses for asthma, cystic fibrosis, or lung cancer were excluded. Cohorts were constructed based on whether ICS therapy was concordant with recommended guidelines of having prior COPD exacerbation. Each COPD patient with prior exacerbation was matched to four patients without exacerbation based on age, gender, Charlson Comorbidity Index, and whether COPD diagnosis code was not elsewhere specified (i.e., 496). Multivariate regressions were estimated to assess the association between use of ICS therapy without prior exacerbation and total healthcare costs, controlling for demographics and clinical characteristics.

RESULTS

The study included 3650 patients: 730 with prior exacerbation and 2920 without prior exacerbation. Patients were 76 years of age and 54% were male. Those with prior exacerbation were more likely to have inpatient stays both prior to (74.4 vs. 44.1%, p<0.05) and following (37.0 vs. 33.1%, p<0.05) the index date. Controlling for patient characteristics, patients who were dispensed ICS without prior exacerbation had $1859 higher in total costs (p<0.05) compared to patients with prior exacerbation during the 12 months following ICS initiation.

LIMITATIONS

The retrospective design of this study limits the interpretation of findings as association and not causality. This study is subject to selection bias due to unobservable confounders.

CONCLUSIONS

Among COPD patients, initiation of ICS without prior exacerbation appears to be associated with increased healthcare costs. These findings suggest that ICS initiation without evidence of exacerbation as consistent with guidelines is associated with adverse economic consequences.

Factors associated with pain medication selection among patients diagnosed with diabetic peripheral neuropathic pain: a retrospective study

OBJECTIVE

To assess the demographic and clinical characteristics associated with initiation of duloxetine therapy compared with other pharmacologic therapies for treatment of diabetic peripheral neuropathic pain (DPNP).

METHODS

This study used administrative claims databases for commercially-insured individuals aged 18-64 years to examine factors associated with treatment among DPNP patients who initiated duloxetine versus tricyclic antidepressants (TCAs), venlafaxine, gabapentin, pregabalin, or opioids between 7/1/2005 and 12/31/2007. Treatment initiation was defined as no pill coverage of the same medication over the previous 90 days. Multiple logistic regression models were estimated to assess factors associated with initiating duloxetine versus each of the other DPNP therapies.

RESULTS

The study included 11,060 DPNP patients with average age of 55 years old. Cardiovascular disease (63-70%), cerebrovascular/peripheral vascular disease (26-33%), low back pain (24-39%), and osteoarthritis (17-26%) were the most common diabetes- and pain-related comorbidities. Controlling for demographic and clinical characteristics, patients who received duloxetine or pregabalin in the prior 12-month period were more likely to initiate duloxetine. Patients from other DPNP treatment cohorts, except for those in the pregabalin cohort, were more likely to re-initiate the same prior therapy than begin treatment with duloxetine (all p<0.05). A history of anxiety disorder was significantly associated with initiation of all DPNP treatments other than duloxetine (all p<0.05), except for TCAs. Patients with low back pain were more likely to initiate duloxetine than TCAs or venlafaxine, but less likely to initiate duloxetine than pregabalin or opioids. Patients with infections related to diabetes were less likely to initiate duloxetine than venlafaxine, gabapentin, or opioids.

LIMITATIONS

Because a retrospective administrative claims database was used, this study is subject to selection bias due to unobservable confounders, inability to measure prescriber preferences or characteristics or disease severity.

CONCLUSIONS

Among commercially-insured DPNP patients, those with prior use of duloxetine or pregabalin were more likely to initiate duloxetine than other treatments. The presence of select comorbidities was also associated with specific medication initiation.

Opioid use and healthcare costs among patients with DPNP initiating duloxetine versus other treatments

OBJECTIVE

To compare opioid utilization and healthcare costs over a 1-year period following the initiation with duloxetine versus other standard of care (SOC) treatments among patients with diabetic peripheral neuropathic pain (DPNP).

METHODS

This retrospective cohort study assessed commercially-insured DPNP patients between 18 and 64 years old who initiated duloxetine or other SOC treatments (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin) between 3/1/2005 and 12/31/2005. Initiation was defined as a 90-day period without available study medication. The first dispense date of the study medication was denoted as the index date. Selected patients had no opioid pill coverage during the 90 days prior to initiation. Duloxetine and SOC patients were matched via propensity scoring (1:1 ratio), controlling for demographics, comorbidities, prior healthcare utilization and costs, and prior medication history. Opioid utilization and healthcare costs over the 12-month post-index period were compared between study cohorts.

RESULTS

The matched sample included 117 patients in each of the duloxetine and SOC cohorts. Compared with SOC-treated patients, duloxetine-treated patients were less likely to use any opioids (52.1 vs. 84.6%, p < 0.05) over the 12-month post-index period. Duloxetine-treated patients, on average, had two fewer opioid prescriptions dispensed, 27 fewer days on opioids, 121 days greater delay in subsequent opioid use, and 1815 mg lower morphine equivalent dosage than SOC-treated patients (all p < 0.05). Also, duloxetine-treated patients had significantly lower total ($18,623 vs. 30,602, p < 0.05) and outpatient costs ($7371 vs. 15,343, p < 0.05). Due to the use of a retrospective administrative claims database, limitations of this study include the potential for selection bias between study cohorts, and inability to measure unobservable confounding and disease severity and/or duration.

CONCLUSIONS

Among commercially-insured DPNP patients, duloxetine-treated patients had delayed and reduced opioid use and lower healthcare costs than SOC-treated patients.

Changes in opioid use and healthcare costs among U.S. patients with diabetic peripheral neuropathic pain treated with duloxetine compared with other therapies

OBJECTIVE

To examine changes in opioid use and healthcare costs among commercially insured patients with diabetic peripheral neuropathic pain (DPNP) who initiated duloxetine versus other standard of care (SOC) medications (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin).

RESEARCH DESIGN AND METHODS

Using an administrative claims database, patients with DPNP aged 18-64 who initiated duloxetine or SOC between March 1, 2005 and December 31, 2005 were identified. Initiation was defined as a 90-day clean period without the available study medication. Selected patients had 12 months of continuous enrollment before and after the index date, and at least one opioid dispensed in the prior 90 days. Duloxetine and SOC patients were further classified into continuous and non-continuous users based on whether the medication possession ratio was > or =0.8. Total opioid days, number of opioid prescriptions dispensed, and cumulative morphine equivalents were examined over the 12-month pre- and post-index periods. Multivariate regressions were applied to assess the changes (pre-index minus post-index) in opioid use (total, short-acting vs. long-acting) and healthcare costs, controlling for demographic and clinical characteristics.

RESULTS

The study sample included 1281 patients: 98 duloxetine continuous, 243 duloxetine non-continuous, 195 SOC continuous, and 745 SOC non-continuous users. Controlling for demographic and clinical characteristics, duloxetine non-continuous and SOC (continuous and non-continuous) patients had significantly less reduction in total opioid days (-24.4, -23.7, -18.5, respectively, all p < 0.05) from the 12-month pre-index to the post-index period than duloxetine continuous patients. Compared with duloxetine non-continuous, SOC continuous, and SOC non-continuous users, duloxetine continuous users had a greater reduction in short-acting hydrocodone use (difference between the 12 month pre-index and post-index periods) in terms of the total number of prescriptions dispensed (adjusted differences: 1.5, 1.7, 1.7, respectively, all p < 0.05), total supply days (adjusted differences: 28.1, 27.3, 29.7, respectively, all p < 0.05), and morphine equivalent dosage (adjusted differences: 1290 mg, 1132 mg, 1127 mg, respectively, all p < 0.05). Duloxetine non-continuous patients had significantly higher adjusted total ($12,729, p < 0.05) and inpatient costs ($14,993, p < 0.05) than duloxetine continuous patients.

LIMITATIONS

Due to the use of a retrospective administrative claims database, this study is subject to selection bias between study cohorts, misidentification of DPNP and/or other comorbidities, and an inability to confirm adherence to therapy or assess indirect costs and costs of over-the-counter medications.

CONCLUSIONS

Among commercially insured patients with DPNP, continuous treatment with duloxetine was associated with a reduction in opioid use between the 12-month pre- and post-index periods compared with treatment with SOC or non-continuous treatment with duloxetine. Duloxetine continuous patients also incurred lower subsequent healthcare costs than non-continuous duloxetine patients.

Duloxetine compliance and its association with healthcare costs among patients with diabetic peripheral neuropathic pain

OBJECTIVE

Duloxetine is approved to treat diabetic peripheral neuropathic pain (DPNP) in the US. The study objective was to examine the predictors of duloxetine compliance, and its association with healthcare costs among DPNP patients.

METHODS

The study used administrative claims databases to identify non-depressed DPNP patients with a duloxetine prescription dispensed between October 1, 2004 and December 31, 2006. Two cohorts of patients were constructed based on compliance to duloxetine therapy over 1-year follow-up with high compliance defined as a medication possession ratio (MPR) > or =0.80. All-cause, diabetes-, and DPNP-related healthcare costs during 1-year follow-up were estimated. Logistic regressions were performed to examine how average daily dose (ADD) of duloxetine and other factors may influence compliance. Multivariate regressions were estimated to examine the association between compliance and healthcare costs.

RESULTS

The study included 1,380 commercially insured (mean age 55 years) and 974 patients with employer-sponsored Medicare supplemental insurance (mean age 75 years). In both populations, patients with an ADD >30 mg were more likely to be compliant with the therapy compared with those with an ADD of < or =30 mg (odds ratio ranged 1.79-3.38, all p<0.05). Controlling for differences in demographics, clinical and economic characteristics, commercially insured low duloxetine compliance patients had greater all-cause ($5,334, p<0.05) and diabetes-related healthcare costs ($3,414, p<0.05) than high-compliance patients, with the biggest difference from inpatient costs (all-cause: $7,508; diabetes-related: $3,785, all p<0.05). Similar trends were found in the Medicare supplemental insured population; however, differences in all-cause healthcare costs were not significant.

CONCLUSIONS

DPNP patients with a higher ADD of duloxetine over a 1-year follow-up period were more compliant with the therapy. Duloxetine patients with high compliance were also associated with lower healthcare costs. Due to the use of a retrospective cohort design on administrative claims database, limitations of this analysis include a lack of formal diagnostic testing of patients, and inability to infer causality or measure factors such as DPNP severity that are not captured in such database.

Emergent combined intracranial thrombolysis and carotid stenting in the hyperacute management of stroke patients with severe cervical carotid stenosis

BACKGROUND AND PURPOSE

The timely re-establishment of intracranial perfusion, the effective prevention of early recurrent strokes, and the limitation of the incidence of reperfusion injury are the major factors that are key to successful treatment of patients with hyperacute stroke who had severe ipsilateral cervical internal carotid artery (ICA) stenosis. In an effort to reduce both the extent of the ongoing neurologic injury and the risk of early recurrent stroke, we have adopted an aggressive combined endovascular approach of intracranial thrombolysis and cervical carotid stent placement during the hyperacute phase. We report on the results of 5 such consecutive patients who presented to our center from January 2003 through January 2005.

MATERIALS AND METHODS

From January 2003 through January 2005, 5 consecutive patients presented to our center with hyperacute strokes and severe ipsilateral cervical ICA stenosis. All were treated with emergent carotid stent placement and intra-arterial thrombolysis. The medical records were reviewed and summarized.

RESULTS

One patient died. The remaining 4 patients had an average hospital stay of 4 days (range, 3-5 days) and a mean National Institutes of Health Stroke Scale (NIHSS) score of 2 (range, 0-3) at the time of discharge. With a mean clinical follow-up of 11 months (range, 6-24 months), all had excellent functional outcome with a modified Rankin score of 0 or 1.

CONCLUSIONS

Data on emergent carotid stent placement in the hyperacute management of stroke are limited. The summarized experience in these 5 patients demonstrates the feasibility of this aggressive therapeutic strategy that may bring about a good outcome.

The anterior spinal artery origin: a microanatomical study

BACKGROUND

Detailed knowledge of the pattern of origin of the anterior spinal artery is critical as surgical and endovascular procedures involving the area of the ventral medulla and the vertebrobasilar junction are commonplace. We conducted a detailed microanatomical study to elucidate the site and pattern of origin of this critically important artery.

METHOD

Nine adult cadaveric heads (18 sides) were examined after injection of colored silicon. In every specimen, the site of origin of the rami of the anterior spinal artery, their course, branching pattern and anastomoses, external diameters, and the distance from neighbor critical vessels were recorded. The dissections were performed with the aid of both the surgical microscope and a 0 degree endoscope.

FINDINGS

The pattern and site of origin of the anterior spinal artery show great variability. Also the distance of the origin of the two rami (right and left) forming the anterior spinal artery from the vertex of the vertebrobasilar junction and from the origin of the posterior inferior cerebellar artery is highly variable.

CONCLUSIONS

Knowledge of the different pattern of origin and course of the proximal portion of the anterior spinal artery is critically important when planning and executing endovascular and surgical procedures involving the distal vertebral artery, the vertebrobasilar junction and the ventral medulla. On the basis of our and other authors' findings, we propose an overall classification of the pattern of origin and distribution of the proximal anterior spinal artery, which has clinical repercussions.

Isolated unilateral sixth nerve palsy as a presenting symptom of cerebral aneurysms. Report of two cases

We describe two patients with intracranial aneurysms who presented with isolated sixth nerve palsy. A 68-year-old woman with gradual onset of horizontal lateral diplopia was found to have a giant aneurysm at the junction of the petrous and cavernous portion of the internal carotid artery. A 58-year-old man presented with gradual onset of occipital pain followed by a sixth nerve palsy. He was found to have a distal anterior inferior cerebellar artery aneurysm which spontaneously thrombosed on subsequent neuroimaging studies. Although uncommon, isolated sixth nerve palsy can be the only neurological sign of an intracranial aneurysm.

Cerebral vasospasm in patients with unruptured intracranial aneurysms

Intracranial arterial vasospasm is a typical sequela of subarachnoid haemorrhage. The association between symptomatic vasospasm and unruptured aneurysms has been sporadically presented in the literature. The pathogenesis of this unusual entity is unclear. The published cases were collected in this review and analysed with regard to timing, clinical presentation and possible relationship with surgical factors. We also added an illustrative case which was recently observed in our department.

Thrombosed giant intracavernous aneurysm with subsequent spontaneous ipsilateral carotid artery occlusion

We report a case of a 47-year-old man with a giant thrombosed aneurysm of the right cavernous internal carotid artery who initially presented with headache, double vision and trigeminal numbness. He experienced subsequent asymtomatic proximal occlusion of the parent vessel, revealed by follow-up angiography. This case illustrates the possibility that a giant thrombosed aneurysm may exert enough compression upon the parent vessel to induce flow stasis with resultant intraluminal thrombosis progressing to occlude the entire parent artery.

Copasetic analysis: a framework for the blind analysis of microarray imagery

From its conception, bioinformatics has been a multidisciplinary field which blends domain expert knowledge with new and existing processing techniques, all of which are focused on a common goal. Typically, these techniques have focused on the direct analysis of raw microarray image data. Unfortunately, this fails to utilise the image's full potential and in practice, this results in the lab technician having to guide the analysis algorithms. This paper presents a dynamic framework that aims to automate the process of microarray image analysis using a variety of techniques. An overview of the entire framework process is presented, the robustness of which is challenged throughout with a selection of real examples containing varying degrees of noise. The results show the potential of the proposed framework in its ability to determine slide layout accurately and perform analysis without prior structural knowledge. The algorithm achieves approximately, a 1 to 3 dB improved peak signal-to-noise ratio compared to conventional processing techniques like those implemented in GenePix when used by a trained operator. As far as the authors are aware, this is the first time such a comprehensive framework concept has been directly applied to the area of microarray image analysis.

In vitro monitoring of rabbit anterior cruciate ligament damage by acoustic emission

Anterior cruciate ligament (ACL) rupture is a major clinical problem leading to instability and degeneration of the knee joint. The problem is compounded by the limited ability of the ACL to heal when ruptured. The existing knowledge regarding the way the ACL ruptures is limited, and this investigation is an attempt to understand the nature of the ruptures using the rabbit as a model. A total of 16 rabbit tibia-ACL-femur complexes were stretched in tension to complete rupture. Four specimens were stretched to failure at a displacement rate of 0.5 mm/min and 12 specimens at 10 mm/min. Acoustic emission (AE) transducers were placed on both the tibia and the femur, and stress wave signals generated during the tensile test were recorded. Fibre fractures produced the highest amplitude signals with a relatively longer rise time. Other failure modes such as matrix failure and debonding produced lower amplitude signals with shorter rise times. We also noted that few events were recorded during the initial period of tensile loading (the elastic phase). The activity then increased significantly after maximum load was reached. The location information provided by the acoustic emission system was consistent with the final site of rupture. We have shown that AE can be used to characterise ligament damage, with fibre pull-outs and fibre fracture producing the highest signal amplitudes.

Escape behaviour in the stomatopod crustacean Squilla mantis, and the evolution of the caridoid escape reaction

The mantis shrimp Squilla mantis shows a graded series of avoidance/escape responses to visual and mechanical (vibration and touch) rostral stimuli. A low-threshold response is mediated by the simultaneous protraction of the thoracic walking legs and abdominal swimmerets and telson, producing a backwards ‘lurch’ or jump that can displace the animal by up to one-third of its body length, but leaves it facing in the same direction. A stronger response starts with similar limb protraction, but is followed by partial abdominal flexion. The maximal response also consists of limb protraction followed by abdominal flexion, but in this case the abdominal flexion is sufficiently vigorous to pull the animal into a tight vertical loop, which leaves it inverted and facing away from the stimulus. The animal then swims forward (away from the stimulus) and rights itself by executing a half-roll. A bilaterally paired, large-diameter, rapidly conducting axon in the dorsal region of the ventral nerve excites swimmeret protractor motoneurons in several ganglia and is likely to be the driver neuron for the limb-protraction response. The same neuron also excites unidentified abdominal trunk motoneurons, but less reliably. The escape response is a key feature of the malacostracan caridoid facies, and we provide the first detailed description of this response in a group that diverged early in malacostracan evolution. We show that the components of the escape response contrast strongly with those of the full caridoid reaction, and we provide physiological and behavioural evidence for the biological plausibility of a limb-before-tail thesis for the evolution of the escape response.

Stochastic acquisition of Qa1 receptors during the development of fetal NK cells in vitro accounts in part but not in whole for the ability of these cells to distinguish between class I-sufficient and class I-deficient targets

Fetal mouse NK cells are grossly deficient in the expression of Ly49 molecules yet show a limited ability to distinguish between wild-type and MHC class I-deficient target cells. In this paper we report that during their development in vitro from immature thymic progenitors, a proportion of C57BL/6 fetal NK cells acquires receptors for a soluble form of the nonclassical class I molecule Qa1b associated with the Qdm peptide, but not for soluble forms of the classical class I molecules Kb and Db. The acquisition of these Qa1 receptors occurs in a stochastic manner that is strictly controlled by cytokines, and in particular is strongly inhibited by IL-4. All fetal NK clones tested, including those that lack detectable Qa1 receptors, express mRNA for CD94 and for both inhibitory and noninhibitory members of the NKG2 family. Fetal NK cells lacking receptors for Qa1 (and also for classical class I molecules) cannot distinguish between wild-type and class I-deficient blasts but, surprisingly, distinguish efficiently between certain wild-type and class I-deficient tumor cells. A variant line that lacks several members of the NKG2 family kills both types of tumor cell equally well, suggesting the existence of NKG2-containing inhibitory receptors that recognize as yet undefined nonclassical class I molecules of restricted distribution.

Sex differences in patients admitted to a regional secure unit

The case notes of all admissions to a Regional Secure Unit over a 12-year period were examined. A higher proportion of females had a diagnosis of personality disorder. Women were less likely to have a prosecuted offence associated with admission but were more likely to be charged with fire-setting. Patients with personality disorder were more likely to be transferred to special hospitals. Women were nearly three times as likely as men to be transferred to maximum security and this was not accounted for by the excess of females with personality disorder. There was net movement of men out of special hospitals whereas the opposite was true for women. Possible explanations for this are discussed.

Spinal dural arteriovenous fistulas: evaluation with MR angiography

PURPOSE

To show that postgadolinium three-dimensional time-of-flight MR angiography shows abnormal intradural vessels associated with spinal dural arteriovenous fistula better than routine MR imaging and provides screening information useful for subsequent diagnostic conventional angiography and/or posttreatment evaluation.

METHODS

Precontrast and postcontrast MR imaging and MR angiograms, as well as subsequent digital subtraction angiograms, were obtained for eight patients with dural arteriovenous fistulas, diagnosed with digital subtraction angiography and verified with surgery. In four patients, MR studies also were obtained after surgery.

RESULTS

All patients had cord hyperintensity of T2-weighted images and postgadolinium enhancement on T1-weighted images. Five had vessellike signal abnormalities in the subarachnoid space on MR. Abnormal intradural vessels were detected in all eight patients with MR angiography. Comparison with digital subtraction angiography revealed these vessels to be primarily enlarged veins of the coronal venous plexus on the cord surface. In six patients, the medullary vein draining the fistula was demonstrated, indicating the level of the fistula, later identified by digital subtraction angiography. After surgical obliteration of the fistula, the draining medullary vein and most or all of the abnormal coronal veins were no longer demonstrated, with decrease or resolution of cord hyperintensity on T2-weighted images.

CONCLUSION

Postgadolinium, spinal MR angiography in cases of suspected dural arteriovenous fistula provides information about intradural veins that supplements the diagnostic value of the MR imaging results, facilitates the subsequent digital subtraction angiography study, and, in treated cases, reflects the success of surgery and/or embolization.

Pharmacological characterization of multidrug resistant MRP-transfected human tumor cells

We have previously identified and characterized a novel member of the ATP-binding cassette superfamily of transport proteins, multidrug resistance protein (MRP), and subsequently demonstrated that its overexpression is sufficient to confer multidrug resistance on previously sensitive cells (Cole et al., Science (Washington DC), 258: 1650-1654, 1992; Grant et al., Cancer Res. 54: 357-361, 1994). In the present study, we have transfected two different eukaryotic expression vectors containing MRP complementary DNA into HeLa cells to study the pharmacological phenotype produced exclusively by overexpression of human MRP. The drug resistance patterns of the two MRP-transfected cell populations were similar. They were characterized by a moderate (5- to 15-fold) level of resistance to doxorubicin, daunorubicin, epirubicin, vincristine, and etoposide, and a low (< or = 3-fold) level of resistance to taxol, vinblastine, and colchicine. The transfectants were not resistant to 9-alkyl anthracyclines, mitoxantrone, or cisplatin. The MRP-transfected cells were also resistant to some heavy metal anions including arsenite, arsenate, and trivalent and pentavalent antimonials but were not resistant to cadmium chloride. Accumulation of radiolabeled vincristine was reduced by 45% in the MRP-transfected cells and could be restored to the levels found in sensitive cells by depletion of ATP. Rates of vincristine efflux did not differ greatly in the sensitive and resistant cells. The cytotoxic effects of vincristine and doxorubicin could be enhanced in a dose-dependent fashion by coadministration of verapamil. Cyclosporin A also increased vincristine toxicity but had less effect on doxorubicin toxicity. The degree of chemosensitization by verapamil and cyclosporin A was similar in MRP-transfected cells and in cells transfected with the vector alone, suggesting that sensitization involved mechanisms independent of MRP expression. Verapamil and cyclosporin A caused a modest increase in vincristine accumulation in the resistant cells but did not restore levels to those of the sensitive cells. Taken together, these data indicate that drug-resistant cell lines generated by transfection with MRP complementary DNA display some but not all of the characteristics of MRP-overexpressing cell lines produced by drug selection in vitro. They further demonstrate that the multidrug resistance phenotype conferred by MRP is similar but not identical to that conferred by P-glycoprotein and includes resistance to arsenical and antimonial oxyanions.

Acute nurse on rotating split

Linda Nazarko's article, Losing the battle of all NHS mothers (Viewpoint, November 24) stuck a chord with me as it echoed the plights I have experienced.