Corrigendum: Safe and effective delivery of supplemental iron to healthy adults: a two-phase, randomized, double-blind trial - the safe iron study

[This corrects the article DOI: 10.3389/fnut.2023.1230061.].

Safe and effective delivery of supplemental iron to healthy adults: a two-phase, randomized, double-blind trial - the safe iron study

Introduction

The safety of novel forms of iron in healthy, iron-replete adults as might occur if used in population-based iron supplementation programs was examined. We tested the hypotheses that supplementation with nanoparticulate iron hydroxide adipate tartrate (IHAT), an iron-enriched Aspergillus oryzae product (ASP), or ferrous sulphate heptahydrate (FS) are safe as indicated by erythrocyte susceptibility to malarial infection, bacterial proliferation, and gut inflammation. Responses to FS administered daily or weekly, and with or without other micronutrients were compared.

Methods

Two phases of randomized, double-blinded trials were conducted in Boston, MA. Phase I randomized 160 volunteers to six treatments: placebo, IHAT, ASP, FS, and FS plus a micronutrient powder (MNP) administrated daily at 60 mg Fe/day; and FS administered as a single weekly dose of 420 mg Fe. Phase II randomized 86 volunteers to IHAT, ASP, or FS administered at 120 mg Fe/day. Completing these phases were 151 and 77 participants, respectively. The study was powered to detect effects on primary endpoints: susceptibility of participant erythrocytes to infection by Plasmodium falciparum, the proliferation potential of selected pathogenic bacteria in sera, and markers of gut inflammation. Secondary endpoints for which the study was not powered included indicators of iron status and gastrointestinal symptoms.

Results

Supplementation with any form of iron did not affect any primary endpoint. In Phase I, the frequency of gastrointestinal symptoms associated with FS was unaffected by dosing with MNP or weekly administration; but participants taking IHAT more frequently reported abdominal pain (27%, p < 0.008) and nausea (4%, p = 0.009) than those taking FS, while those taking ASP more frequently reported nausea (8%, p = 0.009). Surprisingly, only 9% of participants taking IHAT at 120 mg Fe/day (Phase II) reported abdominal pain and no other group reported that symptom.

Discussion

With respect to the primary endpoints, few differences were found when comparing these forms of iron, indicating that 28 days of 60 or 120 mg/day of IHAT, ASP, or FS may be safe for healthy, iron-replete adults. With respect to other endpoints, subjects receiving IHAT more frequently reported abdominal pain and nausea, suggesting the need for further study.

Clinical Trial Registration

ClinicalTrials.gov, NCT03212677; registered: 11 July 2017.

Inhibiting Anti-angiogenic VEGF165b Activates a Novel miR-17-20a-Calcipressin-3 Pathway that Revascularizes Ischemic Muscle in Peripheral Artery Disease

Background

VEGF165a increases the expression of microRNA-17-92 cluster, promoting developmental, retinal, and tumor angiogenesis. We have previously shown that VEGF165b, an alternatively spliced VEGF-A isoform, inhibits the VEGFR-STAT3 pathway in ischemic endothelial cells (ECs) to decrease their angiogenic capacity. In ischemic macrophages (Møs), VEGF165b inhibits VEGFR1 to induce S100A8/A9 expression, which drives M1-like polarization. Our current study aims to determine whether VEGF165b inhibition promotes perfusion recovery by regulating the miR-17-92 cluster in preclinical PAD.

Methods

Hind limb ischemia (HLI) induced by femoral artery ligation and resection was used as a preclinical PAD model. Hypoxia serum starvation (HSS) was used as an in vitro PAD model. VEGF165b was inhibited/neutralized by an isoform-specific VEGF165b antibody.

Results

Systematic analysis of miR-17-92 cluster members (miR-17-18a-19a-19b-20a-92) in experimental-PAD models showed that VEGF165b-inhibition induces miRNA-17-20a (within miR-17-92 cluster) in HSS-ECs and HSS-bone marrow derived macrophages (BMDMs) vs. respective normal and/or isotype matched IgG controls to enhance perfusion-recovery. Consistent with the bioinformatics analysis that revealed RCAN3 as a common target of miR-17 and miR-20a, Argonaute-2 pull-down assays showed decreased miR-17-20a expression and higher RCAN3 expression in the RISC complex of HSS-ECs and HSS-BMDMs vs. the respective controls. Inhibiting miR-17-20a induced RCAN3 levels to decrease ischemic angiogenesis and promoted M1-like polarization to impair perfusion recovery. Finally, using STAT3 inhibitors, S100A8/A9 silencers and VEGFR1-deficient ECs and Møs, we show that VEGF165b inhibition activates the miR-17-20a-RCAN3 pathway independent of VEGFR1-STAT3 or VEGFR1-S100A8/A9 in ischemic ECs and ischemic Møs, respectively.

Conclusion

Our data revealed a hereunto unrecognized therapeutic 'miR-17-20a-RCAN3' pathway in the ischemic vasculature that is VEGFR1-STAT3/S100A8/A9 independent and is activated only upon VEGF165b inhibition in PAD.

A multicenter prospective observational study on the use of type and screen method versus conventional type and crossmatch policy for pre-transfusion testing in the Indian population

Despite knowing the benefits of the type and screen (TS) method in pre-transfusion testing (PTT), most transfusion centers in developing countries continue to be reluctant to adopt a TS strategy over the conventional type and antihuman globulin (AHG) crossmatch (TX) policy in their routine laboratory practice because of the cost of obtaining antibody screening reagents. To generate strong evidence, this multicenter, observational study was conducted in which we collected data prospectively over a 1-year period from six major blood centers in India. The primary objective of this study was to identify the discordance between TS and TX results. A secondary objective was to identify the allo-antibody specificity in patients with positive antibody detection tests. All patients with orders for red blood cell transfusion who met patient selection criteria were subjected to parallel testing by column agglutination technology (CAT) for both the antibody detection test (screen) using a commercial three-cell panel and for the AHG crossmatch. A total of 21,842 patients were tested. In 148 patients with incompatible crossmatches, samples from six patients gave negative results with the antibody detection test, whereas the antibody detection test was positive in samples from 118 patients among the 21,694 crossmatch-compatible cases. The TS approach achieved a positive percent agreement of 95.95 and was found to be significantly effective in preventing the transfusion of serologically incompatible blood. The risk associated with abbreviating the AHG crossmatch was found to be 0.009 percent. Most of the identified clinically significant alloantibodies were directed to Rh antigens (D>E>c>C>e), followed by anti-K and anti-M. This study has generated sufficient robust data for the Indian population by including patients from all major geographical areas of the country and concluded a satisfactory agreement level as well as non-inferiority to the current PTT policy. Therefore, TS policy can be implemented in developing countries with no compromise on blood safety, provided sufficient technical and infrastructural support are available.

A third-line antiretroviral therapy register to track patient clinical and virological outcomes

In 2021, South Africa (SA) had an estimated 7.8 million people living with HIV, of whom 5.6 million were receiving antiretroviral therapy (ART),[1] with 3.4 million on first-line ART, 145 000 on second-line ART (SLART) and >700 on third-line ART (TLART).

Role of placental, fetal and maternal cardiovascular markers in predicting adverse outcome in women with suspected or confirmed pre-eclampsia

OBJECTIVE

To assess the performance of placental, fetal and maternal cardiovascular markers in the prediction of adverse perinatal and maternal outcomes in women with suspected or confirmed pre-eclampsia.

METHODS

This was a prospective prognostic accuracy study of women with suspected or confirmed pre-eclampsia who underwent a series of investigations to measure maternal hemodynamic indices, mean arterial pressure, augmentation index, ophthalmic artery peak systolic velocity (PSV) ratio, uterine artery pulsatility index (UtA-PI), fetal biometric and Doppler parameters, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF). The performance of these markers, individually or in combination, in predicting adverse perinatal and maternal outcomes was then assessed using receiver-operating-characteristics (ROC)-curve analysis. Adverse maternal outcome was defined as one or more of severe hypertension, admission to the intensive care unit, eclampsia, placental abruption, HELLP syndrome, disseminated intravascular coagulation, platelets < 100 × 10⁹ /L, creatinine > 90 μmol/L and alanine aminotransferase > 100 U/L. Adverse perinatal outcome was defined as one or more of preterm birth at or before 34 + 0 weeks, neonatal intensive care unit admission for > 48 h, respiratory distress syndrome, intraventricular hemorrhage, hypoxic ischemic encephalopathy, necrotizing enterocolitis, retinopathy of prematurity and confirmed fetal infection.

RESULTS

We recruited 126 women with suspected (n = 31) or confirmed (n = 95) pre-eclampsia at a median gestational age of 33.9 weeks (interquartile range, 30.9-36.3 weeks). Pregnancies with adverse perinatal outcome compared to those without had a higher median UtA-PI (1.3 vs 0.8; P < 0.001), ophthalmic artery PSV ratio (0.8 vs 0.7; P = 0.01) and umbilical artery PI percentile (82.0 vs 68.5; P < 0.01) and lower median estimated fetal weight percentile (4.0 vs 43.0; P < 0.001), abdominal circumference percentile (4.0 vs 63.0; P < 0.001), middle cerebral artery PI percentile (28.0 vs 58.5; P < 0.001) and cerebroplacental ratio percentile (18.0 vs 46.5; P < 0.001). Pregnancies with adverse perinatal outcome also had a higher median sFlt-1 (8208.0 pg/mL vs 4508.0 pg/mL; P < 0.001), lower PlGF (27.2 pg/mL vs 76.3 pg/mL; P < 0.001) and a higher sFlt-1/PlGF ratio (445.4 vs 74.4; P < 0.001). The best performing individual marker for predicting adverse perinatal outcome was the sFlt-1/PlGF ratio (area under the ROC curve (AUC), 0.87 (95% CI, 0.81-0.93)), followed by estimated fetal weight (AUC, 0.81 (95% CI, 0.73-0.89)). Women who experienced adverse maternal outcome had a higher median sFlt-1 level (7471.0 pg/mL vs 5131.0 pg/mL; P < 0.001) and sFlt-1/PlGF ratio (204.3 vs 93.3; P < 0.001) and a lower PlGF level (37.0 pg/mL vs 66.1 pg/mL; P = 0.01) and estimated fetal weight percentile (16.5 vs 37.0; P = 0.04). All markers performed poorly in predicting adverse maternal outcome, with sFlt-1 (AUC, 0.69 (95% CI, 0.60-0.79)) and sFlt-1/PlGF ratio (AUC, 0.69 (95% CI, 0.59-0.78)) demonstrating the best individual performance. The addition of cardiovascular, fetal or other placental indices to the sFlt-1/PlGF ratio did not improve the prediction of adverse maternal or perinatal outcomes.

CONCLUSIONS

The sFlt-1/PlGF ratio performs well in predicting adverse perinatal outcomes but is a poor predictor of adverse maternal outcomes in women with suspected or diagnosed pre-eclampsia. The addition of cardiovascular or fetal indices to the model is unlikely to improve the prognostic performance of the sFlt-1/PlGF ratio. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Loss of a globally unique kelp forest from Oman

Kelp forests are declining in many regions globally with climatic perturbations causing shifts to alternate communities and significant ecological and economic loss. Range edge populations are often at most risk and are often only sustained through localised areas of upwelling or on deeper reefs. Here we document the loss of kelp forests (Ecklonia radiata) from the Sultanate of Oman, the only confirmed northern hemisphere population of this species. Contemporary surveys failed to find any kelp in its only known historical northern hemisphere location, Sadah on the Dhofar coast. Genetic analyses of historical herbarium specimens from Oman confirmed the species to be E. radiata and revealed the lost population contained a common CO1 haplotype found across South Africa, Australia and New Zealand suggesting it once established through rapid colonisation throughout its range. However, the Omani population also contained a haplotype that is found nowhere else in the extant southern hemisphere distribution of E. radiata. The loss of the Oman population could be due to significant increases in the Arabian Sea temperature over the past 40 years punctuated by suppression of coastal upwelling. Climate-mediated warming is threatening the persistence of temperate species and precipitating loss of unique genetic diversity at lower latitudes.

Impact of atrial fibrillation in patients with colorectal cancer: a national inpatient sample database analysis

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 1–2% overall population (1). Its causal relationship with colorectal cancer (CRC) is much for debate. According to one hypothesis, the presence of autoantibodies directed against ionic channels or acetylcholine receptors can predispose to the development of atrial fibrillation (2–3). Thus, AF may be regarded as an inflammatory complication in patients with colon cancer. Our study objective was to determine if AF impacts the outcome of patients with CRC.

Method

We analyzed the National Inpatient Sample (NIS) database from Oct-2015 to Dec 2018 using Stata 16.0. The NIS databases are released under the Healthcare Cost and Utilization Project, which includes inpatient admissions from the United States' participating hospitals. Total population with CRC were identified using their respective ICD-10 diagnostic codes then divided based on AF. To determine atrial fibrillation association with mortality and complications, we used multivariate logistic regression analysis using weights to generate nationally representative results. Later, a propensity-matched population analysis was done for the accuracy of the results.

Result

We found 245,305 patients admitted with CRC between Oct 2015 to Dec-2018 in the USA, out of which 28,170 (11.5%) were having AF. The mean age for the patients with AF was 77±10 compare to 65±14 years in those without AF. Patients with AF were associated with higher comorbidities and had a high population percentage with Carlson category three or above. There were 1,456 (5.2%) mortalities in the AF group compared to 5,689 (2.6%) in the other. The higher odds of mortality in patients with AF was present in multivariate logistic regression analysis in both non-propensity matched [1.71 (1.45–2.02), P-value: &lt;0.000] and propensity-matched [1.44 (1.18–1.75), P-value: &lt;0.001] cohorts. Patients with AF were hospitalized longer (9.20±7.8 vs. 6.85±7.0 days), leading to a high admission costs (US$ 25,875±22,875 vs. 20,087±19,314). Odds of complications such as need for blood transfusions [1.61 (1.05–1.29), P-value: 0.005], hemorrhage requiring blood transfusion [1.17 (1.05–1.29), P-value: 0.003], lower-GI bleed [1.31 (1.21–1.43), P-value: &lt;0.001], sepsis [1.45 (1.30–1.62), P-value: &lt;0.001], respiratory failure [1.39 (1.15–1.67), P-value: 0.001] etc. were also higher in group of patients with CRC and AF.

Conclusion

In our retrospective, propensity-matched national inpatient sample analyses of patients admitted with colorectal cancer, atrial fibrillation is associated with higher morbidity and mortality. AF was associated with a high burden of complications with prolonged hospital stay leading to increased health care expenditures.

Funding Acknowledgement

Type of funding sources: None.

Gender based outcome of IABP implantation in patients with acute coronary syndrome and cardiogenic shock: a national inpatient sample database analysis

Background

Intra-Aortic Balloon counter-pulsation is frequently used as a circulatory support device in patients requiring hemodynamic support - in cardiogenic shock and in patients at risk of hemodynamic decompensation during a high-risk coronary intervention. Impact of IABP in this patient population has been variable. Certain studies have shown a beneficial effect of IABP on selected populations having acute coronary syndrome with cardiogenic shock (1–3). Our objective was to compare the outcomes based on gender in the ACS population with cardiogenic shock and IABP placement.

Methods

We analyzed the National Inpatient Sample database from Oct-2015 to Dec-2017 released under Healthcare Cost utilization Project in the USA using Stata 16.0. The population was identified using respective ICD-10 codes. We excluded the population with sudden cardiac arrest, pulmonary embolism, and patients with anatomical post-MI complications. Multivariate logistic regression analysis was done to determine the difference in outcomes based on gender using clinically relevant variables. Later, propensity-matched cohort analysis was performed based on the regression variables.

Results

Of 36, 990 patients who met our inclusion criteria 25,670 (69%) were male and 11,320 (31%) were female. The average age for male and female populations was 66±11 and 69±12 years. Femnales were more likely to have higher Charlson co-morbidity index three or above. We found higher mortality in the female population [3,146 (27.79%)] compared to male [5,884 (22.92%)] in univariate analyses. Propensity-matched multivariate regression analysis showed no difference [OR: 1.06 (0.91–1.22) with P-value: 0.482] in mortality after adjusting for clinically relevant variables. Subgroup analysis in STEMI and NSTEMI populations did not show a difference. The average hospital stay was similar in both cohorts, with the male having a higher cost per stay. We found no difference in most of the complications included in our study except for higher coronary artery dissection [OR: 2.98 (1.73–5.13), P-value: &lt;0.001] and lower rates of AKI [OR: 0.72 (0.63–0.83), P-value: &lt;0.001], AKI requiring hemodialysis [OR: 0.74 (0.56–0.97), P-value:0.031] and ventricular tachycardia [OR: 0.73 (0.64–0.84), P-value: &lt;0.001] in the female population.

Conclusion

The inpatient population of ACS with Cardiogenic shock and IABP insertion showed no significant difference in mortality between males and females which was valid for subgroup analysis of NSTEMI and STEMI groups. Complications such as coronary artery dissection were higher, whereas AKI, AKI requiring hemodialysis, and ventricular tachycardias, were lower in females than males.

Funding Acknowledgement

Type of funding sources: None.

420 Impact of Surgical Training on Long-Term Patient Outcomes in Sleeve Gastrectomy

Aim

Although few studies have examined the impact of surgical training on early postoperative outcomes in bariatric surgery, there is limited data on longer-term outcomes in trainee-performed cases. Our aim was to evaluate the effect of surgical training on weight loss outcomes following laparoscopic sleeve gastrectomy (LSG).

Method

Data was prospectively collated on patients undergoing primary LSG at a Quaternary Bariatric London teaching Hospital between 2016-2017. Inclusion criteria was BMI≥35. Exclusion criteria were BMI&lt;35 or &gt; 60, planned HDU admission and LSG with concomitant hiatus hernia repair. Operative time, length of stay, complications and longer-term excess weight loss was recorded with outcomes of consultant and trainee cases compared.

Results

76 LSG patients were included; 44 performed by consultants, 32 by trainees. There was no difference in age, gender, pre-operative weight, BMI and number of obesity-related comorbidities between groups. Operative time (trainee105±10.0 vs consultant91±18.1 mins) and length of stay (trainee2.6±0.4 vs consultant2.8±0.9 days) were similar between groups. There were 3 complications in the trainee group (intra-abdominal collection requiring drainage, wound infection, hypokalaemia); and 2 with consultants (wound infection, intra-operative bleeding with ICU admission). Excess Weight Loss(%) at 2 years was 55.9%±7.5% for trainee cases and 52.4%±6.7% for consultant cases(p=0.49). Excess Weight Loss(%) at 3.5 years was 54.9%±9.9% for trainee cases and 50.7%±9.9% for consultant cases(p=0.54).

Conclusions

Outcomes in trainee performed LSG are comparable to those performed by consultants. Surgical training in a high-volume teaching hospital does not appear to have detrimental effect on patient outcomes following LSG.

Plasma Volume Is an Important Determinant in Assessing Metabolic and Iron Biomarkers in Young Women

Objectives

Plasma volume (PV) variations among individuals can affect the concentration of blood biomarkers but this is not often evaluated in assessing nutritional status. We aimed to assess the association between estimated PV, metabolic and iron biomarkers in young obese and normal weight women.

Methods

Healthy women aged 18–30 y were recruited for the study (n = 47: 25 obese and 22 normal weight). Fasting venous blood samples were obtained to measure serum lipids, comprehensive metabolic panel, iron biomarkers (serum iron, total iron binding capacity, transferrin saturation (%TS), hemoglobin, ferritin and, hepcidin). PV was estimated using Kaplan-Hakim formula: PV = (1-hematocrit) × [a + (b × weight in kg)] where adjustment factors were a = 864, and b = 47.9. Associations between PV and other biomarkers were assessed using Pearson's correlation.

Results

As expected, PV was higher in obese (3482 (545) mL) than normal weight women (2268 (250) mL). When all subjects were combined PV was negatively correlated with HDL (r = −0.49, P = 0.001), creatinine (r = −0.48, P = 0.001), sodium (r = −0.31, P = 0.034), calcium (r = −0.30, P = 0.044), albumin (r = −0.46, P = 0.001), serum iron (r = −0.34, P = 0.022), and %TS (r = −0.31, P = 0.036) but positively correlated with triglycerides (r = 0.40, P = 0.005), cholesterol/HDLC ratio(r = 0.55, P &lt; 0.001). In normal weight women, PV was not correlated with any of these biomarkers. However, in obese women, there was a strong correlation of PV with creatinine (r = −0.61, P = 0.001), calcium (r = −0.50, P = 0.012), and albumin (r = −0.43, P = 0.030).

Conclusions

Our results suggest that differences in PV may account for some variations in serum lipids, creatinine, sodium, calcium, albumin, and iron biomarker concentrations in women. This implies that different cutoffs may be needed for defining deficiencies in obesity after correcting for plasma volume.

Funding Sources

Doris A. Adams Endowed Chair funds at Iowa State University.

AB0756 IMMUNE-MEDIATED BASIS FOR A PHASE 2A CLINICAL STUDY COMPARING RILZABRUTINIB VS GLUCOCORTICOIDS IN RITUXIMAB-REFRACTORY PATIENTS WITH IGG4-RELATED DISEASE

Background:

IgG4-related disease (IgG4-RD) is an immune-mediated disorder causing fibro-inflammatory lesions. Although the cause remains unknown, it may be driven by interactions between B lymphocytes and CD4+ cytotoxic and regulatory T cells and is characterized by an increase in short-lived plasmablasts, circulating antibodies, and macrophages. Standard therapy mainly includes glucocorticoids (GC), limited by toxicity with long-term use (> 6 mo), and to a lesser extent, immunosuppressives (eg, rituximab). Bruton tyrosine kinase (BTK) plays an important role in the activation of multiple immune effector cells such as B cells, mast cells, eosinophils, basophils, monocytes/macrophages, and neutrophils. Dysregulation of the activation of these immune cells results in autoimmune inflammation, tissue damage, and development of fibrosis. Rilzabrutinib is a highly selective oral BTK inhibitor that targets multiple pathways of innate and adaptive immunity (with direct effects on B-cell and FcR pathways) and has the potential to inhibit antigen presentation to autoreactive T cells.

Objectives:

To provide the biological rationale for rilzabrutinib in IgG4-RD.

Methods:

Rilzabrutinib has been evaluated in biochemical, in vitro studies, and in vivo models of inflammatory diseases. Additional support is provided by the phase 2 trial for oral rilzabrutinib in patients with pemphigus vulgaris and the phase 2 trial for oral rilzabrutinib in patients with immune thrombocytopenia (ITP).

Results:

Rilzabrutinib inhibited the activity of BTK and B-cell receptor in B cells (IC50 5-123 nM) and Fc gamma receptor in IgG/Fc gamma receptor-stimulated monocytes (IC50 56 nM) and blocked IgG- and IgM-mediated antibody production in enriched B cells when stimulated in T-cell dependent (anti-CD40+IL-21) and T-cell independent (TLR-9/CpG and TNP-LPS) pathways. The impact of rilzabrutinib on innate cell pathways was further confirmed by significant dose-dependent inhibition of macrophage and neutrophil-driven passive rat Arthus reaction (P < 0.01 vs vehicle) and antibody-induced murine ITP (P < 0.05 vs vehicle). In a 12-week phase 2 pemphigus vulgaris trial, 54% of patients achieved the primary endpoint, control of disease activity (CDA) on low-dose corticosteroids by week 4, and 73% achieved it by week 12. In the phase 2 trial of ITP patients (median 6 prior therapies), rilzabrutinib 400 mg bid showed rapid and sustained improvement in platelet counts and only grade 1/2-related adverse events1. In responders, platelet counts increased as early as day 8, potentially due to innate immune mechanisms. Collectively, results in both B and innate immune cells provide an initial basis for evaluating rilzabrutinib in IgG4-RD. The ongoing phase 2a study (NCT04520451) is investigating rilzabrutinib 400 mg bid (+tapered GC) vs GC control (3:1) for 12 weeks in IgG4-RD patients refractory to rituximab. The primary objective is to evaluate the safety and ability of rilzabrutinib to induce GC-free remission at week 12. Coupled with known preclinical/clinical findings, mechanistic analyses in this ongoing IgG4-RD study will profile B and other immune cell effects pre-/post-rilzabrutinib dosing to enhance the clinical understanding of rilzabrutinib in IgG4-RD.

Conclusion:

Studies of rilzabrutinib that show beneficial effects on both B-cell and innate cell pathways provide support for its therapeutic role in immune-mediated diseases and for targeting the underlying pathophysiological effects of IgG4-RD. Effective and safe therapies that rapidly induce and maintain clinical responses, while minimizing the need for continuous GC treatment, remain an unmet need for patients with IgG4-RD.

References:

[1]Kuter et al. Res Pract Thromb Haemost. 2020;4(suppl 1): PB1318.

Disclosure of Interests:

Li Long Employee of: Principia Biopharma, a Sanofi Company, Matthew Baker: None declared, Mollie Carruthers: None declared, Alireza Meysami: None declared, Robert Spiera Consultant of: research funding and personal fees for consulting from Chemocentryx, Formation Biologics, Roche-Genentech, and Sanofi, Grant/research support from: research funding fees from BMS, Boehringer Ingelheim, Corbus, GSK, and Inflarx; personal fees from AbbVie, CSL Behring, GSK, and Janssen, Mamatha Reddy Employee of: Principia Biopharma, a Sanofi Company, Marianne Kavanagh Employee of: Principia Biopharma, a Sanofi Company, Michelle Francesco Employee of: Principia Biopharma, a Sanofi Company, Claire Langrish Employee of: Principia Biopharma, a Sanofi Company, Ann Neale Employee of: Principia Biopharma, a Sanofi Company, Puneet Arora Employee of: Principia Biopharma, a Sanofi Company, John H. Stone Consultant of: research funding and personal fees for consulting from Principia and Sanofi

Comparative evaluation of the conventional tube test and column agglutination technology for ABO antibody titration in healthy individuals: a report from India

Determination of accurate anti-A/-B titers is important for treatment selection in ABO-incompatible stem cell and solid-organ transplants. The standard method for ABO antibody titration is the conventional tube test (CTT). Dithiothreitol (DTT) is commonly used to inactivate the IgM antibody component. The aim of this study was to compare six different methods for ABO antibody titration and to observe the effectiveness of DTT on antibody estimation. A total of 90 healthy voluntary blood donors were enrolled in this study, including 30 each for blood groups A, B, and O. Antibody titrations were performed and tested using the CTT-immediate spin (IS), CTT-antihuman globulin (AHG) with and without DTT, column agglutination technology (CAT)-IS, and CAT-AHG with and without DTT methods. Bead-CAT was used, and the positive cutoff value was set to 1+ for each method to determine the endpoint of the titer. The median values of anti-A/-B titers by IS were found to be higher than those values by AHG in CTT and CAT among group B and A individuals, whereas no statistically significant differences were observed in values from group O individuals for IS and AHG anti-A/-B titers, estimated by each method. Although there was positive correlation between the anti-A/-B titer results obtained using the CTT and CAT in all blood groups, testing using AHG showed poor agreement with and without DTT pretreatment (kappa value of 0.11 and 0.20, respectively). Moderate agreement was observed between CTT-IS and CAT-IS (kappa value of 0.46). Median anti-A/-B AHG titers were reduced by the use of DTT in all blood group samples. Significant differences in the interpretability of anti-A/-B titers were observed among different methods. A uniform approach for selecting the method for ABO antibody titration is highly recommended, and DTT pretreatment of plasma to neutralize IgM activity should be considered to obtain precise values of IgG anti-A/-B titers. Immunohematology 2021;37:25-32 .

Determination of accurate anti-A/-B titers is important for treatment selection in ABO-incompatible stem cell and solid-organ transplants. The standard method for ABO antibody titration is the conventional tube test (CTT). Dithiothreitol (DTT) is commonly used to inactivate the IgM antibody component. The aim of this study was to compare six different methods for ABO antibody titration and to observe the effectiveness of DTT on antibody estimation. A total of 90 healthy voluntary blood donors were enrolled in this study, including 30 each for blood groups A, B, and O. Antibody titrations were performed and tested using the CTT-immediate spin (IS), CTT-antihuman globulin (AHG) with and without DTT, column agglutination technology (CAT)-IS, and CAT-AHG with and without DTT methods. Bead-CAT was used, and the positive cutoff value was set to 1+ for each method to determine the endpoint of the titer. The median values of anti-A/-B titers by IS were found to be higher than those values by AHG in CTT and CAT among group B and A individuals, whereas no statistically significant differences were observed in values from group O individuals for IS and AHG anti-A/-B titers, estimated by each method. Although there was positive correlation between the anti-A/-B titer results obtained using the CTT and CAT in all blood groups, testing using AHG showed poor agreement with and without DTT pretreatment (kappa value of 0.11 and 0.20, respectively). Moderate agreement was observed between CTT-IS and CAT-IS (kappa value of 0.46). Median anti-A/-B AHG titers were reduced by the use of DTT in all blood group samples. Significant differences in the interpretability of anti-A/-B titers were observed among different methods. A uniform approach for selecting the method for ABO antibody titration is highly recommended, and DTT pretreatment of plasma to neutralize IgM activity should be considered to obtain precise values of IgG anti-A/-B titers. Immunohematology 2021;37:25–32 .

Nutritional Content and Microbial Quality of Complementary Foods Produced from Blends of Orange-Fleshed Sweet Potato and Edible Insects

Objectives

Improved formulations of complementary foods (CFs) with animal-source foods (ASFs) is an eminent strategy to improve infant nutrition, but they are expensive and not readily available in many food insecure settings which are a haven of edible insects. Hence, we developed orange-fleshed sweet potato (OFSP) based CFs supplemented with Cricket or palm weevil larvae (PWL), examined its nutritional content and microbial quality for infant feeding.

Methods

OFSP roots were sourced from local farmers, peeled, sliced, steam cooked and mechanically dried into OFSP flour. Cricket powder and PWL paste were obtained from commercial producers, steam cooked, and mechanically dried into Cricket/PWL flours. OFSP flour was mixed with either Cricket/PWL flours in the ratios of 100:0 (control), 85:15, 70:30, and 50:50 and used to produce ready-to-eat CFs. The CFs were evaluated for nutrient composition and microbial contamination using standard methods. ANOVA followed by Dunnett's test was used to compare all the formulations to the control.

Results

There were increase in protein (4.80 to 36.75%), iron (1.26 to 4.38 mg/100 g), zinc (0.69 to 10.65 mg/100 g) and calcium (45.54 to 152.77 mg/100 g) contents of the OFSP-based CFs with increased supplementation with Cricket/PWL flour. The carbohydrate and β-carotene content decreased but the energy content increased with increased supplementation with cricket/PWL flour from 344.52 Kcal/100 g in 100% OFSP CF to 541.09 Kcal/100 g in 50:50 CFs (OFSP: PWL) (P = 0.001). Aerobic mesophilic count (AMC) of the OFSP: Cricket CFs was 60 cfu/g as compared to 1300 cfu/g for the OFSP: PWL CFs. Comparing the OFSP-based Cricket/PWL CFs to the commercial Cricket or PWL, there was 35–331-fold reduction in AMC. Bacillus cereus (BC), aerobic (APC) and anaerobic plate count (NPC) was 0 cfu/g for the OFSP: Cricket CFs. BC, APC and NPC were 100, 260 and 130 cfu/g respectively for the OFSP: PWL CFs.

Conclusions

Steam cooking, then mechanical drying significantly reduced microbial concentrations in commercial Cricket and PWL to below minimum limits set by the Ghana Standards Authority for CFs requiring heating to boiling before consumption. OFSP-based Cricket/PWL composite flours could be safe viable alternatives as nutritious CFs in countries where they are culturally accepted as food.

Funding Sources

Nutritional Sciences Council at Iowa State University.

Drivers of Perceptions About Turkey Berry and Palm Weevil Larvae Among Ghanaian Women of Reproductive Age: A Mixed Methods Approach

Objectives

Availability and access to diversity of foods that are affordable for all peoples always is important for achieving food security status (FSS). Hence, this study examined the influence of FSS on women's perception on underutilized foods: iron-rich plant, solanum torvum (turkey berry, TUB) and edible insect, Rhynchophorus phoenicis fabricius (palm weevil larvae, PWL).

Methods

This cross-sectional study involved 891 women of reproductive age (WRA) from communities in Upper Manya Krobo district, Kumasi Metropolitan, La-Nkwantanang-Madina and Ho municipality in the Eastern, Ashanti, Greater-Accra and Volta regions of Ghana respectively. Data was collected on socio-demographic characteristics, FSS and perceptions about TUB and PWL using a pretested semi-structured questionnaire. Logistic regression models were used to determine effect of FSS on perception outcomes. Also, 2 focus group discussions (FGD) of 10 WRA each were conducted in each municipality/district and analyzed for major themes and patterns.

Results

Mean age was 33 ± 8 y and 36% were food secure. High favorable perception about TUB was 60.9% compared to 17.4% for PWL. WRA residing in big towns in the Greater-Accra region were 2.5 times more likely to have high favorable perceptions about TUB and 4.8 times more likely to have low favorable perceptions about PWL compared to WRA in small towns in the Volta region (P = 0.03). Compared to food insecure WRA, food secure WRA were 2.9 times more likely to have high favorable perceptions about TUB and 4.5 times more likely to have low favorable perceptions about PWL (P = 0.001). FGD participants identified TUB as “the blood-giving plant” and PWL as “the meat of delight”. TUB use barriers included its “hard to grind numerous seeds”, “bitter taste” and “funny smell”. PWL use barriers included “it's like a maggot” and “it's scarce”. FGD participants requested education on nutritional benefits of TUB and PWL and processing of these foods into products that can be liked by everyone.

Conclusions

Drivers of favorable perception about TUB and PWL were region of residence and FSS. Nutrition education and local processing of TUB and PWL into ready-to-use products is recommended as a low-cost sustainable strategy for improving nutrient density of complementary and household foods in communities where these foods are culturally accepted.

Funding Sources

Iowa State University.

Is it possible to constantly and accurately monitor blood sugar levels, in people with Type 1 diabetes, with a discrete device (non-invasive or invasive)?

Real-time continuous glucose monitors using subcutaneous needle-type sensors continue to develop. The limitations of currently available systems, however, include time lag behind changes in blood glucose, the invasive nature of such systems, and in some cases, their accuracy. Non-invasive techniques have been developed, but, to date, no commercial device has been successful. A key research priority for people with Type 1 diabetes identified by the James Lind Alliance was to identify ways of monitoring blood glucose constantly and accurately using a discrete device, invasive or non-invasive. Integration of such a sensor is important in the development of a closed-loop system and the technology must be rapid, selective and acceptable for continuous use by individuals. The present review provides an update on existing continuous glucose-sensing technologies, and an overview of emergent techniques, including their accuracy and limitations.

P4171Population characteristics, interventions and outcomes in hospitalized orthotopic heart transplant patients with sudden cardiac arrest: a nationwide United States analysis from 2007 to 2015

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the United States (US), claiming up to 450,000 lives annually and accounting for ∼25% of deaths following orthotopic heart transplantation (OHT),

Purpose

We sought to characterize OHT patients suffering SCA and their subsequent management, in comparison to the general, native heart (NH) population, using a large national inpatient database.

Methods

A cross-sectional analysis was performed among US OHT & NH patients hospitalized with incident SCA or ventricular fibrillation/flutter. We analyzed demographics, baseline characteristics, procedural utilization and outcomes. Groups were compared with standard statistical techniques. A P-value <0.05 was considered significant.

Results

From 2007–2015, 920 SCA admissions were identified among 121,083 (0.8%) OHT hospitalizations, compared to 1,731,658 (0.6%) in the general population (P<0.001). OHT patients were younger (P<0.001) and predominantly men (P<0.001). More OHT patients had diabetes (P=0.01), while the NH group had more coronary disease (P=0.01). Mechanical circulatory support use was similar in both groups overall, and OHT patients were more likely to undergo transplantation (P=0.015). Pacemaker/defibrillator implants were more common in NH than OHT patients (P<0.001). Acute kidney injury and in-hospital mortality were significantly greater in OHT patients.

Table 1. SCA in OHT & general populations Orthotopic Heart Transplant General Population P-value (N=121,083) (N=278,463,550) Sudden cardiac arrest (SCA) events, n (%) 920 (0.8%) 1,731,658 (0.6%) <0.001 Age, mean (SD) 57 (17) 66 (16) <0.001 Male sex, n (%) 644 (72%) 1,004,362 (58%) <0.001 Coronary artery disease, n (%) 275 (30%) 675,908 (39%) 0.012 Mechanical circulatory support, n (%) 64 (7%) 104,151 (6%) 0.230 Repeat heart transplantation, n (%) 5 (0.5%) 1199 (0.1%) 0.015 Pacemaker or defibrillator implant, n (%) 45 (5%) 136,314 (8%) <0.001 In-hospital mortality, n (%) 555 (60%) 932,812 (54%) 0.014 Cardiogenic shock, n (%) 78 (8%) 208,778 (12%) <0.001 Acute kidney injury, n (%) 418 (45%) 608,035 (35%) 0.003

Conclusions

SCA hospitalizations occur more often and with higher mortality in OHT patients compared to the general population. Earlier recognition of at-risk patients may result in improved utilization of potentially life-saving therapies.

Assessment of Gastrointestinal Symptoms and Non-transferrin Bound Iron After Oral Ferrous Sulfate and Iron-enriched Aspergillus Oryzae Supplementation in Women (P24-039-19)

Objectives

Iron deficiency anemia (IDA) is a widespread nutritional deficiency. Iron supplementation with ferrous sulfate (FeSO4) is the most common strategy to treat IDA; however, the compliance with daily FeSO4 administration is poor, due to contraindicating side effects. Previously, we have reported that A. oryzae (Ultimine®; ULT) is a novel iron source. Therefore, the objective of this study was to determine the biochemical assessment, non-transferrin bound iron (NTBI) and commonly related gastrointestinal side effects to assess the safety of A. oryzae compared to FeSO4.

Methods

Female participants (n = 16) with serum ferritin concentrations 40 µg/L were randomized to a double-blind, 9-wk cross-over study with a 3-wk placebo washout period between treatments. Oral iron supplements (65 mg Fe), FeSO4 and ULT were administered for 21 consecutive days for each subject. Side effect questionnaires were collected 3d/wk over the 9-wk study period. Side effects and biochemical markers (nausea, heartburn, abdominal pain, fatigue, headache, diarrhea, constipation, oxidative stress and liver and kidney function) from iron supplementation were evaluated, along with serum iron, % transferrin saturation (TS) and NBTI 8 h curves.

Results

Serum iron, TS, and NTBI were all markedly higher with FeSO4 at each time-point from 2–8 hours (P < 0.001) compared to ULT, whereas NTBI was undetected. Among treatments, FeSO4 resulted in higher inflammation, though not statistically significant. Compliance based on returned pills was higher with ULT (97.3%) than placebo and FeSO4 (95.2% and 93.2%, respectively). Subjects taking FeSO4 reported abdominal discomfort 2% more than ULT, which was not significantly different. FeSO4 caused marginally higher incidence of combined nauseation, constipation and diarrhea when subjects were taking FeSO4 (P < 0.07). Iron status was maintained similarly by both oral iron supplements. Oxidative stress, inflammation, kidney and liver function markers were not elevated with ULT supplementation, suggesting safety of its consumption.

Conclusions

Better compliance and less gastrointestinal related side effects were reported with ULT compared to FeSO4, while maintaining normal iron status. Our data suggests ULT is a safe oral iron supplement for treatment of IDA.

Funding Sources

Cura Global Health, Inc.

Rapid and Reliable Qualitative Methods for Identification of Iron Fortificants in Wheat Flour (P13-015-19)

Objectives

Fortification is a common strategy to reduce the prevalence of iron deficiency anemia (IDA). Currently, manufacturers are able to fortify wheat flour with cheaper iron compounds with lower bioavailability, leading to less of an impact on IDA. Therefore, a method is needed for government agencies to monitor the type of iron added to flour. The objective was to develop a quick and simple method to qualitatively determine iron compounds commonly used for fortifying wheat flour.

Methods

Unfortified wheat flour was fortified with 40 ppm using these salts: ferric pyrophosphate (FePP), ferrous sulfate (FeSO4), ferrous citrate (FeC), ferrous fumarate (FeF), and sodium iron EDTA (NaFeEDTA), except for electrolytic iron (EFe) where 60 ppm was added. Iron salts were identified based on their magnetic property, solubility in water or acid, and oxidation state. EFe was identified by passing a magnet through the flour. Ferrous and ferric salts were identified using potassium thiocyanate (KSCN) in 3 N hydrochloric acid (HCl) with and without hydrogen peroxide (H2O2). Ferric salts (NaFeDTA and FePP) were identified using Ferrozine and ascorbic acid. Poor solubility of FeF in weak acid with KSCN was used to differentiate it from FeSO4 and FeC. Acidity testing with phenolphthalein and sodium hydroxide (NaOH) further differentiated FeC from FeSO4. Flour samples were tested in triplicates and blinded samples were tested independently.

Results

EFe from flour was visible on the magnet. In addition to producing red specks with KSCN, NaFeEDTA in water produced strong color with Ferrozine and ascorbic acid, unlike FePP. Using KSCN and H2O2, FeF did not produce pink color with 0.1 N HCl, unlike FeSO4 and FeC. Acidity testing differentiated FeSO4 and FeC; FeSO4 produced pink color with less NaOH than FeC. Blinded flour samples were independently and correctly identified to confirm the validity of the methods.

Conclusions

These quick, inexpensive, and reliable qualitative methods will be useful for agencies to identify the type of iron added to flour to monitor the quality of iron fortification strategies.

Funding Sources

Supported by Nutrition International through a grant from Global Affairs Canada.

Iron Supplementation Confers Protection on Disease Severity in Dextran Sodium Sulfate (DSS)-Induced Colitis in Rats (OR15-05-19)

Objectives

Koji iron, enriched with FeSO4 (Ultimine®; ULT), is a novel source of supplemental iron. Previously, we reported ULT had similar absorption as ferrous sulfate (FeSO4), while resulting in less reported adverse effects in women. Iron deficiency anemia is a common manifestation of inflammatory bowel disease (IBD) due to malabsorption and gastrointestinal (GI) bleeding. Therefore, the objective of our study was to identify the efficacy of 2 forms of iron supplementation on impaired GI integrity and anemia caused by dextran sulfate sodium (DSS)-induced colitis.

Methods

Six wk old Sprague Dawley rats (n = 40) were randomly assigned to one of four treatment groups (n = 10/group): 1) Control with no DSS; 2) Control + DSS only (Nfe); 3) DSS + ULT; 4) DSS + FeSO4. Animals were maintained on the AIN-93 G diets for 7 d. Colitis was induced by administering fresh 3.5% (w/v) DSS ad lib throughout the study. Daily iron supplementation (6 mg Fe/kg BW) was provided in a pulverized treat, and disease activity indices were observed (gross bleeding, stool consistency and weight loss). Histological scoring of colonic ulcerations, inflammation and grade were assessed. Iron status indicators and liver hepcidin were detected using ELISA and qRT-PCR, respectively.

Results

The severity score of IBD was significantly higher in the animals without iron supplementation than those treated with iron (P < 0.0001). Moreover, iron supplementation protected against diminished hemoglobin and hematocrit levels as a result of DSS treatment (P = 0.001 and P = 0.03, respectively); whereas, these parameters were not significantly (NS) different between ULT and FeSO4. Improvement was found with post mortem disease score of DSS-induced rats with ULT compared to FeSO4 and Nfe by 14% and 39%, respectively (NS). Compared to healthy controls, FeSO4 resulted in a 3.5-fold increase in liver hepcidin gene expression, whereas ULT caused no change.

Conclusions

The results of this study highlight the beneficial effects iron supplementation has on the disease activity evoked by severe GI inflammation. Furthermore, this data suggests ULT attenuates the progression of IBD by supporting iron homeostasis. Additional analyses will explore the possible mechanisms of these results by identifying the systemic inflammation.

Funding Sources

College of Human Sciences, Iowa State University Collaborative Seed Grant Program.

Edible Insects but Not Solanum Torvum Improved Body Composition and Iron Status in Protein and Iron Deficient Rats (P24-007-19)

Objectives

Nutritious underutilized foods (NUFs) such as Solanum torvum (STO) and edible insects are potential sustainable dietary approaches to prevent malnutrition and improve food security. However, little is known about nutrient bioavailability from NUFs. This study determined the effect of STO and insect powders on improving nutritional status of malnourished rats.

Methods

Malnutrition was induced in weanling male Sprague-Dawley rats by feeding 5% protein with low Fe (LPI) diet for 21 days. During 14-day repletion, 5 groups of rats (n = 8) were fed the LPI diet supplemented with cricket, palm weevil larvae, STO, cricket + STO and casein + ferrous sulfate (HPI, positive control) while another group remained on the LPI diet (negative control). Repletion diets contained 15% protein and 20 ppm Fe, but palm larvae diet contained only 10 ppm Fe. Body composition was measured by dual X-ray absorptiometry. Hemoglobin (Hb) repletion method was used to compare relative bioavailability (RBV) of the HPI group to the other groups.

Results

Collectively, there were no differences in improved growth rate and body composition measures in groups repleted with edible insects and HPI (P = 0.08). Growth rate was 7.9 times higher in HPI compared to STO and 4.2 times higher in HPI compared to LPI (P < 0.0001). Changes in body composition were similar in STO and LPI but significantly different from HPI. Increase in Hb Fe with cricket (2.00 ± 0.90 mg) and palm weevil larvae (1.17 ± 0.75 mg) was comparable to HPI (1.94 ± 0.74 mg) (P = 0.27). Compared to HPI, there were significant differences in Hb Fe with STO (−0.08 ± 0.37 mg) and LPI (0.55 ± 0.18 mg). When RBV was calculated based on Hb Fe and food intake, RBV was 1.3 for palm weevil larvae but this was not significantly different from HPI (RBV = 1.00) and cricket (RBV = 0.99) (P = 0.83). RBV was similar in STO and LPI, and 100 times lower compared to HPI (P < 0.0001).

Conclusions

Though other benefits of STO may be plausible, no nutritional benefits were found in this study, but cricket and palm weevil larvae could be excellent alternative sources of protein and bioavailable Fe and can be sustainable, cheap and locally available foods to prevent malnutrition in humans in countries where they are culturally accepted.

Funding Sources

Doris A. Adams endowment funds from the College of Human Sciences at Iowa State University, Ames.

Surgical options for glycaemic control in Type 1 diabetes

In recent years, bariatric surgery, also referred to as metabolic surgery, has become the most successful treatment option in those with Type 2 diabetes and obesity. There are some similarities in the pathological pathways in Type 1 and Type 2 diabetes, but the use of surgery in Type 1 diabetes remains unestablished and controversial. The treatment and management of Type 1 diabetes can be very challenging but recent advances in surgical interventions and technology has the potential to expand and optimize treatment options. This review discusses the current status of some surgical options available to people with Type 1 diabetes. These include implantable continuous glucose monitoring systems, continuous intraperitoneal insulin infusion pumps, closed-loop insulin delivery systems (also known as the artificial pancreas system) utilizing the latter two modalities of glucose monitoring and insulin delivery, and bariatric or metabolic surgery. Whole pancreas and islet transplantation are beyond the scope of this review but are briefly discussed.

Clinical and laboratory profile of anti-M

Anti-M is a frequently detected naturally occurring antibody that has been reported in various clinical settings and also in voluntary donors. We describe here the clinical and laboratory findings of 11 cases with anti-M detected at our center. This report is a retrospective study in which we reviewed our immunohematology laboratory records for cases involving anti-M. Both donor and patient data from a 28-month period (September 2014 to December 2016) were reviewed. During this period, 11 examples of anti-M were detected (8 patients, 1 voluntary whole blood donor, and 1 hematopoietic stem cell donor. Anti-M was also detected in one external quality assessment scheme sample received during this period. In conclusion, anti-M can be detected in various clinical settings. This antibody can be clinically significant; in the laboratory, it can present as a serologic problem such as an ABO group discrepancy or an incompatible crossmatch. After detection, management and course of action is determined by both the antibody characteristics and the clinical setting. Anti-M is a frequently detected naturally occurring antibody that has been reported in various clinical settings and also in voluntary donors. We describe here the clinical and laboratory findings of 11 cases with anti-M detected at our center. This report is a retrospective study in which we reviewed our immunohematology laboratory records for cases involving anti-M. Both donor and patient data from a 28-month period (September 2014 to December 2016) were reviewed. During this period, 11 examples of anti-M were detected (8 patients, 1 voluntary whole blood donor, and 1 hematopoietic stem cell donor. Anti-M was also detected in one external quality assessment scheme sample received during this period. In conclusion, anti-M can be detected in various clinical settings. This antibody can be clinically significant; in the laboratory, it can present as a serologic problem such as an ABO group discrepancy or an incompatible crossmatch. After detection, management and course of action is determined by both the antibody characteristics and the clinical setting.

Selective RET kinase inhibition for patients with RET-altered cancers

Background

Alterations involving the RET kinase are implicated in the pathogenesis of lung, thyroid and other cancers. However, the clinical activity of multikinase inhibitors (MKIs) with anti-RET activity in RET-altered patients appears limited, calling into question the therapeutic potential of targeting RET. LOXO-292 is a selective RET inhibitor designed to inhibit diverse RET fusions, activating mutations and acquired resistance mutations.

Patients and methods

Potent anti-RET activity, high selectivity, and central nervous system coverage were confirmed preclinically using a variety of in vitro and in vivo RET-dependent tumor models. Due to clinical urgency, two patients with RET-altered, MKI-resistant cancers were treated with LOXO-292, utilizing rapid dose-titration guided by real-time pharmacokinetic assessments to achieve meaningful clinical exposures safely and rapidly.

Results

LOXO-292 demonstrated potent and selective anti-RET activity preclinically against human cancer cell lines harboring endogenous RET gene alterations; cells engineered to express a KIF5B-RET fusion protein -/+ the RET V804M gatekeeper resistance mutation or the common RET activating mutation M918T; and RET-altered human cancer cell line and patient-derived xenografts, including a patient-derived RET fusion-positive xenograft injected orthotopically into the brain. A patient with RET M918T-mutant medullary thyroid cancer metastatic to the liver and an acquired RET V804M gatekeeper resistance mutation, previously treated with six MKI regimens, experienced rapid reductions in tumor calcitonin, CEA and cell-free DNA, resolution of painful hepatomegaly and tumor-related diarrhea and a confirmed tumor response. A second patient with KIF5B-RET fusion-positive lung cancer, acquired resistance to alectinib and symptomatic brain metastases experienced a dramatic response in the brain, and her symptoms resolved.

Conclusions

These results provide proof-of-concept of the clinical actionability of RET alterations, and identify selective RET inhibition by LOXO-292 as a promising treatment in heavily pretreated, multikinase inhibitor-experienced patients with diverse RET-altered tumors.

A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia

AIM

Hypoglycaemia in Type 1 diabetes is associated with mortality and morbidity, especially where awareness of hypoglycaemia is impaired. Clinical pathways for access to continuous glucose monitoring (CGM) and flash glucose monitoring technologies are unclear. We assessed the impact of CGM and flash glucose monitoring in a high-risk group of people with Type 1 diabetes.

METHODS

A randomized, non-masked parallel group study was undertaken. Adults with Type 1 diabetes using a multiple-dose insulin-injection regimen with a Gold score of ≥ 4 or recent severe hypoglycaemia were recruited. Following 2 weeks of blinded CGM, they were randomly assigned to CGM (Dexcom G5) or flash glucose monitoring (Abbott Freestyle Libre) for 8 weeks. The primary outcome was the difference in time spent in hypoglycaemia (below 3.3 mmol/l) from baseline to endpoint with CGM versus flash glucose monitoring.

RESULTS

Some 40 participants were randomized to CGM (n = 20) or flash glucose monitoring (n = 20). The participants (24 men, 16 women) had a median (IQR) age of 49.6 (37.5-63.5) years, duration of diabetes of 30.0 (21.0-36.5) years and HbA_1c of 56 (48-63) mmol/mol [7.3 (6.5-7.8)%]. The baseline median percentage time < 3.3 mmol/l was 4.5% in the CGM group and 6.7% in the flash glucose monitoring. At the end-point the percentage time < 3.3 mmol/l was 2.4%, and 6.8% respectively (median between group difference -4.3%, P = 0.006). Time spent in hypoglycaemia at all thresholds, and hypoglycaemia fear, were different between groups, favouring CGM.

CONCLUSION

CGM more effectively reduces time spent in hypoglycaemia in people with Type 1 diabetes and impaired awareness of hypoglycaemia compared with flash glucose monitoring. (Clinical Trial Registry No: NCT03028220).

Sociotechnical Requirements Analysis for Clinical Systems

Objective: We explore sociotechnical requirements by examining the use of a computerized patient record system in an intensive care unit of a U.S. hospital and present two sociotechnical requirements, awareness and coordination, embedded in the users’ work.

Method: The study is based on observation during seven months of the use of a computerized patient record system in a surgical intensive care unit. During that period semi-formal interviews, informal interviews were held.

Results and Conclusions: A key step in the design of clinical systems is the development and analysis of requirements. However, traditional requirements analysis is based on a set of assumptions that break down in the highly collaborative, exception-filled clinical domain. Sociotechnical requirement analysis enabled the designers to gather a much richer description of the environment surrounding the computer system, highlighting awareness and coordination, embedded in the users’ work.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

A Physiologically Based Pharmacokinetic Model for Ganciclovir and Its Prodrug Valganciclovir in Adults and Children

A physiologically based pharmacokinetic (PBPK) model has been developed for ganciclovir and its prodrug valganciclovir. Initial bottom-up modeling based on physicochemical drug properties and measured in vitro inputs was verified in preclinical animal species, and then, a clinical model was verified in a stepwise fashion with pharmacokinetic data in adult, children, and neonatal patients. The final model incorporated conversion of valganciclovir to ganciclovir through esterases and permeability-limited tissue distribution of both drugs with active transport processes added in gut, liver, and kidney. A PBPK model which accounted for known age-related tissue volumes, composition and blood flows, and renal filtration clearance was able to simulate well the measured plasma exposures in adults and pediatric patients. Overall, this work illustrates the stepwise development of PBPK models which could be used to predict pharmacokinetics in infants and neonates, thereby assisting drug development in a vulnerable patient population where clinical data are challenging to obtain.

Tuberculosis diagnostics in Fiji: how reliable is culture?

SETTINGS

Acid-fast bacilli (AFB) smear microscopy and Mycobacterium tuberculosis culture are the first-line diagnostic tests for tuberculosis (TB). The contamination of TB cultures significantly reduces the reliability of TB diagnosis.

OBJECTIVE

To investigate factors associated with TB culture contamination in Fiji, and the relative diagnostic performance of culture compared to microscopy.

DESIGN

All tests performed at the Daulakao Mycobacterium Reference Laboratory (DMRL) in Fiji from 2010 to 2012 were reviewed. Study variables included AFB smear and TB culture results, age and type of specimen, referring TB testing centre and patient age.

RESULTS

Of 5708 specimens reviewed, 70% had both AFB smear and culture results recorded; 421 specimens were contaminated; 2.7% of specimens were either degraded or had no result recorded. There was moderate agreement (κ = 0.577) between the two tests. Culture was more likely to be positive at higher AFB smear scores. Culture contamination was associated with distance from the DMRL, sample age and operator-associated factors.

CONCLUSION

Increases in the speed of referral from TB testing centres or the addition of preservatives to sputum specimens may results in less culture contamination. The planned introduction of liquid culture techniques in combination with culture on Ogawa media is likely to increase the sensitivity of TB diagnosis in Fiji.

Effect of Maternal Cigarette Smoking on Newborn Iron Stores

BACKGROUND

Maternal smoking has been known to have a negative impact on the well being of the developing fetus. Prenatal smoking has been associated with premature births, low birth weight and with certain birth defects. Small research studies have also found a negative correlation between maternal smoking and neonatal body iron.

OBJECTIVES

To study and compare the relationship between maternal and infants' body iron in smokers and non-smokers in a large matched-pair cohort.

METHODS

This was a prospective cohort study involving 144 mothers - 72 smokers and 72 non-smokers and their respective infants. Samples were obtained from maternal and infants' cord blood at delivery for Serum transferrin receptor (sTfR) and ferritin levels. Serum TfR and ferritin were measured by RAMCO ELISA and RIA assays. Total Body Iron (TBI) was calculated using the sTfR/ferritin ratio in a previously described formula by Cook et al.

RESULTS

Women who smoked had lower sTfR, higher ferritin and higher body iron compared to nonsmoking women. In contrast to their respective mothers, we found a small, but statistically significant negative correlation between smoking and infants' total body iron. The number of packs per day smoked was also negatively correlated with infants' ferritin and total body iron. Lower birth weight was noted in babies of smokers compared to nonsmokers (mean /- SD =3270 +/-475 vs. 3393 g +/- 475 g, p=0.03).

CONCLUSION

Women who smoked during pregnancy had higher iron stores but their newborn infants had lower iron stores than those of non-smoking mothers. The more packs per day (PPD) and more days smoked during pregnancy led to lower total body iron of the babies. There may be a negative dose-dependent response between fetal smoke exposure and infant iron stores.

Laparoscopic common bile duct exploration versus pre or post-operative ERCP for common bile duct stones in patients undergoing cholecystectomy: is there any difference?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was: in patients with symptomatic gallstones and concomitant common bile duct (CBD) stones, is a single-stage surgical strategy (laparoscopic cholecystectomy (LC) with common bile duct exploration) preferable, or a two-stage procedure involving LC with pre or post-operative endoscopic retrograde cholangiography (ERCP)? Two hundred and six papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. A recent large meta-analysis concluded no significant difference in the clinical effectiveness or complication rate of either strategy. Three recent smaller studies concurred with this conclusion; however each noted improved cost-effectiveness of the single-stage approach advocating its use as the superior strategy when local resources and expertise are available. We conclude that for patients with symptomatic gallstones and concomitant choledocholithiasis, a single-stage surgical procedure is equivalent to two-stage LC and ERCP in terms of clinical outcomes, is associated with a shorter overall hospital stay and may be more cost-effective. On this basis a single-stage procedure is recommended for management of symptomatic gallstones and choledocholithiasis where local resources and expertise permit.