Neighbourhood factors and tuberculosis incidence in Cape Town: A negative binomial regression and spatial analysis

OBJECTIVES

Although the link between poverty and tuberculosis (TB) is widely recognised, limited studies have investigated the association between neighbourhood factors and TB incidence. Since the factors influencing different episodes of TB might be different, this study focused on the first episode of TB disease (first-episode TB).

METHODS

All first episodes in previously linked and geocoded TB notification data from 2007 to 2015 in Cape Town, South Africa, were aggregated at the neighbourhood level and merged with the 2011 census data. We conducted an ecological study to assess the association between neighbourhood incidence of first-episode TB and neighbourhood factors (total TB burden [all episodes] in the previous year, socioeconomic index, mean household size, mean age, and percentage males) using a negative binomial regression. We also examined the presence of hotspots in neighbourhood TB incidence with the Global Moran's I statistic and assessed spatial dependency in the association between neighbourhood factors and TB incidence using a spatial lag model.

RESULTS

The study included 684 neighbourhoods with a median first-episode TB incidence rate of 114 (IQR: 0-345) per 100,000 people. We found lower neighbourhood socioeconomic index (SEI), higher neighbourhood total TB burden, lower neighbourhood mean household size, and lower neighbourhood mean age were associated with increased neighbourhood first-episode TB incidence. Our findings revealed a hotspot of first-episode TB incidence in Cape Town and evidence of spatial dependency in the association between neighbourhood factors and TB incidence.

CONCLUSION

Neighbourhood TB burden and SEI were associated with first-episode TB incidence, and there was spatial dependency in this association. Our findings can inform targeted interventions to reduce TB in high-risk neighbourhoods, thereby reducing health disparities and promoting health equity.

Effect of everolimus on skin lesions in patients treated for subependymal giant cell astrocytoma and renal angiomyolipoma: final 4-year results from the randomized EXIST-1 and EXIST-2 studies

BACKGROUND

Tuberous sclerosis complex (TSC) is a genetic disorder associated with tumour growth in various organs, including the brain, kidneys, heart and skin. Cutaneous lesions are prevalent manifestations of TSC, occurring in up to 90% of patients. Oral mammalian target of rapamycin inhibitors, such as everolimus, is believed to be effective for treatment of TSC-associated lesions because they act on the underlying disease pathophysiology.

OBJECTIVE

We evaluated the long-term effect of oral everolimus on TSC-associated skin lesions as a secondary objective in the phase III studies EXIST-1 (NCT00789828) and EXIST-2 (NCT00790400) after approximately 4 years of treatment.

MATERIALS AND METHODS

Everolimus was dosed 4.5 mg/m² /day (titrated to trough 5-15 ng/mL) in patients with TSC-associated subependymal giant cell astrocytoma in EXIST-1, and 10 mg/day initially in adult patients with TSC- or sporadic lymphangioleiomyomatosis-associated renal angiomyolipoma in EXIST-2. Following positive results from the core phase, remaining patients were offered open-label everolimus in an extension. Skin lesion response rate was the proportion of patients achieving complete or partial clinical response.

RESULTS

A total of 105 patients in EXIST-1 and 107 in EXIST-2 received everolimus and had ≥1 skin lesion at baseline. Skin lesion response rate (95% confidence interval) was 58.1% (48.1-67.7%) in EXIST-1 and 68.2% (58.5-76.9%) in EXIST-2; most were partial responses. At week 192 (EXIST-1: n = 55; EXIST-2: n = 56), 69% and 66% had a response. Most common drug-related adverse event was stomatitis (41-45%).

CONCLUSION

Oral everolimus improved TSC-related skin lesions, with responses sustained over 4 years of treatment in EXIST-1 and EXIST-2.

Final overall survival analysis for the phase II RECORD-3 study of first-line everolimus followed by sunitinib versus first-line sunitinib followed by everolimus in metastatic RCC

Background

RECORD-3 compared everolimus and sunitinib as first-line therapy, and the sequence of everolimus followed by sunitinib at progression compared with the opposite (standard) sequence in patients with metastatic renal cell carcinoma (mRCC). This final overall survival (OS) analysis evaluated mature data for secondary end points.

Patients and methods

Patients received either first-line everolimus followed by second-line sunitinib at progression (n = 238) or first-line sunitinib followed by second-line everolimus (n = 233). Secondary end points were combined first- and second-line progression-free survival (PFS), OS, and safety. The impacts of neutrophil lymphocyte ratio (NLR) and baseline levels of soluble biomarkers on OS were explored.

Results

At final analysis, median duration of exposure was 5.6 months for everolimus and 8.3 months for sunitinib. Median combined PFS was 21.7 months [95% confidence interval (CI) 15.1–26.7] with everolimus-sunitinib and 22.2 months (95% CI 16.0–29.8) with sunitinib-everolimus [hazard ratio (HR)_{EVE-SUN/SUN-EVE}, 1.2; 95% CI 0.9–1.6]. Median OS was 22.4 months (95% CI 18.6–33.3) for everolimus-sunitinib and 29.5 months (95% CI 22.8–33.1) for sunitinib-everolimus (HR_{EVE-SUN/SUN-EVE}, 1.1; 95% CI 0.9–1.4). The rates of grade 3 and 4 adverse events suspected to be related to second-line therapy were 47% with everolimus and 57% with sunitinib. Higher NLR and 12 soluble biomarker levels were identified as prognostic markers for poor OS with the association being largely independent of treatment sequences.

Conclusions

Results of this final OS analysis support the sequence of sunitinib followed by everolimus at progression in patients with mRCC. The safety profiles of everolimus and sunitinib were consistent with those previously reported, and there were no unexpected safety signals.

Clinical Trials number

ClinicalTrials.gov identifier, NCT00903175

P3-16-18: Phase 2, Open-Label Study of EZN-2208 (PEG-SN38) in Patients with Previously Treated Metastatic Breast Cancer

Background

EZN-2208 is a water-soluble PEGylated conjugate of SN38 that results in parenteral delivery, increased solubility, higher exposure, and longer apparent half-life of SN38, as well as more profound deoxyribonucleic acid (DNA) damage and inhibition of angiogenesis. EZN-2208 results in prolonged exposure of tumors to SN38 via preferential accumulation of EZN-2208 in the tumor and prolonged release of SN38 in the blood.

Methods: This trial evaluated EZN-2208 delivered as a 1-h IV infusion weekly for 3 wks in 4-wk cycles. The primary objective was to determine the overall response rate (RR) in female patients with metastatic breast cancer (MBC) who had received prior adjuvant or metastatic therapy with either 1) anthracycline and taxane (AT) or 2) anthracycline, taxane, and capecitabine (Xeloda®) (ATX). Secondary objectives included evaluation of RR based on tumor receptor status, duration of response, progression-free survival (PFS), overall survival (OS), and safety and toxicity. Response was evaluated using RECIST (v1.1).

Results: 148 patients received EZN-2208 in the AT (n=65; median age = 56 y [31-84 y]) or ATX (n=83; median age = 55 y [36-83 y]) cohorts. All 65 patients in the AT cohort had received 0–2 lines of prior cytotoxic therapy for MBC; for the ATX cohort, 31 patients (37%) had received 0–2 prior lines of cytotoxic therapy for MBC, 50 patients (60%) had received 3–4 prior lines, and 2 patients (2%) had received 5 prior lines. Preliminary results follow; final data will be presented at the meeting. Median (range) cycles of EZN-2208 was 2.3 (0.3-14) for AT and 2 (0.3-15) for ATX. Best overall response is shown in the table. RR (PR+uPR) was 22% for AT and 10% for ATX.

Median (95% CI) time to progression was 3.8 mo (3.6−7.4) for AT and 3.3 mo (1.8−3.7) for ATX. Median (95% CI) duration of response was 4.0 mo (3.7−5.6) for AT and 5.2 mo (1.9-..) for ATX. 6-mo PFS (95% CI) was 34% (19%-50%) for AT and 19% (9%-29%) for ATX. Median PFS (95% CI) was 3.8 mo (2.7−5.6) for AT and 2.9 mo (1.83.7) for ATX. Median OS (95% CI) was 9.1 mo (6.1−12.7) for AT and 7.9 mo (6.4−12.9) for ATX. Grade 3 or 4 drug-related adverse events (>10% of patients in either arm) included neutropenia (43%, 33%), diarrhea (11%, 8%), and leukopenia (11%, 6%).

Estimates of the lifetime direct costs of treatment for metastatic breast cancer

OBJECTIVE

Breast cancer remains the highest incident cancer among females in the United States and previous research suggests that a considerable portion of patients will eventually progress to the metastatic phase of the disease. This paper provides the first estimate of the lifetime direct costs of treating metastatic disease for one annual diagnostic cohort of breast cancer patients.

METHODS

Incidence rates were combined with US population counts to estimate the number of breast cancer cases diagnosed in 1994. Estimates of progression to metastatic disease (from Canadian provincial cancer registry data), costs of care (derived from patients' claims histories), survival (from SEER data), and national mortality rates (from US Census Bureau) were integrated, using Statistics Canada's Population Health Model (POHEM) to calculate lifetime costs.

RESULTS

This study estimates that more than 40% of the women diagnosed with breast cancer will progress to metastatic disease. On average, women with metastatic disease are expected to live 3 years and to incur direct treatment costs of approximately dollar 60,000 per case, resulting in a total lifetime cost for the cohort of almost dollar 4.2 billion.

CONCLUSIONS

The high rate of recurrence of breast cancer argues for the development of interventions that can prevent or delay the onset of metastatic disease. These estimates of lifetime costs and the methodology on which they are based can be used to evaluate the cost-effectiveness of such secondary prevention strategies. These estimates also can serve as a benchmark against which the lifetime costs of treating other diseases can be assessed.

Gastroparesis after lung transplantation. Potential role in postoperative respiratory complications

BACKGROUND

We observed an unexpectedly high incidence of postoperative gastroparesis among lung and heart-lung transplant recipients.

PURPOSE

To identify the incidence of GI complications and to describe the clinical profiles of patients who developed symptomatic gastroparesis after lung transplantation.

PATIENTS AND METHODS

Retrospective study of GI symptoms and complications identified during 3 years of follow-up of 38 adult lung and heart-lung transplant recipients.

RESULTS

Sixteen of 38 patients (42%) reported one or more GI complaint and received a specific GI diagnosis. Nine of 38 patients (24%) complained of early satiety, epigastric fullness, anorexia, nausea, or vomiting. Gastroparesis was suspected when endoscopic evaluation revealed undigested food in the stomach after overnight fast and symptoms could not be attributed to peptide disease or cytomegalovirus gastritis. Delayed gastric emptying was confirmed by gastric scintigraphy. Mean gastric empty (t1/2) was 263 +/- 115 min (normal < 95 min). Gastroparesis occurred in 4 of 13 right lung, 2 of 12 left lung, 1 of 9 bilateral single lung, and 2 of 4 heart-lung recipients (p = NS). Patients responded partially to metoclopramide or cisapride, with the exception of two patients who required placement of jejunal feeding tubes secondary to severe symptoms. In long-term follow-up, symptoms resolved in all patients and treatment with medications or mechanical intervention was successfully discontinued. Four of nine patients (44%) suffering from gastroparesis developed obliterative bronchiolitis (OB). Food particles were discovered in the BAL fluid of two such symptomatic patients. In contrast, only 6 of 29 (21%) nonsymptomatic patients developed OB (p = 0.16).

CONCLUSION

Symptomatic gastroparesis is a frequent complication of lung or heart-lung transplantation that may promote microaspiration into the lung allograft.

A comparative analysis of functional status among Spanish- and English-speaking patients with dementia

The assessment of functional capacity is regarded as an important part of a comprehensive diagnostic work-up for dementia. However, there is a paucity of data regarding comparative functional performance among different ethnic/cultural groups. In this study, we compared Spanish- and English-speaking dementia patients and normal controls on a comprehensive functional assessment battery administered within the clinical setting. Despite equivalent levels of cognitive impairment, Spanish-speaking dementia patients evidenced more difficulties on certain functional tasks relative to their English-speaking counterparts. On the other hand, Spanish- and English-speaking controls did not differ with regards to their functional performance. Results suggest that the extent of deterioration in specific functional subskills may be related to the degree to which they have been overlearned and practiced. Further, they indicate the potential utility of direct functional assessment in both Spanish- and English-speaking populations.

T cell responses specific for subregions of allogeneic MHC molecules

The repertoire of C3H (H-2k) CD4+ T cells for I-Ab allopolymorphisms was analyzed by studying the responses of unprimed populations of T cells and of I-Ab-specific T cell clones for recombinant MHC molecules containing combinations of polymorphic subregions of the alpha- and beta-chains from the I-Ab and I-Ak molecules. In this system, polymorphisms in the predicted MHC alpha-helices were more potent than polymorphisms in the beta-strands in stimulating unprimed alloreactive T cells. Similarly, 75% of I-Ab-specific T cell clones responded to recombinants containing b polymorphisms in both the alpha- and beta-chains helices and tolerated the substitution of k polymorphisms in the beta-pleated sheet. Furthermore, 20% of the clones responded to a molecule containing allogeneic b residues in just the beta-chain helix. The results demonstrate that the T cell response to allogeneic MHC molecules consists largely of sets of T cells with overlapping specificities for subregions of the MHC molecule. In addition, they highlight the importance of the alpha-helices in these responses and a diminished role for polymorphisms in the beta-strands when, as in the present case, MHC structure and conformation is tolerant of beta-sheet substitutions. These results sharply contrast with observations made in the analysis of Ag-specific T cells and lead to the suggestion that a subset of alloreactive T cells are not peptide specific and can directly recognize MHC polymorphisms.

T cell responses specific for subregions of allogeneic MHC molecules

The repertoire of C3H (H-2k) CD4+ T cells for I-Ab allopolymorphisms was analyzed by studying the responses of unprimed populations of T cells and of I-Ab-specific T cell clones for recombinant MHC molecules containing combinations of polymorphic subregions of the alpha- and beta-chains from the I-Ab and I-Ak molecules. In this system, polymorphisms in the predicted MHC alpha-helices were more potent than polymorphisms in the beta-strands in stimulating unprimed alloreactive T cells. Similarly, 75% of I-Ab-specific T cell clones responded to recombinants containing b polymorphisms in both the alpha- and beta-chains helices and tolerated the substitution of k polymorphisms in the beta-pleated sheet. Furthermore, 20% of the clones responded to a molecule containing allogeneic b residues in just the beta-chain helix. The results demonstrate that the T cell response to allogeneic MHC molecules consists largely of sets of T cells with overlapping specificities for subregions of the MHC molecule. In addition, they highlight the importance of the alpha-helices in these responses and a diminished role for polymorphisms in the beta-strands when, as in the present case, MHC structure and conformation is tolerant of beta-sheet substitutions. These results sharply contrast with observations made in the analysis of Ag-specific T cells and lead to the suggestion that a subset of alloreactive T cells are not peptide specific and can directly recognize MHC polymorphisms.

A single amino acid substitution in a common African allele of the CD4 molecule ablates binding of the monoclonal antibody, OKT4

The CD4 molecule is a relatively non-polymorphic 55 kDa glycoprotein expressed on a subset of T lymphocytes. A common African allele of CD4 has been identified by non-reactivity with the monoclonal antibody, OKT4. The genetic basis for the OKT4- polymorphism of CD4 is unknown. In the present paper, the structure of the CD4 molecule from an homozygous CD4OKT4- individual was characterized at the molecular level. The size of the CD4OKT4- protein and mRNA were indistinguishable from those of the OKT4+ allele. The polymerase chain reaction (PCR) was used to map the structure of CD4OKT4- cDNAs by amplifying overlapping DNA segments and to obtain partial nucleotide sequence after asymmetric amplification. PCR was then used to clone CD4OKT4- cDNAs spanning the coding region of the entire, mature CD4 protein by amplification of two overlapping segments followed by PCR recombination. The nucleotide sequence of CD4OKT4- cDNA clones revealed a G----A transition at bp 867 encoding an arginine----tryptophan substitution at amino acid 240 relative to CD4OKT4+. Expression of a CD4OKT4- cDNA containing only this transition, confirmed that the arginine----tryptophan substitution at amino acid 240 ablates the binding of the mAb OKT4. A positively charged amino acid residue at this position is found in chimpanzee, rhesus macaque, mouse and rat CD4 suggesting that this mutation may confer unique functional properties to the CD4OKT4- protein.

Structurally interdependent and independent regions of allelic polymorphism in class II MHC molecules. Implications for Ia function and evolution

Possible interactions between regions of allelic polymorphism in the alpha- and beta-chains of class II MHC molecules were examined by measuring the efficiency of surface expression and the reactivity with mAb of wild-type and recombinant A alpha A beta-chain pairs from the b, d, and k haplotypes. These studies revealed regions of polymorphism within the alpha- and beta-chains that interact with complementary regions in the other chain. Unexpectedly, almost all the variable segments of both the class II MHC alpha- and beta-chains either directly contributed to or were near sites of interchain interactions. The exception was the beta HV3 (hypervariable (HV] segment (residues 61-71), which appeared to neither participate in nor be affected by interchain interactions. This division of the MHC molecule into interacting vs independent regions of allelic structural variation suggests that mutagenesis experiments involving the beta HV3 segment can be analyzed in a straightforward manner, as such mutations appear unlikely to alter the conformation of other molecular segments. Furthermore, functions attributed to the beta HV3 segment either experimentally or by population analysis should have a high probability of transfer by beta HV3 exchange (either experimentally or evolutionarily), because epitopes assigned to this region of the molecule are not affected by sequences outside this segment. This is of special importance because of the apparent involvement of this region in defining a potential site of interaction with antigenic peptides and TCR. In contrast, almost all other variable segments of the MHC molecule appear to have the capacity to contribute to interactions involving at least one other variable segment. This suggests not only that the experimental analysis of the contributions of these regions to various functions requires a consideration of inter- and intrachain interaction, but also that the transfer of function by genetic exchange of these structurally dependent regions is unpredictable. Selection must therefore operate on these interacting HV segments in the context of the complete alpha beta heterodimer. These results support our earlier arguments for cis-co-evolution of alpha- and beta-chain polymorphism and the absence of selection for F1 (hybrid) class II molecules. Finally, asymmetries observed in the contributions of particular pairs of HV segments to the efficient expression of Ia alpha beta heterodimers provide a basis for understanding mechanistically how cis-co-evolution may have occurred.

Structurally interdependent and independent regions of allelic polymorphism in class II MHC molecules. Implications for Ia function and evolution

Possible interactions between regions of allelic polymorphism in the alpha- and beta-chains of class II MHC molecules were examined by measuring the efficiency of surface expression and the reactivity with mAb of wild-type and recombinant A alpha A beta-chain pairs from the b, d, and k haplotypes. These studies revealed regions of polymorphism within the alpha- and beta-chains that interact with complementary regions in the other chain. Unexpectedly, almost all the variable segments of both the class II MHC alpha- and beta-chains either directly contributed to or were near sites of interchain interactions. The exception was the beta HV3 (hypervariable (HV] segment (residues 61-71), which appeared to neither participate in nor be affected by interchain interactions. This division of the MHC molecule into interacting vs independent regions of allelic structural variation suggests that mutagenesis experiments involving the beta HV3 segment can be analyzed in a straightforward manner, as such mutations appear unlikely to alter the conformation of other molecular segments. Furthermore, functions attributed to the beta HV3 segment either experimentally or by population analysis should have a high probability of transfer by beta HV3 exchange (either experimentally or evolutionarily), because epitopes assigned to this region of the molecule are not affected by sequences outside this segment. This is of special importance because of the apparent involvement of this region in defining a potential site of interaction with antigenic peptides and TCR. In contrast, almost all other variable segments of the MHC molecule appear to have the capacity to contribute to interactions involving at least one other variable segment. This suggests not only that the experimental analysis of the contributions of these regions to various functions requires a consideration of inter- and intrachain interaction, but also that the transfer of function by genetic exchange of these structurally dependent regions is unpredictable. Selection must therefore operate on these interacting HV segments in the context of the complete alpha beta heterodimer. These results support our earlier arguments for cis-co-evolution of alpha- and beta-chain polymorphism and the absence of selection for F1 (hybrid) class II molecules. Finally, asymmetries observed in the contributions of particular pairs of HV segments to the efficient expression of Ia alpha beta heterodimers provide a basis for understanding mechanistically how cis-co-evolution may have occurred.

A new scale for the assessment of functional status in Alzheimer's disease and related disorders

Assessment of the functional competencies of patients with dementia is typically conducted in an indirect manner. Psychological tests of cognition or descriptions by relatives or other caregivers are often used to make judgments as to the patient's ability to adapt to the demands of the environment. However, these methods have built-in biases. The need for direct assessment of functional status was addressed by developing a standardized operational procedure to examine areas of functional competence which may become impaired in Alzheimer's disease and other related memory disorders. The resulting instrument has high interrater and test-retest reliabilities. Convergent validity is evidenced by significant correlations between the scale and established measures of functional status. Patients with Alzheimer's disease exhibited deficits in functional capacities relative to age-equivalent normal controls and to elderly patients with a primary major depression.

ON THE RELATIONSHIP BETWEEN INTERNAL PRESSURE AND ULTRASONIC VELOCITY

Because of the relevance of internal pressure data to sonochemical kinetics, some interest attaches to expressions which permit evaluation of Pi from readily available or easily measured quantities. One such expression is developed in this paper. It relates Pi to the velocity u of ultrasonic waves transmitted through the liquid and takes the form u√D = K′√(Rm)Pi where K′ is a constant proportional to √(Cp/Cv)√(1/RT), and D and Rm denote the density and molar refraction of the liquid.The utility of this expression is tested against some 100 liquids (including a few binary liquid mixtures and aqueous electrolyte solutions), and it is shown that the equation offers an acceptable and quite general method for calculating Pi.

A NOTE ON THE ELECTRICAL CONDUCTANCES OF DIELECTRIC FLUIDS IN ULTRASONIC FIELDS

The electrical conductances of ethyl bromide, n-propyl bromide, n-butyl bromide, methanol, and ethanol in ultrasonic fields have been measured at frequencies between 250 kc/s and 2 Mc/s and intensities between 0.7 and 24 w/cm2. Measurements were made at room temperature, using a simple d-c. technique. It is shown that a simple transient increase in conductance, such as has previously been observed by Seidl, may be confined to unassociated fluids and that it can occasionally give way to a much more complex—and not as yet fully understood—behavior pattern.