Investigating One Health risks for human colonisation with extended spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in Malawian households: a longitudinal cohort study

BACKGROUND

Low-income countries have high morbidity and mortality from drug-resistant infections, especially from enteric bacteria such as Escherichia coli. In these settings, sanitation infrastructure is of variable and often inadequate quality, creating risks of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales transmission. We aimed to describe the prevalence, distribution, and risks of ESBL-producing Enterobacterales colonisation in sub-Saharan Africa using a One Health approach.

METHODS

Between April 29, 2019, and Dec 3, 2020, we recruited 300 households in Malawi for this longitudinal cohort study: 100 each in urban, peri-urban, and rural settings. All households underwent a baseline visit and 195 were selected for longitudinal follow-up, comprising up to three additional visits over a 6 month period. Data on human health, antibiotic usage, health-seeking behaviours, structural and behavioural environmental health practices, and animal husbandry were captured alongside human, animal, and environmental samples. Microbiological processing determined the presence of ESBL-producing E coli and Klebsiella pneumoniae, and hierarchical logistic regression was performed to evaluate the risks of human ESBL-producing Enterobacterales colonisation.

FINDINGS

A paucity of environmental health infrastructure and materials for safe sanitation was identified across all sites. A total of 11 975 samples were cultured, and ESBL-producing Enterobacterales were isolated from 1190 (41·8%) of 2845 samples of human stool, 290 (29·8%) of 973 samples of animal stool, 339 (66·2%) of 512 samples of river water, and 138 (46·0%) of 300 samples of drain water. Multivariable models illustrated that human ESBL-producing E coli colonisation was associated with the wet season (adjusted odds ratio 1·66, 95% credible interval 1·38-2·00), living in urban areas (2·01, 1·26-3·24), advanced age (1·14, 1·05-1·25), and living in households where animals were observed interacting with food (1·62, 1·17-2·28) or kept inside (1·58, 1·00-2·43). Human ESBL-producing K pneumoniae colonisation was associated with the wet season (2·12, 1·63-2·76).

INTERPRETATION

There are extremely high levels of ESBL-producing Enterobacterales colonisation in humans and animals and extensive contamination of the wider environment in southern Malawi. Urbanisation and seasonality are key risks for ESBL-producing Enterobacterales colonisation, probably reflecting environmental drivers. Without adequate efforts to improve environmental health, ESBL-producing Enterobacterales transmission is likely to persist in this setting.

FUNDING

Medical Research Council, National Institute for Health and Care Research, and Wellcome Trust.

TRANSLATION

For the Chichewa translation of the abstract see Supplementary Materials section.

Efficacy, Safety, Patient Experience, and Tolerability of Risankizumab Administered by On-Body Injector for Moderate to Severe Crohn's Disease

INTRODUCTION

In patients with moderate to severe Crohn's disease (CD), intravenous induction and subcutaneous maintenance dosing with risankizumab was efficacious and well tolerated. Long-term management of CD via self-administration of risankizumab using an on-body injector (OBI) may improve treatment adherence through convenience and ease of use.

METHODS

Within the FORTIFY maintenance study, 46 patients from the United States (US) sites participated in an open-label extension Substudy and received 180 mg or 360 mg risankizumab delivered subcutaneously via OBI [360 mg (2.4 mL, 150 mg/mL) or 180 mg (1.2 mL, 150 mg/mL)]. At the Week 0 visit, patients were trained (pre-injection) by site staff, using Instructions for Use (IFU) and a training video, to self-administer risankizumab at Weeks 0 (on site), 8 (at home), and 16 (on site). Key objectives of the Substudy 4 were to assess OBI usability (observer rating of successful self-administration), hazard-free self-injection at Weeks 0 and 16, and patient rating of acceptability using the Self-Injection Assessment Questionnaire (SIAQ) at Weeks 0, 8, and 16. Additionally, the proportion of patients in clinical remission (CD Activity Index < 150) was collected at Weeks 0 and 16.

RESULTS

All patients successfully self-administered risankizumab via OBI, including two patients who successfully self-administered with a second OBI (i.e., required two injection attempts). Acceptability of self-injection was high. Two patients (n = 2) experienced a use-related hazard. Stable clinical remission was observed with both risankizumab doses. Two patients experienced injection site reactions; neither was related to the OBI per investigator's assessment. Two device-related adverse events related to topical adhesive reactions were reported, both mild and resolved. No new safety risks were observed.

CONCLUSION

The efficacy and safety of maintenance risankizumab delivered via OBI and OBI usability support the use of this device in patients with moderate to severe CD.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers NCT03105102 (FORTIFY).

Molnupiravir versus placebo in unvaccinated and vaccinated patients with early SARS-CoV-2 infection in the UK (AGILE CST-2): a randomised, placebo-controlled, double-blind, phase 2 trial

BACKGROUND

The antiviral drug molnupiravir was licensed for treating at-risk patients with COVID-19 on the basis of data from unvaccinated adults. We aimed to evaluate the safety and virological efficacy of molnupiravir in vaccinated and unvaccinated individuals with COVID-19.

METHODS

This randomised, placebo-controlled, double-blind, phase 2 trial (AGILE CST-2) was done at five National Institute for Health and Care Research sites in the UK. Eligible participants were adult (aged ≥18 years) outpatients with PCR-confirmed, mild-to-moderate SARS-CoV-2 infection who were within 5 days of symptom onset. Using permuted blocks (block size 2 or 4) and stratifying by site, participants were randomly assigned (1:1) to receive either molnupiravir (orally; 800 mg twice daily for 5 days) plus standard of care or matching placebo plus standard of care. The primary outcome was the time from randomisation to SARS-CoV-2 PCR negativity on nasopharyngeal swabs and was analysed by use of a Bayesian Cox proportional hazards model for estimating the probability of a superior virological response (hazard ratio [HR]>1) for molnupiravir versus placebo. Our primary model used a two-point prior based on equal prior probabilities (50%) that the HR was 1·0 or 1·5. We defined a priori that if the probability of a HR of more than 1 was more than 80% molnupiravir would be recommended for further testing. The primary outcome was analysed in the intention-to-treat population and safety was analysed in the safety population, comprising participants who had received at least one dose of allocated treatment. This trial is registered in ClinicalTrials.gov, NCT04746183, and the ISRCTN registry, ISRCTN27106947, and is ongoing.

FINDINGS

Between Nov 18, 2020, and March 16, 2022, 1723 patients were assessed for eligibility, of whom 180 were randomly assigned to receive either molnupiravir (n=90) or placebo (n=90) and were included in the intention-to-treat analysis. 103 (57%) of 180 participants were female and 77 (43%) were male and 90 (50%) participants had received at least one dose of a COVID-19 vaccine. SARS-CoV-2 infections with the delta (B.1.617.2; 72 [40%] of 180), alpha (B.1.1.7; 37 [21%]), omicron (B.1.1.529; 38 [21%]), and EU1 (B.1.177; 28 [16%]) variants were represented. All 180 participants received at least one dose of treatment and four participants discontinued the study (one in the molnupiravir group and three in the placebo group). Participants in the molnupiravir group had a faster median time from randomisation to negative PCR (8 days [95% CI 8-9]) than participants in the placebo group (11 days [10-11]; HR 1·30, 95% credible interval 0·92-1·71; log-rank p=0·074). The probability of molnupiravir being superior to placebo (HR>1) was 75·4%, which was less than our threshold of 80%. 73 (81%) of 90 participants in the molnupiravir group and 68 (76%) of 90 participants in the placebo group had at least one adverse event by day 29. One participant in the molnupiravir group and three participants in the placebo group had an adverse event of a Common Terminology Criteria for Adverse Events grade 3 or higher severity. No participants died (due to any cause) during the trial.

INTERPRETATION

We found molnupiravir to be well tolerated and, although our predefined threshold was not reached, we observed some evidence that molnupiravir has antiviral activity in vaccinated and unvaccinated individuals infected with a broad range of SARS-CoV-2 variants, although this evidence is not conclusive.

FUNDING

Ridgeback Biotherapeutics, the UK National Institute for Health and Care Research, the Medical Research Council, and the Wellcome Trust.

Predictability and durability of mitral valve repair in patients with severe degenerative mitral regurgitation in medium sized centres

INTRODUCTION

Mitral valve repair (MVr) is now the treatment of choice to correct severe degenerative mitral regurgitation (MR). Repair rates vary greatly from centre to centre, and the concept of heart valve centres of excellence has been established.

OBJECTIVE

The purpose of this study was to see whether large international centre repair rates, and outcomes, are transferrable to medium-sized centres with an interest in mitral repair.

METHODS

Between 2011 and 2018, a total of 346 patients underwent mitral valve surgery by a single surgeon. Of these, 238 consecutive patients had repairs, or attempted repairs for degenerative MR, and are included in this study.

RESULTS

The study sample consisted of 71% male patients and had a mean age of 64.4 ± 12.3 years; 66% of the study population had concomitant procedures. The overall repair rate in this cohort is 99%. Mean follow up was 3.7 ± 1.9 years. At 5 years, the freedom from MR ≥ 3+ was 95.9 ± 1.9% and at 7 years 91.1 ± 3.8%. Freedom from reoperation at 5 years was 92.9 ± 3.7%, while the 5 years actuarial survival was 89.1 ± 3.7%. On a multivariate analysis, predischarge echo grade was associated with higher risk of future reoperation (odds ratio (OR) = 21.82, p = 0.05). Only age (OR = 1.3, p = 0.03) was predictive of long-term survival.

CONCLUSIONS

In specialised medium-sized heart centres, where the surgical team have undergone specialist mitral training, favourable short- and long-term outcomes are achievable with mitral repair rates similar to those from large international centres of excellence. In these heart centres, early surgery should be considered for all patients with severe degenerative MR.

247 QUALITY IMPROVEMENT IN DEMENTIA CARE: STREAMLINING CARE PATHWAYS IN A PSYCHIATRY OF OLD AGE SERVICE

Background

Dementia is increasingly considered a public health priority worldwide in the context of predicted increased prevalence. In Ireland, there are an estimated 67,000 persons living with dementia and by 2041 it is expected to rise to 145,000 persons. Challenges in dementia care have been highlighted in health services across Europe and the ineffective structure of dementia care with fragmented non-person-centred pathways has been identified.

Methods

An initial review of the existing cognitive impairment diagnostic pathways in our specialised Psychiatry of Old Age (POA) Service was undertaken. This included surveying the multidisciplinary team to identify challenges, clinical chart review and audit of physical examination equipment. Diagnostic pathway was updated based on findings and informed by the developing national ‘Model of Care for Dementia in Ireland’ and best practice.

Results

Review findings included lack of standardisation of memory assessment, delays in accessing neuroimaging and laboratory results, gaps in staff training. A care pathway document was developed detailing requirements for care from the point of referral through to cognitive impairment diagnosis. Staff training was completed to accompany the introduction of standardised dementia assessment scales. Access to laboratory/radiology booking was enhanced. A cognitive remediation group was developed by Occupational Therapy as part of post-diagnostic supports for service users. Preliminary data indicates improvements in satisfaction of those attending the group. Physical examination equipment audit resulted in quality improvements.

Conclusion

We demonstrate that a quality improvement approach can be implemented to enhance assessment, diagnosis and care provided to support diagnosis of cognitive impairment and dementia in POA service. The enhanced diagnostic care pathways will be assessed over time to assess impact on care of service users. Preliminary findings are positive and it is an approach that can be adopted in other services and inform development of national memory service developments.

Consenting practices in interventional cardiology: an analysis from the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Background

Consenting practices in interventional cardiology vary across different procedures, operators, centres and nations.

Purpose

In order to define best practice for obtaining informed patient consent, it is first necessary to understand how consenting practice differs.

Methods

An online survey of 20 questions was sent to all members of the European Association of Percutaneous Cardiovascular Interventions, addressing consenting practices in elective and emergency scenarios.

Results

We received 483 responses from 74 countries. The majority of respondents (77%) were European operators. Responses were received from consultant cardiologists (n=370), fellows in training (n=55), allied health professionals (n=36) and others (n=21).

Across all respondents, in elective practice, 427 (88.4%) operators obtain written consent for every procedure, the remainder (9.5%) obtain verbal consent only. Consent is obtained by the consultant or fellow who directly performs the procedure in 56.9% cases. For coronary angiography, pre-emptive consent for possible additional procedures (pressure wire and PCI) is taken by operators in all cases (58.6%), some cases (30.6%) and never (11.0%). Prior to interventional therapies, written information detailing the risk of the procedure is provided in every case by 63.8% of operators, sometimes by 25.1% of operators, and is never provided by 11.0% of operators.

In emergency settings, where patients are conscious and have capacity to consent, 274 (56.7%) of respondents obtain written consent, 155 (33.1%) obtain verbal consent only and 52 (10.8%) stated that a consent process was not required. Where consciousness and capacity are impaired, 218 (45.1%) always, 118 (24.4%) sometimes and 145 (30%) never document a written capacity and best interests' assessment.

When asked to rate the overall quality of consenting practices in their own institution, 279 (57.8%) stated these were “excellent” or “above average”, 165 (34.2%) were “average” and 39 operators described consenting practices in their institution as “below average” or “poor”.

Conclusions

Diversity in consenting practice spans elective and emergency procedures. These results suggest that there is substantial variation in the understanding of the rationale, legal requirement, and perceived best practices for consent. Further work should consider the merits of standardisation of consent processes across Europe.

Funding Acknowledgement

Type of funding sources: None.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy

BACKGROUND

Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy.

METHODS

A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences.

RESULTS

Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable.

CONCLUSION

A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Breast Health Experiences in Women with Cerebral Palsy: A Qualitative Approach

Background: All women, regardless of disability status, should receive screening for breast cancer. In 2010, only 61.4% of women with disabilities (WWD) received a mammogram in the past 2 years compared to 75% of women without disabilities. The purpose of this study is to explore breast cancer screening experiences of women with cerebral palsy (CP) with the aim of identifying factors that could improve screening rates for WWD.

Methods: Thirty women with CP, 22–72 years of age, residing in New York, Chicago, or Los Angeles areas participated in individual or group interviews about breast health. Twenty-five of the participants identified themselves as white, and one self-identified as Hispanic or Latina. Facilitators used a semistructured guide across the three sites. Qualitative analysis utilized an iterative coding process to generate themes related to breast health.

Results: We identified six predominant themes in these interviews, which revolved around physical, environmental, and emotional barriers and facilitators. Within each theme, we identified subthemes. Physical barriers included the most highly identified subthemes of age, pain, holding breath, holding still, spasticity, standing, fatigue, and positioning. Self-advocacy and communication between the health care professional and the patient were the most common subthemes identified among the emotional facilitators.

Conclusion: Women with CP perceive a variety of issues impacting breast health. These findings are multifaceted and suggest that improving screening rates for women with CP should address these barriers and facilitators.

Assessments and Interventions for Spasticity in Infants With or at High Risk for Cerebral Palsy: A Systematic Review

BACKGROUND

The majority of children with cerebral palsy develop spasticity, which interferes with motor development, function, and participation. This systematic review appraised current evidence regarding assessments and interventions for spasticity in children aged less than two years with or at high risk for cerebral palsy and integrated findings with parent preferences.

METHODS

Five databases (CINAHL, EMBASE, OVID/Medline, SCOPUS, and PsycINFO) were searched. Included articles were screened using PRISMA guidelines. Quality of the evidence was reviewed by two independent reviewers using Quality Assessment of Diagnostic Accuracy Studies, second edition (QUADAS-2), the RTI Item Bank on Risk of Bias and Precision of Observational Studies (RTI), or The Cochrane Collaboration's tool for assessing risk of bias in randomized trials (RoB). An online survey was conducted regarding parent preferences through social media channels.

RESULTS

Twelve articles met inclusion criteria. No high-quality assessment tool emerged for this population. Six interventions (botulinum toxin-A, orthotic use, radial extracorporeal shock wave therapy, erythropoietic stimulating agents, medical cannabis, and homeopathy) were identified. There was low-quality evidence for the use of botulinum toxin-A and radial extracorporeal shock wave therapy to improve short-term outcomes. Survey respondents indicated that spasticity assessments and interventions are highly valued, with nonpharmacologic interventions ranked most preferably.

CONCLUSIONS

Further research is needed to validate assessments for spasticity in children younger than two years. Conditional recommendations can be made for botulinum toxin-A and radial extracorporeal shock wave therapy based on low level of evidence to reduce spasticity in children aged less than two years.

The Feeding Practices and Structure Questionnaire: development and validation of age appropriate versions for infants and toddlers

Background

In order to measure and understand trajectories of parental feeding practices and their relationship with child eating and weight, it is desirable to perform assessment from infancy and across time, in age-appropriate ways. While many feeding practices questionnaires exist, none is presently available that enables tracking of feeding practices from infancy through childhood. The aim of the study was to develop a version of the Feeding Practices and Structure Questionnaire (FPSQ) for parents with infants and toddlers (< 2 years) to be used in conjunction with the original FPSQ for older children (≥2 years) to measure feeding practices related to non-responsiveness and structure across childhood.

Methods

Constructs and items for the FPSQ for infants and toddlers were derived from the existing and validated FPSQ for older children and supplemented by a review of the literature on infant feeding questionnaires. Following expert review, two versions of the questionnaire were developed, one for milk feeding parents and one for solid feeding parents. Data from two studies were combined (child ages 0–24 months) to test the derived constructs with Confirmatory Factor Analysis for the milk feeding (N = 731) and solid feeding (N = 611) versions.

Results

The milk feeding version consisted of four factors (18 items) and showed acceptable model fit and good internal reliability: ‘feeding on demand vs. feeding routine’ (α = 0.87), ‘using food to calm’ (α = 0.87), ‘persuasive feeding’ (α = 0.71), ‘parent-led feeding’ (α = 0.79). The same four factors showed acceptable model fit for the solid feeding version (21 items), likewise with good internal reliability (α = 0.74, 0.86, 0.85, 0.84 respectively). Two additional factors (13 items) were developed for the solid feeding version that appeared developmentally appropriate only for children aged 12 months or older: ‘family meal environment’ (α = 0.81) and ‘using (non-)food rewards’ (α = 0.92). The majority of factor-factor correlations were in line with those of the original FPSQ.

Conclusions

The FPSQ milk and solid feeding versions are the first measures specifically developed as precursors to the FPSQ to measure parental feeding practices in children < 2 years, particularly practices related to non-responsiveness and structure. Further validation in more diverse samples is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01079-x.

Women with cerebral palsy: A qualitative study about their experiences with sexual and reproductive health education and services

PURPOSE

To explore the recalled experiences of women with CP regarding sexual health education and services they received.

METHODS

Semi-structured interviews and focus groups were conducted at four academic tertiary hospitals with 33 adult women with CP. Templates were used to ask about four key content domains: appointment planning (including planning for a gynecologic exam), accessibility of services, experiences with providers, and recommendations for improvement. Sessions were transcribed verbatim and analyzed to generate a coding dictionary. Blinded coding was carried out for each transcript, with duplicate coding used to confirm identified themes. Iterative analysis was used to identify and consolidate coding and key themes.

RESULTS

Similar barriers were discussed at the four sites, including lack of accessible exam tables, hospital staff unfamiliar with physical disabilities, and assumptions that women with CP are not sexually active. Many described the sexual education they received as brief, omitted, or mistimed. Self-advocacy was crucial, and recommended strategies ranged from pre-gynecologic exam medication to visit checklists.

CONCLUSION

Reproductive health education for young women with CP is frequently inadequate. Medical professionals lack relevant knowledge and awareness; medical facilities lack necessary infrastructure. Recommendations for improvements are made.

Network Implementation of Guideline for Early Detection Decreases Age at Cerebral Palsy Diagnosis

BACKGROUND AND OBJECTIVES

Early diagnosis of cerebral palsy (CP) is critical in obtaining evidence-based interventions when plasticity is greatest. In 2017, international guidelines for early detection of CP were published on the basis of a systematic review of evidence. Our study aim was to reduce the age at CP diagnosis throughout a network of 5 diverse US high-risk infant follow-up programs through consistent implementation of these guidelines.

METHODS

The study leveraged plan-do-study-act and Lean methodologies. The primary outcome was age at CP diagnosis. Data were acquired during the corresponding 9-month baseline and quarterly throughout study. Balancing measures were clinic no-show rates and parent perception of the diagnosis visit. Clinic teams conducted strengths, weaknesses, opportunities, and threats analyses, process flow evaluations, standardized assessments training, and parent questionnaires. Performance of a 3- to 4-month clinic visit was a critical process step because it included a Hammersmith Infant Neurologic Examination, a General Movements Assessment, and standardized assessments of motor function.

RESULTS

The age at CP diagnosis decreased from a weighted average of 19.5 (95% confidence interval 16.2 to 22.8) to 9.5 months (95% confidence interval 4.5 to 14.6), with P = .008; 3- to 4-month visits per site increased from the median (interquartile range) 14 (5.2-73.7) to 54 (34.5-152.0), with P < .001; and no-show rates were not different. Parent questionnaires revealed positive provider perception with improvement opportunities for information content and understandability.

CONCLUSIONS

Large-scale implementation of international guidelines for early detection of CP is feasible in diverse high-risk infant follow-up clinics. The initiative was received positively by families and without adversely affecting clinic operational flow. Additional parent support and education are necessary.

Introducing the CSP Analyzer: A novel Machine Learning-based application for automated analysis of two-dimensional NMR spectra in NMR fragment-based screening

NMR-based screening, especially fragment-based drug discovery is a valuable approach in early-stage drug discovery. Monitoring fragment-binding in protein-detected 2D NMR experiments requires analysis of hundreds of spectra to detect chemical shift perturbations (CSPs) in the presence of ligands screened. Computational tools are available that simplify the tracking of CSPs in 2D NMR spectra. However, to the best of our knowledge, an efficient automated tool for the assessment and binning of multiple spectra for ligand binding has not yet been described. We present a novel and fast approach for analysis of multiple 2D HSQC spectra based on machine-learning-driven statistical discrimination. The CSP Analyzer features a C# frontend interfaced to a Python ML classifier. The software allows rapid evaluation of 2D screening data from large number of spectra, reducing user-introduced bias in the evaluation. The CSP Analyzer software package is available on GitHub https://github.com/rubbs14/CSP-Analyzer/releases/tag/v1.0 under the GPL license 3.0 and is free to use for academic and commercial uses.

Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy

BACKGROUND

Although literature suggests that parents need support when their child is diagnosed with cerebral palsy (CP), it is unclear to what extent providers implement these supports in practice and what parental perspectives surround provider early diagnosis and management of CP. Therefore, we aimed to characterize and compare experiences of providers and parents of children with CP with regards to early detection and intervention.

METHOD

Seventeen parents participated in day-long world-café style workshops focused on categories extracted from the International Classification of Function framework and recent systematic reviews of early detection for CP. Thirty regional providers (generalists, specialists, and therapists) caring for infants with CP completed surveys with scaled score and open-ended questions. Quantitative and qualitative data were independently assessed by two reviewers to identify prominent themes.

RESULTS

All parents (100%) stated early diagnosis or high risk for CP classification was beneficial compared with only 50% of providers who often gave early CP diagnoses before 12 months. Top parent priorities were honesty and positively phrased messages. Providers most often addressed cognition, primary care need, motor, and feeding issues (80%, 62%, 54%, 54% frequently/sometimes). Matching priorities for discussion were neuroimaging timing/risk/benefit, cognition, primary care, motor, and feeding/nutrition. Discordance occurred for participation, parent well-being, pain and vision, with parents wanting more education and resources.

CONCLUSIONS

Receiving early diagnoses or high-risk for CP classification is a parent priority. Alignment between parents and providers exists for International Classification of Function domains of body functions/structures and activity, but less for those of environment, personal, and participation.

P6138Quality of clinical trial evidence on devices and drugs approved to treat coronary artery disease

Background

Regulatory approval of drugs and devices follow two different pathways. Whether different approval pathways underlie meaningful differences in quality of clinical trial evidence is unknown. We aimed to compare the quality of evidence of clinical trials that served as a basis for approval by the U.S. Food and Drug Administration (FDA) of drugs and devices used for the treatment of coronary artery disease.

Methods

FDA databases were searched for devices (i.e., coronary artery drug-eluting stents) and drugs (i.e., agents targeting atherothrombosis) approved between January 1st, 2001 and December 31st, 2017. FDA medical reviews were screened to identify trials that served for approval purposes. The pre-specified primary outcome was the prevalence of randomized trials used for approval (i.e. number of randomized trials/overall number of trials).

Results

A total of 97 trials were identified, 39 serving for approval of 13 devices and 58 serving for approval of 8 drugs. Devices were evaluated by fewer trials per item as compared with drugs (3.0±1.4 vs. 7.3±5.3, P=0.012) with similar study size (501 [100–1314] vs. 379 [183–904] patients per trial, P=0.55). Trials evaluating devices were less frequently randomized (56.4% vs. 94.8%, P<0.001) and more frequently designed powered for clinical endpoints (53.8% vs. 17.2%, P<0.001) as compared to those evaluating drugs. Use of randomization declined over time among trials supporting FDA approval of devices. In addition, significant differences were present between trials evaluating devices and those evaluating drugs in terms of study design, comparator used, blinding to treatment allocation, primary hypothesis, primary endpoint, and type of patients included.

Use of randomized trials for approval

Conclusions

There are substantial differences in clinical trial evidence serving for FDA approval of devices and drugs used for treatment of coronary artery disease. The lower degree of randomized evidence used for approval of devices as compared to drugs raises some concerns, particularly in view of its decline over time.

122Mechanism and impact of lesion morphology on the late lumen loss of drug-eluting resorbable magnesium scaffolds: a serial optical coherence tomography study

Introduction

Resorbable Magnesium Scaffolds have demonstrated favourable clinical results with acceptable late lumen loss (LLL). However, the pathomechanisms influencing LLL of resorbable sirolimus-eluting metallic scaffold (Magmaris) have not been analyzed.

Purpose

Using serial optical coherence tomography (OCT), we investigated potential factors, i.e. the contribution of recoil versus neointimal hyperplasia (NIH).

Methods

Patients who were enrolled into BIOSOLVE-II, and underwent serial angiography and OCT (baseline and follow-up: 6-month and/or 1-year) were analyzed. Patients were divided into 2 groups based on angiographic in-scaffold LLL <0.5mm or ≥0.5mm. Endpoints were late absolute recoil and NIH area as assessed by OCT.

Results

A total of 70 patients (LLL <0.5mm: n=41, LLL ≥0.5mm: n=29) were serially analyzed. Patient and lesion characteristics were comparable and there was no significant difference in mean and minimal scaffold area between groups at baseline. Late absolute recoil was significantly smaller among patients with LLL <0.5mm (0.53±0.68 mm2) compared with those with LLL ≥0.5mm (1.48±1.20 mm2, P<0.001) (Figure). A small difference in NIH area at follow-up was observed (LLL <0.5mm: 1.47±0.33 mm2 vs. LLL ≥0.5mm: 1.68±0.34 mm2, P=0.013). In a matched-frame analysis (baseline and follow-up), late absolute recoil varied according to the underlying plaque type (lipid: 0.63±1.23 mm2, calcified: 0.81±1.44 mm2, and fibrous: 1.20±1.52 mm2, P<0.001), while there was no difference with regards to NIH area (P=0.132).

Conclusion

The main driver of late lumen loss of sirolimus-eluting absorbable metal scaffold was late scaffold recoil, while the contribution of NIH was modest. The degree of late scaffold recoil depended on the underlying plaque type and was highest among fibrotic lesions. Future studies will address the impact of procedural factors such as adequate lesion preparation and post-dilatation.

Acknowledgement/Funding

Biotronik

An examination of children's eating behaviours as mediators of the relationship between parents' feeding practices and early childhood body mass index z-scores

OBJECTIVE

Parent's use of restrictive feeding practices is associated with child weight. Similarly, the literature shows that children's eating behaviours are also associated with child weight. Given this interrelationship between children's eating behaviours, restrictive feeding practices and child weight, examination of possible mediator relationships is warranted. This study aimed to examine the relationships between overt restriction and covert restriction with child body mass index z-scores (BMIz) and determine if children's eating behaviours (satiety responsiveness and food responsiveness) act as mediators.

METHOD

Parents of Australian children (n = 977) 2.0-5.0 years of age (49.4% male) provided data in an online survey on child eating behaviours, parent's restrictive feeding practices and child anthropometrics (modified z-scores were created to screen for biologically implausible values). Correlation analysis was used to determine variables to include in mediation models. Hayes' PROCESS macros in spss was used to examine mediation, controlling for covariates of child BMIz.

RESULTS

Overt restriction was the only parent feeding practice related to child BMIz (B = 0.132, P = 0.04). Mediation analysis showed that the indirect effect of overt restriction on child BMIz (controlling for child age, gender, parent BMI and income) became non-significant when controlling for food responsiveness, thus suggesting full mediation, explaining 5.75% of the relation.

CONCLUSION

Overt restriction and covert restriction have distinctly different relationships with children's eating behaviours. Food responsiveness appears an important intermediary in the relationship between overt restriction and child BMIz.

Serum NGAL can act as an early renal safety biomarker during long-term nucleos(t)ide analogue antiviral therapy in chronic hepatitis B

Tubular renal toxicity is a side-effect of long-term therapy with nucleos(t)ide analogue(s) (NA) in chronic hepatitis B (CHB). There are no established surrogate markers in plasma of early NA-related toxicity. Neutrophil gelatinase-associated lipocalin (NGAL) is a protein produced by tubular cells following renal damage. We aimed therefore to retrospectively compare conventional renal markers (estimated glomerular filtration rates (eGFR) and urinary protein/creatinine ratio uPCR) with a sensitive biomarker (NGAL) in CHB patients on long-term NA therapy and assess the ability of new markers to predict NA-related renal toxicity (new onset of nonalbumin proteinuria). A total of 192 naïve CHB patients (median age 41 years, 78% males, 25% HBeAg+, 35% cirrhosis) were NA treated for at least 5 years (median 8.34 years, range 5.54-11.1 years). The eGFR and uPCR were compared at baseline and last clinical visit with serum NGAL concentrations measured by ELISA at same time-points and assessed according to the presence/absence of nonalbumin proteinuria at last visit. While baseline and last visit eGFR were similar (median:78 vs 84 mL/min), serum NGAL concentrations increased during therapy (median:9.4 vs 16.4 ng/mL, P < .05). The proportion of patients with proteinuria (uPCR > 15) increased between baseline and last visit (4.6% vs 21.4%, P < .05), with 30 (16%) patients having de novo nonalbumin proteinuria at last visit. High baseline NGAL concentrations were exclusive to patients with de novo nonalbumin proteinuria (median:31.7 vs 7.8 ng/mL, P < .01) and baseline NGAL levels >25 mg/mL were predictive of nonalbumin proteinuria at last visit (AUROC = 0.813). In conclusion, serum NGAL can act as a surrogate marker of early renal injury (de novo nonalbumin proteinuria) in CHB on long-term NA therapy.

Contextualizing disability: a cross-sectional analysis of the association between the built environment and functioning among people living with spinal cord injury in the United States

STUDY DESIGN

Secondary analysis of cross-sectional data from a multisite cohort study.

OBJECTIVES

To analyze the association between the built environment and physical functioning reported by adults living with chronic spinal cord injury (SCI).

SETTING

Four US Spinal Cord Injury Model Systems centers in New Jersey, Colorado, Illinois, and Michigan.

METHODS

Participants were from the Spinal Cord Injury-Functional Index/Capacity (SCI-FI/C) development study. Survey data from N = 402 participants were geocoded for analysis. Geographic Information Systems (GIS) analysis was used to define five- and half-mile buffer areas around participants' residential addresses to represent the community and neighborhood environments, respectively, and to create measures of land use, residential density, destination density, and park space. The relationships between these built environment features and four domains of physical functioning-basic mobility, wheelchair mobility, self-care, and fine motor function-were modeled using ordinary least squares (OLS) regression.

RESULTS

People with paraplegia living in neighborhoods with more destinations and a nearby park reported higher levels of self-care functioning. For people with tetraplegia, living in a community with more destinations was associated with better wheelchair mobility and fine motor functioning, and living in a neighborhood with high land use mix was associated with higher fine motor functioning scores.

CONCLUSIONS

The association between the built environment and functioning after SCI is supported and in need of further investigation. Understanding the environmental context of disability may lead to community-based interventions and effective public policy that will attenuate the experience of limitations and promote accessibility on a larger scale.

Breast cancer screening in women with cerebral palsy: Could care delivery be improved?

BACKGROUND

Women with disabilities (WWD) have reported lower mammography rates than the general population, however rates for women with cerebral palsy (CP) have not been specifically studied.

OBJECTIVE

To evaluate mammography rates in women with CP and to identify strengths and barriers with their screening experience.

METHODS

Women with CP 40 years or older (n = 118) participating in a prospective cross-sectional survey were queried regarding screening status, imaging modality, and accommodation needs and availability. Categorical variables were summarized and Chi-square testing used to assess factors contributing to screening compliance. The effect of functional factors on screening was evaluated using logistic regression.

RESULTS

77 women (65.3%) had mammograms within the past two years; 56 (47.5%) were screening mammograms. Severity of fine motor deficits was associated with lack of screening (OR 0.559, p = 0.019). 85 (72.0%) experienced positive staff attitudes. Facilities most often met needs for ramps, elevators, and/or wide doorways (92.9%), exam explanations (84.4%), and accessible parking (82.5%). Needs least often met included accommodations for standing (59.3%) or for difficulties with arm/shoulder positioning (57.1%), and wheelchair-accessible mammogram machines (59.1%).

CONCLUSIONS

The screening compliance rate for women with CP is low, although the 2-year mammography rate is comparable to that reported for WWD and the general female U.S.

POPULATION

Women were usually offered respectful care. Adequate physical accommodations during the procedure were reported less often than overall facility environmental accommodations. These findings demonstrate the need for improved screening rates in women with CP, and highlight areas for improving their screening experience.

Implementation of Early Diagnosis and Intervention Guidelines for Cerebral Palsy in a High-Risk Infant Follow-Up Clinic

BACKGROUND

Cerebral palsy is the most common physical disability in childhood, and is mostly diagnosed after age 2 years. Delays in diagnosis can have negative long-term consequences for children and parents. New guidelines for early cerebral palsy diagnosis and intervention were recently published, after systematic review of the evidence by international multidisciplinary experts aiming to decrease age at diagnosis. The current study tested the feasibility of implementing these guidelines in an American clinical setting.

METHODS

We designed a stepwise implementation process in a neonatal intensive care follow-up clinic. Efficacy was tested by comparing 10-month pre- and post-implementation periods. Clinic visit types, cerebral palsy diagnosis, provider competencies and perspectives, and balancing measures were analyzed.

RESULTS

Changes to infrastructure, assessments, scheduling algorithms, documentation and supports in diagnosis or counseling were successfully implemented. Number of three- to four-month screening visits increased (255 to 499, P < 0.001); mean age at diagnosis decreased (18 to 13 months, P < 0.001). Clinic team awareness of early diagnosis and interventions increased (P < 0.001). There was no decrease in family satisfaction with overall clinic function. Opportunities for improvements included documentation for transitioning patients, generalizabilty across hospital clinics, systematic identification of high-risk status during hospitalization, and need for cerebral palsy care guidelines for infants under age 2 years.

CONCLUSIONS

We demonstrated for the first time in a US clinical setting the feasibility of implementation of international early diagnosis and treatment guidelines for cerebral palsy. This process is adaptable to other settings and underscores the necessity of future research on cerebral palsy treatments in infancy.

Maternal perception of weight status in first-born Australian toddlers aged 12-16 months--the NOURISH and SAIDI cohorts

BACKGROUND

The preference amongst parents for heavier infants is in contrast to obesity prevention efforts worldwide. Parents are poor at identifying overweight in older children, but few studies have investigated maternal perception of weight status amongst toddlers and none in the Australian setting.

METHODS

Mothers (n = 290) completed a self-administered questionnaire at child age 12-16 months, defining their child's weight status as underweight, normal weight, somewhat overweight or very overweight. Weight-for-length z-score was derived from measured weight and length, and children categorized as underweight, normal weight, at risk overweight or obese (WHO standards). Objective classification was compared with maternal perception of weight status. Mean weight-for-length z-score was compared across categories of maternal perception using one-way ANOVA. Multinomial logistic regression was used to determine child or maternal characteristics associated with inaccurate weight perception.

RESULTS

Most children (83%) were perceived as normal weight. Twenty nine were described as underweight, although none were. Sixty-six children were at risk of overweight, but 57 of these perceived as normal weight. Of the 14 children who were overweight, only 4 were identified as somewhat overweight by their mother. Compared with mothers who could accurately classify their normal weight child, mothers who were older had higher odds of perceiving their normal weight child as underweight, while mothers with higher body mass index had slightly higher odds of describing their overweight/at risk child as normal weight.

CONCLUSION

The leaner but healthy weight toddler was perceived as underweight, while only the heaviest children were recognized as overweight. Mothers unable to accurately identify children at risk are unlikely to act to prevent further excess weight gain. Practitioners can lead a shift in attitudes towards weight in infants and young children, promoting routine growth monitoring and adequate but not rapid weight gain.

Patterns of Sacral Sparing Components on Neurologic Recovery in Newly Injured Persons With Traumatic Spinal Cord Injury

OBJECTIVE

To assess the patterns of sacral sparing and recovery in newly injured persons with traumatic spinal cord injury (SCI).

DESIGN

Retrospective analysis of data from the national Spinal Cord Injury Model Systems (SCIMS) database for patients enrolled from January 2011 to February 2015.

SETTING

SCIMS centers.

PARTICIPANTS

Individuals (N=1738; age ≥16y) with traumatic SCI admitted to rehabilitation within 30 days after injury with follow-up at discharge, at 1 year, or both.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury examination results at admission and follow-up (discharge or 1y, or both).

RESULTS

Conversion from an initial American Spinal Injury Association Impairment Scale (AIS) grade A to incomplete status was 20% at rehabilitation discharge and 27.8% at 1 year, and was greater in cervical and low paraplegia levels (T10 and below) than in high paraplegia level injuries (T1-9). Conversion from AIS B to motor incomplete was 33.9% at discharge and 53.6% at 1 year, and the initial sparing of all sacral sensory components was correlated with the greatest conversion to motor incomplete status at discharge and at 1 year. For patients with initial AIS C, the presence of voluntary anal contraction (VAC) in association with other sacral sparing was most frequently observed to improve to AIS D status at discharge. However, the presence of VAC alone as the initial sacral sparing component had the poorest prognosis for recovery to AIS D status. At follow-up, regaining sacral sparing components correlated with improvement in conversion for patients with initial AIS B and C.

CONCLUSIONS

The components of initial and follow-up sacral sparing indicated differential patterns of neurologic outcome in persons with traumatic SCI. The more sacral components initially spared, the greater the potential for recovery; and the more sacral components gained, the greater the chance of motor recovery. Consideration of whether VAC should remain a diagnostic criterion sufficient for motor incomplete classification in the absence of other qualifying sublesional motor sparing is recommended.

Examining the connectivity between different cellular processes in the Barrett tissue microenvironment

In Barrett associated tumorigenesis, oxidative phosphorylation and glycolysis are reprogrammed early in the disease sequence and act mutually to promote disease progression. However, the link between energy metabolism and its connection with other central cellular processes within the Barrett microenvironment is unknown. The aim of this study was to examine the relationship between metabolism (ATP5B/GAPDH), hypoxia (HIF1α), inflammation (IL1β/SERPINA3), p53 and obesity status using in-vivo and ex-vivo models of Barrett oesophagus. At the protein level, ATP5B (r = 0.71, P < 0.0001) and p53 (r = 0.455, P = 0.015) were found to be strongly associated with hypoxia. In addition, levels of ATP5B (r = 0.53, P = 0.0031) and GAPDH (r = -0.39, P = 0.0357) were positively associated with p53 expression. Moreover, we demonstrate that ATP5B (r = 0.8, P < 0.0001) and GAPDH (r = 0.43, P = 0.022) were positively associated with IL1β expression. Interestingly, obesity was negatively associated with oxidative phosphorylation (r = -0.6016, P = 0.0177) but positively associated with glycolysis (r = 0.743, P = 0.0015). Comparable correlations were exhibited in the ex-vivo explant tissue between metabolism, p53, hypoxia, inflammation and angiogenesis (P < 0.05). We have shown that metabolism is closely linked with many cellular processes in the Barrett tissue microenvironment.

A locally invasive giant cell tumor of the skull base: case report

Giant cell tumors (GCTs) are rare, usually affecting the epiphyses in long bones of the extremities. They seldom occur in the skull, where they preferentially affect the sphenoid and temporal bones. Considered to be benign, locally aggressive lesions, they may cause cranial nerve deficits by compression but infrequently invade the dura and parenchyma of the brain. Several case reports with follow-up describe gross total resection of skull base GCT to be curative. Anything short of total resection usually results in recurrence within 4 years. Radiation therapy, although controversial, is reserved for lesions that cannot be completely resected. Some argue, however, against the use of radiation because there are reported cases of malignant transformation. Here we describe the case of a large GCT that was invasive to the dura, temporal lobe, as well as the third division of the trigeminal nerve, and to date gross total resection has been curative of this lesion. The patient has not undergone radiation therapy.

Abatacept (CTLA-4IG) treatment reduces the migratory capacity of monocytes in patients with rheumatoid arthritis

OBJECTIVE

The binding of abatacept (CTLA-4Ig) to the B7 ligands CD80 and CD86 prevents the engagement of CD28 on T cells and thereby prevents effector T cell activation. In addition, a direct effect of CTLA-4Ig on antigen-presenting cells (APCs) could contribute to the therapeutic effect. To further elucidate the mechanism of CTLA-4Ig, we performed phenotype and functional analyses of APCs in patients with rheumatoid arthritis (RA) before and after the initiation of CTLA-4Ig therapy.

METHODS

Peripheral blood mononuclear cells were analyzed before and at 2 and 4 weeks after the initiation of CTLA-4Ig therapy. Proportions of APCs were determined by flow cytometry. CD14+ monocytes were further analyzed for the expression of costimulatory and adhesion molecules and for their transendothelial migratory capacity in vitro. In addition, CD14+ monocytes from healthy controls were analyzed for their migratory and spreading capacity.

RESULTS

Proportions and absolute numbers of monocytes were significantly increased in RA patients treated with CTLA-4Ig. The expression of several adhesion molecules was significantly diminished. In addition, monocytes displayed a significant reduction in their endothelial adhesion and transendothelial migratory capacity upon treatment with CTLA-4Ig. Likewise, isolated monocytes from healthy controls revealed a significant reduction in their migratory and spreading activity after preincubation with CTLA-4Ig or anti-CD80 and anti-CD86 antibodies.

CONCLUSION

We describe direct effects of CTLA-4Ig therapy on phenotype and functional characteristics of monocytes in RA patients that might interfere with the migration of monocytes to the synovial tissue. This additional mechanism of CTLA-4Ig might contribute to the beneficial effects of CTLA-4Ig treatment in RA patients.