Systematic review of the patient burden of generalised myasthenia gravis in Europe, the Middle East, and Africa

BACKGROUND

Myasthenia gravis (MG) is a rare autoimmune disease characterised by muscle weakness, and progression from ocular (oMG) to generalised (gMG) symptoms results in a substantial negative impact on quality of life (QoL). This systematic review aimed to provide an overview of the patient burden experienced by people living with gMG.

METHODS

Electronic database searches (conducted March 2022), supplemented by interrogation of grey literature, were conducted to identify studies reporting patient burden outcomes in patients with gMG in Europe, the Middle East and Africa. Results were synthesised narratively due to the heterogeneity across trials.

RESULTS

In total, 39 patient burden publications (representing 38 unique studies) were identified as relevant for inclusion in the systematic review, consisting of 37 publications reporting formal patient-reported outcome measures (PROMs), and two publications describing alternative qualitative assessments of patient experience. The studies included a variety of measures including generic and disease-specific PROMs, as well as symptom-specific PROMs focusing on key comorbidities including depression, anxiety, fatigue and sleep disturbance. The findings showed some variation across studies and PROMs; however, in general there was evidence for worse QoL in patients with gMG than in healthy controls or in patients with oMG, and a trend for worsening QoL with increasing MG severity.

CONCLUSIONS

This review highlights the importance of considering patient QoL when developing and assessing treatment and management plans for patients with gMG. However, the heterogeneity identified across studies illustrates the need for further representative and well-powered studies in large cohorts administering consistent, validated questionnaires.

TRIAL REGISTRATION

The protocol for this systematic review was registered in PROSPERO: CRD42022328444.

Reliability and validity of PRO-CTCAE® daily reporting with a 24-hour recall period

PURPOSE

The standard recall period for the patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE®) is the past 7 days, but there are contexts where a 24-hour recall may be desirable. The purpose of this analysis was to investigate the reliability and validity of a subset of PRO-CTCAE items captured using a 24-hour recall.

METHODS

27 PRO-CTCAE items representing 14 symptomatic adverse events (AEs) were collected using both a 24-hour recall (24 h) and the standard 7 day recall (7d) in a sample of patients receiving active cancer treatment (n = 113). Using data captured with a PRO-CTCAE-24h on days 6 and 7, and 20 and 21, we computed intra-class correlation coefficients (ICC); an ICC ≥ 0.70 was interpreted as demonstrating high test-retest reliability. Correlations between PRO-CTCAE-24h items on day 7 and conceptually relevant EORTC QLQ-C30 domains were examined. In responsiveness analysis, patients were deemed changed if they had a one-point or greater change in the corresponding PRO-CTCAE-7d item (from week 0 to week 1).

RESULTS

PRO-CTCAE-24h captured on two consecutive days demonstrated that 21 of 27 items (78%) had ICCs ≥ 0.70 (day 6/7 median ICC 0.76), (day 20/21 median ICC 0.84). Median correlation between attributes within a common AE was 0.75, and the median correlation between conceptually relevant EORTC QLQ-C30 domains and PRO-CTCAE-24 h items captured on day 7 was 0.44. In the analysis of responsiveness to change, the median standardized response mean (SRM) for patients with improvement was - 0.52 and that for patients with worsening was 0.71.

CONCLUSION

A 24-hour recall period for PRO-CTCAE items has acceptable measurement properties and can inform day-to-day variations in symptomatic AEs when daily PRO-CTCAE administration is implemented in a clinical trial.

Cancer survivor perspectives on sharing patient-generated health data with central cancer registries

PURPOSE

Central cancer registries collect data and provide population-level statistics that can be tracked over time; yet registries may not capture the full range of clinically relevant outcomes. Patient-generated health data (PGHD) include health/treatment history, biometrics, and patient-reported outcomes (PROs). Collection of PGHD would broaden registry outcomes to better inform research, policy, and care. However, this is dependent on the willingness of patients to share such data. This study examines cancer survivors' perspectives about sharing PGHD with central cancer registries.

METHODS

Three U.S. central registries sampled colorectal, non-Hodgkin lymphoma, and metastatic breast cancer survivors 1-4 years after diagnosis, recruiting them via mail to participate in one of seven focus groups (n = 52). Group discussions were recorded, transcribed, and thematically analyzed.

RESULTS

Most survivor-participants were unaware of the existence of registries. After having registries explained, all participants expressed their willingness to share PGHD with them if treated confidentially. Participants were willing to provide information on a variety of topics (e.g., medical history, medications, symptoms, financial difficulties, quality of life, biometrics, nutrition, exercise, and mental health), with a focus on long-term effects of cancer and its treatment. Participants' preferred mode for providing data varied. Participants were also interested in receiving information from registries.

CONCLUSIONS

Our results suggest that registry-based collection of PGHD is acceptable to most cancer survivors and could facilitate registry-based efforts to collect PGHD/PROs. Central cancer registry-based collection of PGHD/PROs, especially on long-term effects, could enhance registry support of cancer control efforts including research and population health management.

Validation of the German patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE™)

BACKGROUND

Integrating the patient's perspective has become an increasingly important component of adverse event reporting. The National Cancer Institute has developed a Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™). This instrument has been translated into German and linguistically validated; however, its quantitative measurement properties have not been evaluated.

PATIENTS AND METHODS

A German language survey that included 31 PRO-CTCAE items, as well as the EORTC QLQ-C30 and the Oral Mucositis Daily Questionnaire (OMDQ), was distributed at 10 cancer treatment settings in Germany and Austria. Item quality was assessed by analysis of acceptability and comprehensibility. Reliability was evaluated by using Cronbach's' alpha and validity by principal components analysis (PCA), multitrait-multimethod matrix (MTMM) and known groups validity techniques.

RESULTS

Of 660 surveys distributed to the study centres, 271 were returned (return rate 41%), and data from 262 were available for analysis. Participants' median age was 59.7 years, and 69.5% of the patients were female. Analysis of item quality supported the comprehensibility of the 31 PRO-CTCAE items. Reliability was very good; Cronbach's' alpha correlation coefficients were >0.9 for almost all item clusters. Construct validity of the PRO-CTCAE core item set was shown by identifying 10 conceptually meaningful item clusters via PCA. Moreover, construct validity was confirmed by the MTMM: monotrait-heteromethod comparison showed 100% high correlation, whereas heterotrait-monomethod comparison indicated 0% high correlation. Known groups validity was supported; PRO-CTCAE scores were significantly lower for those with impaired versus preserved health-related quality of life.

CONCLUSION

A set of 31 items drawn from the German PRO-CTCAE item library demonstrated favourable measurement properties. These findings add to the body of evidence that PRO-CTCAE provides a rigorous method to capture patient self-reports of symptomatic toxicity for use in cancer clinical trials.

Comparison of the Non-VKA Oral Anticoagulants Apixaban, Dabigatran, and Rivaroxaban in the Extended Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis

Background

Historically, warfarin or aspirin have been the recommended therapeutic options for the extended treatment (>3 months) of VTE. Data from Phase III randomised controlled trials (RCTs) are now available for non-VKA oral anticoagulants (NOACs) in this indication. The current systematic review and network meta-analysis (NMA) were conducted to compare the efficacy and safety of anticoagulants for the extended treatment of VTE.

Methods

Electronic databases (accessed July 2014 and updated April 2016) were systematically searched to identify RCTs evaluating apixaban, aspirin, dabigatran, edoxaban, rivaroxaban, and warfarin for the extended treatment of VTE. Eligible studies included adults with an objectively confirmed deep vein thrombosis, pulmonary embolism or both. A fixed-effect Bayesian NMA was conducted, and results were presented as relative risks (RRs). Sensitivity analyses examining (i) the dataset employed according to the time frame for outcome assessment (ii) the model used for the NMA were conducted.

Results

Eleven Phase III RCTs (examining apixaban, aspirin, dabigatran, rivaroxaban, warfarin and placebo) were included. The risk of the composite efficacy outcome (VTE and VTE-related death) was statistically significantly lower with the NOACs and warfarin INR 2.0–3.0 compared with aspirin, with no significant differences between the NOACs. Treatment with apixaban (RR 0.23, 95% CrI 0.10, 0.55) or dabigatran (RR 0.55, 95% Crl 0.43, 0.71) was associated with a statistically significantly reduced risk of ‘major or clinically relevant non-major bleed’ compared with warfarin INR 2.0–3.0. Apixaban also showed a significantly reduced risk compared with dabigatran (RR 0.42, 95% Crl 0.18, 0.97) and rivaroxaban (RR 0.23, 95% Crl 0.09, 0.59). Sensitivity analyses indicate that results were dependent on the dataset, but not on the type of NMA model employed.

Conclusions

Results from the NMA indicate that NOACs are an effective treatment for prevention of VTE or VTE-related death) in the extended treatment setting. However, bleeding risk differs between potential treatments, with apixaban reporting the most favourable profile compared with other NOACs, warfarin INR 2.0–3.0, and aspirin.

Prevalence and determinants of fatigue in patients with moderate to severe chronic GvHD

Although fatigue is common after allogeneic hematopoietic cell transplantation, little is known about fatigue in patients with chronic GvHD (cGvHD). The aim of this study was to explore factors associated with fatigue in cGvHD. Data were drawn from a sequentially recruited, cross-sectional study of adults with moderate or severe cGvHD (n=263). Respondents were classified as fatigued or not fatigued based on their response to a single item regarding loss of energy from the Lee cGvHD Symptom Scale. In univariate analysis, factors significantly associated with fatigue included performance status, number of prior cGvHD therapies, cGvHD symptom bother, self-assessed physical and mental health, nutritional status, walk velocity and self-reported physical activity. There were no significant associations between fatigue and disease-related cGvHD variables. Multivariable logistic regression demonstrated that being less active and having pulmonary and/or muscle/joint symptoms were independently associated with fatigue. In conclusion, clinically significant fatigue was prevalent in more than one-third of subjects with cGvHD, and was disabling. Absence of association with measures of cGvHD severity underscores the need to elucidate the pathogenesis of fatigue and its relationship with inflammatory activity. Pulmonary and muscle/joint symptoms and physical inactivity represent potential targets for intervention in clinical studies.

Comparison of the Novel Oral Anticoagulants Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in the Initial and Long-Term Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis

Background

Anticoagulation with low molecular weight heparin and vitamin K antagonists is the current standard of care (SOC) for venous thromboembolism (VTE) treatment and prevention. Although novel oral anti-coagulants (NOACs) have been compared with SOC in this indication, no head-to-head randomised controlled trials (RCTs) have directly compared NOACs. A systematic review and network meta-analysis (NMA) were conducted to compare the efficacy and safety of NOACs for the initial and long-term treatment of VTE.

Methods

Electronic databases (accessed July 2014) were systematically searched to identify RCTs evaluating apixaban, dabigatran, edoxaban, and rivaroxaban versus SOC. Eligible patients included adults with an objectively confirmed deep vein thrombosis (DVT), pulmonary embolism (PE) or both. A fixed-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as relative risks (RR) and 95% credible intervals (Crl).

Results

Six Phase III RCTs met criteria for inclusion: apixaban (one RCT; n = 5,395); rivaroxaban (two RCTs; n = 3,423/4,832); dabigatran (two RCTs; n = 2,539/2,568); edoxaban (one RCT; n = 8,240). There were no statistically significant differences between the NOACs with regard to the risk of ‘VTE and VTE-related death. Apixaban treatment was associated with the most favourable safety profile of the NOACs, showing a statistically significantly reduced risk of ‘major or clinically relevant non-major (CRNM) bleed’ compared with rivaroxaban (0.47 [0.36, 0.61]), dabigatran (0.69 [0.51, 0.94]), and edoxaban (0.54 [0.41, 0.69]). Dabigatran was also associated with a significantly lower risk of ‘major or CRNM bleed’ compared with rivaroxaban (0.68 [0.53, 0.87]) and edoxaban (0.77 [0.60, 0.99]).

Conclusions

Indirect comparisons showed statistically similar reductions in the risk of ‘VTE or VTE-related death for all NOACs. In contrast, reductions in ‘major or CRNM bleed’ for initial/long-term treatment were significantly better with apixaban compared with all other NOACs, and with dabigatran compared with rivaroxaban and edoxaban. Results from the current analysis indicate that the NOACs offer clinical benefit over conventional therapy while highlighting relative differences in their bleeding profile.

NIH response criteria measures are associated with important parameters of disease severity in patients with chronic GVHD

Lack of standardized criteria measuring therapeutic response remains an obstacle to the development of better treatments for chronic GVHD (cGVHD). This cross-sectional prospective study examined the concurrent and predictive validity of 18 clinician-reported ('Form A') and 8 patient-reported ('Form B') response measures proposed by NIH criteria. Concurrent parameters of interest were NIH global score, cGVHD activity, Lee symptom score and SF36 PCS. Patient cohort included 193 adults with moderate-to-severe cGVHD. Measures associated with the highest number of outcomes were lung function score (LFS), 2-min walk, grip strength, 4-point health-care provider (HCP) and patient global scores, 11-point clinician- and patient-reported global symptom severity scores, and Karnofsky performance score (KPS). Measures associated with survival in univariate analyses led to a Cox model containing skin erythema, LFS, KPS, eosinophil count and interval from cGVHD diagnosis to enrollment as jointly associated with survival. In conclusion, 4-point HCP and patient global scores and 11-point clinician- and patient-reported global symptom severity scores are associated with the majority of concurrent outcomes. Skin erythema is a potentially reversible sign of cGVHD that is associated with survival. These results define a subset of measures that should be prioritized for evaluation in future studies.

Comparison of ionisation chamber and semiconductor detector devices for measurement of the dose-width product for panoramic dental units

Doses for panoramic dental radiography are assessed in terms of the dose-width product (DWP) or dose-area product, which gives a measure of the radiation through a whole exposure. The DWP can be measured using a pencil ionisation chamber (IC) similar to that used for computed tomography dose assessment. However, ICs are sensitive to radiation incident from all directions and so backscatter from the image receptor may increase the recorded dose. This study compares measurements performed using four options: a pencil IC mounted straight on the image receptor, the IC mounted with a steel plate to the rear to standardise scatter conditions, the IC mounted with a steel plate and lead collimators in front to minimise the effect of extra-focal radiation, and a Quart Dido employing a one square centimetre semiconductor detector (SD) designed for panoramic measurements. The results indicate that modification of the current method by incorporating a steel plate reduced the measurement dose by 7% on average, but the reduction was greater for units with semiconductor imaging plates. The measurements with the SD agree more closely with the IC with the steel plate to the rear. An IC with a backing plate to standardise scatter or a suitable SD is recommended for measurement on panoramic dental units.

System dynamic modelling to assess economic viability and risk trade-offs for ecological restoration in South Africa

Can markets assist by providing support for ecological restoration, and if so, under what conditions? The first step in addressing this question is to develop a consistent methodology for economic evaluation of ecological restoration projects. A risk analysis process was followed in which a system dynamics model was constructed for eight diverse case study sites where ecological restoration is currently being pursued. Restoration costs vary across each of these sites, as do the benefits associated with restored ecosystem functioning. The system dynamics model simulates the ecological, hydrological and economic benefits of ecological restoration and informs a portfolio mapping exercise where payoffs are matched against the likelihood of success of a project, as well as a number of other factors (such as project costs and risk measures). This is the first known application that couples ecological restoration with system dynamics and portfolio mapping. The results suggest an approach that is able to move beyond traditional indicators of project success, since the effect of discounting is virtually eliminated. We conclude that systems dynamic modelling with portfolio mapping can guide decisions on when markets for restoration activities may be feasible.

Duration of serological response to canine parvovirus-type 2, canine distemper virus, canine adenovirus type 1 and canine parainfluenza virus in client-owned dogs in Australia

OBJECTIVE

To determine whether client-owned dogs in Australia, last vaccinated with Canvac(®) vaccines containing canine parvovirus-type 2 (CPV-2), canine distemper virus (CDV), canine adenovirus type 2 (CAV-2) ± canine parainfluenza virus (CPiV) at least 18 months ago, were seropositive or responded serologically to revaccination.

METHODS

A total of 235 dogs were recruited from 23 veterinary clinics, representing a variety of breeds, ages and time since last vaccination (TSLV: range 1.5-9 years, mean 2.8 years). Dogs had a blood sample taken and were revaccinated on day 0. A second blood sample was taken 7-14 days later. Blood samples were assessed for antibody titres to CPV-2 (by haemagglutination inhibition) and CDV, CAV type 1 (CAV-1) and CPiV (by virus neutralisation). Dogs with a day 0 titre >10 or a four-fold increase in titre following revaccination were considered to be serological responders.

RESULTS

The overall percentage of dogs classified as serological responders was 98.7% for CPV-2, 96.6% for CDV, 99.6% for CAV-1 and 90.3% for CPiV.

CONCLUSIONS

These results suggest that the duration of serological response induced by modified-live vaccines against CPV-2, CDV, CAV-1 and CPiV, including Canvac(®) vaccines, is beyond 18 months and may extend up to 9 years. Accordingly, these vaccines may be considered for use in extended revaccination interval protocols as recommended by current canine vaccine guidelines.

Oral chronic graft-vs.-host disease characterization using the NIH scale

Chronic graft-vs.-host disease (cGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Oral cGVHD is manifested by mucosal, salivary, and/or sclerotic changes that have been linked to pain and poor quality of life. Our aim was to describe the demographic, clinical, and laboratory markers of oral cGVHD in alloHSCT patients (N = 187) enrolled in a cGVHD cross-sectional study at the NIH (#NCT00331968). We propose a meaningful and reproducible measure of disease defined by a cut-off point reflecting clinical minimally detectable change (0-2 = no oral cGVHD, 3-15 = oral cGVHD) on the 15-point NIH cGVHD clinician assessment scale. Forty-four patients had oral cGVHD. Oral cGVHD was associated with a quiescent or de novo type of cGVHD onset (p = 0.05), higher cGVHD severity (p = 0.033), lower albumin (p = 0.0008), higher total complement (p = 0.012), greater bother from foods or oral ulcers and greater mouth pain, and sensitivity (p < 0.0001). Multivariable logistic regression modeling with albumin, mouth pain, and total complement was 74.3% predictive of oral cGVHD and 80.2% predictive of non-oral cGVHD. We propose the use of >2 points on the NIH scale as a reproducible definition of clinically significant oral cGVHD, which may be useful in clinical settings or as eligibility criterion or as an endpoint in clinical trials.

Clinical laboratory markers of inflammation as determinants of chronic graft-versus-host disease activity and NIH global severity

Chronic graft versus host disease (cGVHD) remains a major cause of non-relapse morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Currently there are no accepted measures of cGVHD activity to aid in clinical management and disease staging. We analyzed clinical markers of inflammation in the sera of patients with established cGVHD and correlated those with definitions of disease activity. 189 adults with cGVHD (33% moderate and 66% severe according to NIH global scoring) were consecutively enrolled onto a cross-sectional prospective cGVHD natural history study. At the time of evaluation, 80% were receiving systemic immunosuppression and failed a median of 4 prior systemic therapies (PST) for their cGVHD. Lower albumin (p<0.0001), higher CRP (C-reactive protein; p=0.043), higher platelets (p=0.030) and higher number of PST (p<0.0001) were associated with active disease defined as clinician's intention to intensify or alter systemic therapy due to the lack of response. Higher platelet count (p=0.021) and higher number of PST (p<0.0001) were associated with more severe diseased defined by NIH global score. This study identified common laboratory indicators of inflammation that can serve as markers of cGVHD activity and severity.

A systematic review of tacrolimus ointment compared with corticosteroids in the treatment of atopic dermatitis

OBJECTIVE

A systematic review and meta-analysis was conducted to determine the efficacy and tolerability of tacrolimus ointment for the treatment of atopic dermatitis (AD) compared with topical corticosteroids.

METHODS

Electronic searches were performed in Medline, Embase and the Cochrane Library, as well as relevant conference proceedings. Two researchers independently selected trials investigating the efficacy and/or safety of tacrolimus ointment in the treatment of AD. No language restrictions were applied. Relevant outcome data from included trials were extracted by two independent reviewers. Direct meta-analysis to calculate relative risks (RR) (95% confidence intervals (CIs)) was conducted on dichotomous efficacy/safety outcomes of interest.

RESULTS

Seventeen trials comparing tacrolimus ointment with topical corticosteroids in both paediatric (n = 2328) and adult (n = 2849) patients were identified. No studies comparing tacrolimus ointment with class IV topical corticosteroids were identified. Tacrolimus 0.1% ointment was found to be of similar efficacy to class I/II and class III topical corticosteroids. In three individual trials (comparing tacrolimus 0.1% ointment to a topical corticosteroid), evaluation of the Physician's Global Evaluation of Clinical Response (PGECR) resulted in RRs of 0.95 (95% CI 0.78-1.16), 3.09 (95% CI 2.14-4.45) and 1.35 (95% CI 0.86-2.12), where values above one favour tacrolimus ointment. With the exception that tacrolimus ointment caused more skin burning than comparator treatments (tacrolimus 0.03% versus a class III topical corticosteroid, the RR was 3.00 (95% CI 1.21-7.43) in favour of the corticosteroid), no significant differences with regards to side-effects and withdrawals due to AEs were found. Quality of life data were reported in two studies. While one study reported greater improvements in tacrolimus-treated adult patients compared with topical steroids, the second reported greater improvements in paediatric patients treated with steroids compared with tacrolimus ointment.

CONCLUSIONS

The current review and meta-analysis showed tacrolimus ointment to be of similar efficacy to corticosteroids. The interpretation of available data is limited by heterogeneity in outcome measures between trials. Further trials are needed to assess the impact of treatments on patient reported outcomes.

Safety and tolerability of donepezil, rivastigmine and galantamine for patients with Alzheimer's disease: systematic review of the 'real-world' evidence

BACKGROUND/AIMS

The purpose of this systematic review was to compare the safety and tolerability of the cholinesterase inhibitors (ChEIs) donepezil, rivastigmine and galantamine for treating mild to moderate Alzheimer's disease (AD) patients in routine clinical practice.

METHODS

Electronic databases (Cochrane Library, Medline, EMBASE; accessed October 2008) and manual bibliographic searches were conducted to identify head-to-head non-randomised studies examining ChEIs for the treatment of AD. Data were extracted by 2 independent reviewers.

RESULTS

Twelve head-to-head studies comparing ChEIs met the pre-specified inclusion criteria; 6 retrospective analyses and 6 prospective cohort studies. Donepezil was the most widely studied treatment and galantamine the least widely prescribed therapy. Fewer donepezil-treated subjects withdrew due to adverse events (AEs) compared with rivastigmine and galantamine-treated subjects. The incidence of gastrointestinal (GI) AEs was lower following treatment with donepezil compared with rivastigmine and galantamine. Non-GI (CNS and cardiovascular) AEs occurred at a low frequency, and had a similar incidence in subjects treated with the different ChEIs.

CONCLUSIONS

Subjects with mild to moderate AD treated in routine clinical practice with donepezil were more adherent to pharmacotherapy, and had a lower risk of GI AEs compared with rivastigmine or galantamine. This finding accords with results reported in the randomised clinical trial literature.

Reliability of the School Food Checklist for in-school audits and photograph analysis of children's packed lunches

BACKGROUND

Assessment of children's diets is problematic, typically relying on error-prone parent or child recall or reporting, or resource intensive direct observation. The School Food Checklist (SFC) is an objective instrument comprising of 20 food and beverage categories designed to measure the foods contained in children's packed lunches. The present study aimed to assess intra-rater and inter-rater reliability of each of the food and beverage categories of the SFC for both in-school audits and photograph analysis of children's school lunches.

METHODS

Participants comprised 176 children aged 5-8 years from five primary schools in Northern Metropolitan Melbourne. The SFC was used to measure the foods contained in children's packed lunches in the school setting and using photographs. Photograph analysis was conducted by the auditors 2-3 months after completion of in-school audits.

RESULTS

Both intra-rater [intra-class correlation coefficient (ICC) = 0.78-1] and inter-rater (ICC = 0.50-0.95) reliability analysis indicated strong agreement for in-school auditing. With the exception of the food category titled 'leftovers', there was strong intra-rater reliability for auditors' live audits and their analysis of photographs [ICC = 0.57-0.98 (Auditor 1); ICC = 0.72-0.90 (Auditor 2)], and strong inter-rater reliability for photograph analysis (ICC = 0.68-0.92).

CONCLUSIONS

The SFC is a reliable method of measuring the foods and beverages contained in children's packed lunches when used in the school setting or for photograph analysis. This finding has broad implications, particularly for the use of photograph analysis, because this approach offers a convenient and cost effective method of measuring what food and beverages children bring to school in home packed lunches.

Bystander effect and adaptive response in C3H 10T½ cells

PURPOSE

To address the relationship between the bystander effect and the adaptive response that can compete to impact on the dose-response curve at low doses.

MATERIALS AND METHODS

A novel radiation apparatus, where targeted and non-targeted cells were grown in close proximity, was used to investigate these phenomena in C3H 10T(1/2) cells. It was further examined whether a bystander effect or an adaptive response could be induced by a factor(s) present in the supernatants of cells exposed to a high or low dose of X-rays, respectively.

RESULTS

When non-hit cells were co-cultured for 24 h with cells irradiated with 5 Gy alpha-particles, a significant increase in both cell killing and oncogenic transformation frequency was observed. If these cells were treated with 2 cGy X-rays 5 h before co-culture with irradiated cells, approximately 95% of the bystander effect was cancelled out. A 2.5-fold decrease in the oncogenic transformation frequency was also observed. When cells were cultured in medium donated from cells exposed to 5 Gy X-rays, a significant bystander effect was observed for clonogenic survival. When cells were cultured for 5 h with supernatant from donor cells exposed to 2 cGy and were then irradiated with 4 Gy X-rays, they failed to show an increase in survival compared with cells directly irradiated with 4 Gy. However, a twofold reduction in the oncogenic transformation frequency was seen.

CONCLUSIONS

An adaptive dose of X-rays cancelled out the majority of the bystander effect produced by alpha-particles. For oncogenic transformation, but not cell survival, radioadaption can occur in unirradiated cells via a transmissible factor(s).

A review of medicinal plant research at the University of the West Indies, Jamaica, 1948-2001

This review summarizes research carried out on Jamaican medicinal plants at the Faculty of Pure and Applied Science, The University of the West Indies (UWI), Mona, Jamaica, between 1948 and 2001. The plants identified as being medicinal are listed along with their folk use and a summary of the scientific research done at UWI leading to the identification of natural products (NPs) and determination of their bioactivity. Natural product research on Jamaican medicinal plants began with the inception of UWI in 1948, leading to many postgraduate degrees being awarded (22 MPhil and 31 PhD). At least 334 plant species growing in Jamaica have been identified as having medicinal qualities, 193 of these have been tested for their bioactivity. Crude extracts from 80 of these plants have reasonable bioactivity and natural products (NP) have been identified from 44 plants. At least 29 of these NPs were found to be bioactive. Only 31 of the plants tested at UWI are endemic to Jamaica. Of these 23% were bioactive, as compared to 11% of the non-endemics. Based on these results, patents have been obtained and drugs have been developed. This review represents the first attempt to gather this information together in one place.

Origin of second harmonic generation optical activity of a tryptophan derivative at the air/water interface

Second harmonic generation optical activity (SHG-OA) of chiral monolayers of the tryptophan derivative N(alpha)-(tert-butoxycarbonyl)-tryptophan (BOC-Trp) at an air/water interface has been studied in detail. In combination with previously reported experimental measurements with the fundamental frequency variant Planck's 'h/' omega=2.20 eV (lambda=564 nm), new measurements with lambda=564 and 800 nm fully characterize the nonlinear susceptibility tensors of chiral and achiral (racemic) monolayers under two-photon resonant and nonresonant conditions of the fundamental frequency. A realistic computational approach including semiempirical, intermediate neglect of differential overlap (ZINDO/S) calculations has been used to calculate the nonlinear susceptibilities of model achiral and chiral monolayers composed of indole chromophores. There is satisfactory agreement between calculated and observed nonlinear susceptibilities, which constrains certain structural parameters of the monolayers including the absolute orientation of the long molecular axis of indole at the air/water interface. The origin of SHG-OA of BOC-Trp monolayers is discussed with reference of two distinct mechanisms at the microscopic level, designated type I or chiral assembly and type II or electronic coupling. Both mechanisms are studied in detail within the framework of ZINDO/S calculations. The dominant effect for the BOC-Trp monolayers is type I, involving chiral assembly of indole chromophores.

Second-harmonic generation optical activity of a polypeptide alpha-helix at the air/water interface

Quantitative measurements of second-harmonic generation optical activity (SHG-OA) have been performed for alpha-helical polypeptides poly-(gamma-benzyl-L-glutamate) and poly-(gamma-ethyl-L-glutamate) adsorbed at the airwater interface, with the fundamental frequency variant Planck's over 2piomega = 2.96 eV (lambda = 417 nm). The chiral component of the nonlinear susceptibility chi(XYZ) ((2)) is small for both polymers, being comparable in magnitude with the susceptibility chi(XXZ) ((2)) of the clean airwater interface. The microscopic origin of the nonlinear response has been investigated by using semiempirical ZINDOS calculations in conjunction with standard time-dependent perturbation theory to evaluate the molecular hyperpolarizability tensor of a model alpha-helix composed of glycine residues. Calculated nonlinear susceptibilities (per monomer unit) are in good agreement with experimental measurements for both the chiral and achiral response. The computational results indicate that charge transfer transitions of the alpha-helix have a large influence on the achiral components of the hyperpolarizability tensor, and produce characteristic features in the response under suitable experimental conditions. The dominant origin of SHG-OA for the model alpha-helix is a structural effect due to the tilt of the plane of each amide group of the helix relative to the helical axis. SHG-OA is associated with the orientational distribution of isolated, achiral chromophores, and is present in the absence of electronic coupling between the amide subunits of the polypeptide alpha-helix.

Investigation of interactions of polypyrimidine tract-binding protein with artificial internal ribosome entry segments

Most eukaryotic translation initiation is thought to be dependent on the 5'-cap structure of the mRNA. It is becoming apparent, however, that the mRNAs of many genes contain IRESs (internal ribosome entry segments) within the 5'-UTR (5'-untranslated region) that allow ribosomes to initiate translation independently of the 5'-cap. IRESs can enable the expression of these genes under conditions (such as viral infection, cellular stress and apoptosis) when cap-dependent translation initiation is compromised, and also provide a target for regulation of gene expression. Recent results from our laboratory and others suggest that 10% of mRNAs (approximately 4000 genes) use this mechanism to initiate translation. One of the central goals of those working in the field of translation is to identify the sequence motif(s) and proteins that are required for internal ribosome entry. We have identified recently a unique PTB (polypyrimidine tract-binding protein) motif (CCU)n that is present in a large subset of cellular IRESs, and the results suggest that PTB itself is involved either directly or indirectly in ribosome recruitment. Here, we describe further investigations of PTB with artificial sequences that harbour this motif.

Nonlinear Susceptibility of a Cyanobiphenyl Derivative at the Air/Water Interface: Improved Measurement of Molecular Orientation by Optical Second Harmonic Generation

The nonlinear susceptibility tensor, chi(2), for second harmonic generation (SHG) by a monolayer of the cyanobiphenyl derivative 4-n-octyl-4'-cyanobiphenyl (8CB) at the air/water interface has been measured with the fundamental frequency variant Planck's over 2piomega=1.55 eV (lambda=800 nm). The contribution of the water subphase was estimated by measuring the magnitudes and relative phases of the nonlinear susceptibilities of the bare and monolayer-covered water surfaces. All nonzero elements of chi(2) are placed on an absolute scale by comparison with SHG in reflection from a z-cut quartz crystal. The experimental measurements for the 8CB monolayer are compared with computed susceptibilities derived by using standard time-dependent perturbation theory in conjunction with a semiempirical electronic structure model. Good agreement has been found between experimental and computational results when the average tilt angle of the cyanobiphenyl chromophore of 8CB is in the range 60-70 degrees relative to the surface normal. A critique is given of an alternative, simplified measurement procedure of the tilt angle in which only the dominant element of the molecular hyperpolarizability tensor is considered. It is shown that the simplified procedure is invalid for 8CB monolayers when the tilt angle is greater than approximately 70 degrees.

Orientation and confinement of cells on chemically patterned polystyrene surfaces

UV/ozone oxidation was combined with a photomasking technique to produce adjacent regions of different chemistry on polystyrene (PS) surfaces. The surface chemistry and topography were studied using AFM, XPS and contact angle measurements. The physicochemical patterns were visualised by the condensation of water vapour upon the surfaces and by the differential attachment of Chinese hamster ovarian (CHO) cells. The orientation of CHO cells on 55 and 125 microm wide oxidised PS strips were measured and found to be highly dependent on the width of the oxidised feature. CHO cells in relatively close proximity to a linear polar/non-polar border showed significant axial alignment along the border. CHO cells can also be confined to specific regions of the polymer surface. Cells attached to larger areas (75 microm x 75 microm) were found to have a smaller average cell size than cells attached to the smaller (56 microm x 56 microm) areas.

Internal ribosome entry segment-mediated translation during apoptosis: the role of IRES-trans-acting factors

During apoptosis, there is a reduction in translation initiation caused by caspase cleavage of several of the factors required for the cap-dependent scanning mechanism. Under these circumstances, many proteins that are required for apoptosis are instead translated by the alternative method of internal ribosome entry. This mechanism requires the formation of a complex RNA structural element and in the presence of internal ribosome entry segment (IRES)-trans-acting factors (ITAFs), the ribosome is recruited to the RNA. The interactions of several ITAFs with IRESs have been investigated in detail, and several mechanisms of action have been noted, including acting as chaperones, stabilising and remodelling the RNA structure. Structural remodelling by PTB in particular will be discussed, and how this protein is able to facilitate recruitment of the ribosome to several IRESs by causing previously occluded sites to become more accessible.

The influence of electrostatic forces on protein adsorption

In this paper we investigate the importance of electrostatic double layer forces on the adsorption of human serum albumin by UV-ozone modified polystyrene. Electrostatic forces were measured between oxidized polystyrene surfaces and gold-coated atomic force microscope (AFM) probes in phosphate buffered saline (PBS) solutions. The variation in surface potential with surface oxygen concentration was measured. The observed force characteristics were found to agree with the theory of electrical double layer interaction under the assumption of constant potential. Chemically patterned polystyrene surfaces with adjacent 5 microm x 5 microm polar and non-polar domains have been studied by AFM before and after human serum albumin adsorption. A topographically flat surface is observed before protein adsorption indicating that the patterning process does not physically modify the surface. Friction force imaging clearly reveals the oxidation pattern with the polar domains being characterised by a higher relative friction compared to the non-polar, untreated domains. Far-field force imaging was performed on the patterned surface using the interleave AFM mode to produce two-dimensional plots of the distribution of electrostatic double-layer forces formed when the patterned polystyrene surfaces is immersed in PBS. Imaging of protein layers adsorbed onto the chemically patterned surfaces indicates that the electrostatic double-layer force was a significant driving force in the interaction of protein with the surface.

Improved cellular adhesion to acetone plasma modified polystyrene surfaces

The plasma polymerization of acetone has been used to modify polystyrene substrates for the controlled growth of human fibroblast cells. The surface modified polystyrene was studied by X-ray photoelectron spectroscopy, water contact angle and atomic force microscopy. This showed the surface oxygen levels and wettability to increase rapidly with exposure to the acetone plasma. High-resolution XPS allowed the determination of the relative amounts of surface hydroxyl, carbonyl and carboxyl groups. This showed that there was little incorporation of carboxyl groups in the deposited films. AFM measurements revealed the films to be conformal with a surface roughness equivalent to that of the underlying polystyrene substrate with film growth rates of approximately 0.5 nm min(-1). High edge-definition patterns were produced with a simple masking procedure and allowed the confinement of cells to selected areas of the substrate. These chemically patterned surfaces allowed the study of cells confined to particular regions of the substrate as a function of incubation time.

Cellular attachment and spatial control of cells using micro-patterned ultra-violet/ozone treatment in serum enriched media

Ultra-violet Ozone (UVO) modified polystyrene (PS) surfaces were analyzed by X-ray photoelectron spectroscopy (XPS), atomic force microscopy (AFM), contact angle (CA), optical microscopy (OM) and cell culture experiments. UV/Ozone treatment up to 900 s was used to increase the surface oxygen concentration of PS surfaces from 0% to approximately 35% (unwashed) and 0% to approximately 27% (washed). The observed differences in oxygen concentration, between washed and unwashed surfaces, have been previously attributed to the removal of low molecular weight debris produced in this treatment process. Surface roughness (Rq) is known to affect cellular attachment and proliferation. AFM studies of the UV/Ozone treated PS surfaces show the surface roughness is an order of magnitude less than that expected to cause an effect. UV/Ozone treatment of PS showed a marked change in CA which decreased to approximately 60 degrees after 900 s treatment. The increased attachment and proliferation of Chinese hamster ovarian (CHO) and mouse embryo 3T3-L1 (3T3) cells on the treated surfaces compared to untreated PS were found to correlate strongly with the increase in surface oxygen concentration. Surface chemical oxidation patterns on the PS were produced using a simple masking technique and a short UV/Ozone treatment time, typically 20-45 s. The chemical patterns on PS were visualized by water condensation and the spatially selective attachment of CHO and 3T3-L1 cells cultured with 10% (v/v) serum. This paper describes an easily reproducible, one step technique to produce a well-defined, chemically heterogeneous surface with a cellular resolution using UV/Ozone modification. By using a variety of cell types, that require different media conditions, we have been able to expand the potential applications of this procedure.

Privileged structures: applications in drug discovery

Over the past 15 years the privileged structure concept has emerged as a fruitful approach to the discovery of novel biologically active molecules. Privileged structures are molecular scaffolds with versatile binding properties, such that a single scaffold is able to provide potent and selective ligands for a range of different biological targets through modification of functional groups. In addition, privileged structures typically exhibit good drug-like properties, which in turn leads to more drug-like compound libraries and leads. The net result is the production of high quality leads that provide a solid foundation for further development. The identification of privileged structures will be discussed, emphasizing the importance of understanding the structure-target relationships that confer "privileged" status. This understanding allows privileged structure based libraries to be targeted at distinct target families (e.g. GPCRs, LGIC, enzymes/kinases). Privileged structures have been successfully exploited across and within different target families and promises to be an effective approach to the discovery and optimization of novel bioactive molecules. The application of the privileged structure approach, both in traditional medicinal chemistry and in the design of focused libraries, will be discussed with the aid of illustrative examples.

The Bystander Response in C3H 10T½ Cells: The Influence of Cell-to-Cell Contact

Although radiation-induced heritable damage in mammalian cells was thought to result from the direct interaction of radiation with DNA, it is now accepted that biological effects may occur in cells that were not themselves traversed by ionizing radiation but are close to those that were. However, little is known about the mechanism underlying such a bystander effect, although cell-to-cell communication is thought to be of importance. Previous work using the Columbia microbeam demonstrated a significant bystander effect for clonogenic survival and oncogenic transformation in C3H 10T(1/2) cells. The present study was undertaken to assess the importance of the degree of cell-to-cell contact at the time of irradiation on the magnitude of this bystander effect by varying the cell density. When 10% of cells were exposed to a range of 2-12 alpha particles, a significantly greater number of cells (P < 0.0001) were inactivated when cells were irradiated at high density (>90% in contact with neighbors) than at low density (<10% in contact). In addition, the oncogenic transformation frequency was significantly higher in high-density cultures (P < 0.0004). These results suggest that when a cell is hit by radiation, the transmission of the bystander signal through cell-to-cell contact is an important mediator of the effect, implicating the involvement of intracellular communication through gap junctions.

UV-ozone modification of plasma-polymerised acetonitrile films for enhanced cell attachment

Plasma polymerisation is of great interest for modifying the surface properties of biomedical devices in order to control, for example, protein adsorption and cell attachment. In this paper we present results for plasma-polymerised acetonitrile deposited onto silicon or polystyrene substrates. The chemistry of films deposited under a range of experimental conditions was studied by X-ray photoelectron spectroscopy (XPS) and Fourier transform infrared spectroscopy (FTIR). XPS provided evidence that the elemental composition of the films varied with rf power to flow rate parameter (W/F) with films produced at higher W/F being deficient in nitrogen. FTIR revealed that the plasma deposited film contained a wide range of nitrogen functional groups including amine, imine and nitrile. Oxidation of the films by exposure to radiation from a low pressure mercury vapour lamp in an air ambient increased the surface oxygen levels from 3 to 17at.% after 300 s exposure. XPS also revealed that the oxidation process proceeded via the formation of carbonyl groups at short exposure times (<60s) while longer treatment times (>60s) resulted in an increase in the concentration of carboxyl groups. To assess their potential to support cell growth, polystyrene culture dishes coated with plasma deposited films and UV-ozone oxidised films were seeded with 1BR.3.N human fibroblast cells and incubated for up to 72 h. Un-oxidised plasma-polymerised acetonitrile films were found to give comparable cell attachment densities as tissue culture polystyrene. The greatest cell attachment density was found with plasma polymer films which had been UV-ozone treated for the longest time (300 s). Enhanced attachment to this surface was attributed to the high level of carboxylic groups found on this substrate.

Cigarette smoking, appendectomy, and tonsillectomy as risk factors for the development of primary sclerosing cholangitis: a case control study

BACKGROUND AND AIMS

The strong clinical association between primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) suggests common factors in their pathogenesis. Smoking, previous appendectomy, and tonsillectomy have been associated with a decreased risk of developing UC. In this study, our aim was to examine these risk factors in patients with PSC with and without underlying inflammatory bowel disease (IBD).

METHODS

The smoking habits and history of previous appendectomy and/or tonsillectomy of 170 patients with PSC, 41 without underlying IBD, 170 patients with UC but normal liver function tests, and 170 age and sex matched community controls were obtained by questionnaire.

RESULTS

A total of 112 PSC patients (66%) had never smoked compared with 66 controls (39%). Only 12 PSC patients (7%) were current smokers versus 43 controls (25%). The resultant odds ratio of having PSC was 0.17 (95% confidence interval (CI) 0.08-0.35) among current smokers and 0.33 (95% CI 0.21-0.52) among ever (former+current) smokers. Among former smokers, the odds of having PSC were also significantly decreased (odds ratio 0.45, 95% CI 0.26-0.73; p<0.05). In the subgroup of PSC patients without IBD, only 5% were current smokers versus 26% of matched controls, and never smokers were overrepresented (68% v 37%). The rate of previous appendectomy was similar in all three study groups (14%, 12%, and 13%) but the frequency of tonsillectomy was reduced in the PSC group (21% v 31%; p=0.05).

CONCLUSION

PSC, like UC, is a disease of non-smokers as the odds of having PSC was significantly decreased among current and former smokers. The association between non-smoking and PSC was independent of whether the PSC patient had underlying IBD. Previous tonsillectomy but not appendectomy may also be associated with a decreased risk of PSC but this warrants further study.

Alverine citrate fails to relieve the symptoms of irritable bowel syndrome: results of a double-blind, randomized, placebo-controlled trial

BACKGROUND

Alverine citrate has been used in the treatment of irritable bowel syndrome for many years.

AIMS

To compare the efficacy and safety of a new formulation of alverine citrate, a 120-mg capsule, with placebo given three times daily for 12 weeks.

METHODS

One hundred and seven patients with irritable bowel syndrome were entered into this three-centre, double-blind, randomized, placebo-controlled, parallel group trial. The primary end-point was relief of abdominal pain indicated by improvement in the scores for severity and frequency. Secondary efficacy variables included scores for other clinical symptoms and for overall well-being.

RESULTS

The severity and frequency of abdominal pain improved in 66% and 68% of patients treated with alverine citrate vs. 58% and 69% of the placebo group, but these differences were not significant. The mean percentage reduction in the scores for abdominal pain from baseline to the final assessment, although greater in the alverine citrate group (43.7%) compared with the placebo group (33.3%), was not statistically significant.

CONCLUSIONS

Alverine citrate is no better than placebo at relieving the symptoms of irritable bowel syndrome. Future trials should be designed to take into account the high and persistent placebo response seen in this condition.