[Exploration and practice of artificial intelligence assisted primary vision health management]

It has attracted much attention worldwide that the application of artificial intelligence (AI) in primary screening and clinical diagnosis and treatment of eye diseases. In recent years, this technology has also been widely used in various grass-roots eye disease management, effectively improving the current situation of weak eye disease diagnosis ability and shortage of human resources in primary medical institutions. At present, there is no reference standard or guideline for the management mode, implementation content and management method of vision health management based on this technology, which are in urgent need of standardization. The article described the work mode exploration of AI-assisted grass-roots visual health management in Shanghai and shared practical experience. The aim is to provide reference for other provinces in China to carry out relevant work.

[Clinicopathological characteristics of anti-PD-1 associated gastroenteritis]

Objective: To investigate the clinicopathological features of anti-PD-1 related gastroenteritis, understand and recognize the disease, and avoid misdiagnoses. Methods: Three cases of anti-PD-1 related gastroenteritis diagnosed and treated at the Zhongshan Hospital Affiliated to Fudan University, Shanghai, China from 2020 to 2021 were collected. The clinical and pathological features were analyzed and the patients were followed up by telephone. Results: The three patients were all male and aged 63, 39 and 73 years, respectively. They had previously developed gastrointestinal symptoms as a result of immunotherapy for a malignant tumor. Endoscopically, 2 patients presented with pancolitis, and 1 patient presented with a large antral ulcer involving the pyloric canal in the stomach. Histologically, there were marked atrophy and thinning of the epithelium, diffuse infiltration of numerous neutrophils in the lamina propria, formation of micro-abscesses in the crypt/glandular lumen, structural changes (branching and distortion) of the glands, and significant glandular dilatation. In addition, chronic inflammatory features (e.g., lymphoplasmacytosis) were focally seen in 2 cases. Cytomegalovirus immunohistochemical stains were negative in all 3 cases. Based on the history and morphology, all 3 cases were diagnosed as anti-PD-1 related gastroenteritis. According to the above diagnosis, the treatment for all 3 patients was to stop anti-PD-1 therapy and use corticosteroids. Clinical follow-up was conducted. The gastrointestinal symptoms of all 3 patients improved significantly and diarrhea symptoms were relieved after stopping immunotherapy. Conclusions: Anti-PD-1 related gastroenteritis is not rare, but pathologists may lack sufficient understanding of it. Combined with clinical history and pathologic characteristics of the lesion, pathologists should consider this disease to avoid the misdiagnoses and missed diagnoses.

[Challenges of artificial intelligence used for eye disease screening in recent China communities]

Due to factors such as medical resources, public awareness, funding for general screening, or optimized screening models, community-based screening is far from meeting the demand. Artificial intelligence (AI) can replace some of the medical work and combine it with the "Internet+" model to transfer medical resources to improve accessibility and availability. However, the application of AI technology to community-based screening still faces many challenges, such as most AI products cannot be directly applied to community-based screening, the inability to integrate multimodal information such as medical history, symptoms, and images, and the lack of relevant regulations and health policies for productization and implementation. Therefore, we suggest that the relevant departments take actions: (1) to build standardized big data sets, unlock data barriers, and accelerate the development and application of AI technology; (2) to train "AI+" medical staffs as soon as possible; (3) to establish relevant laws and regulations; (4) to establish relevant R&D plans and quality standards and regulatory frameworks for AI products; (5) to encourage more investment in medical AI infrastructure in the central and western regions and remote and poor areas.

[Analysis of community intervention effects for diabetic eye diseases in Shanghai Xinjing community from 2016 to 2018]

Objective: To analyze the effects of community-based interventions for diabetic eye diseases in Xinjing community, Shanghai from 2016 to 2018. Methods: Based on the project of "Establishment of Service Model for Comprehensive Prevention and Treatment of Diabetic Eye Diseases in Shanghai", the participants were not suffering diabetic retinopathy (DR) in Xinjing community in 2016 before interventions and received community-based interventions for diabetic eye diseases. The incidence of DR, visual acuity and awareness of DR were used as evaluation indicators to analyze the effects of interventions for diabetic eye diseases in the community. Results: A total of 537 patients were included in this study, the incidence of DR among diabetic patients in Xinjing community was 7.6% after interventions. The duration of diabetes (OR= 1.065) and HbA1c (OR= 1.090) were the risk factors of DR. Before and after the interventions, the patients with monocular low vision and binocular low vision were 27 cases (5.0%), 8 cases (1.5%), 19 cases (3.5%) and 7 cases (1.3%) respectively. After interventions, the awareness on the prevention and treatment of DR increased significantly, and the proportion of regular visits to ophthalmology examination, diet control and physical exercise also increased significantly. Conclusion: Community-based interventions for diabetic eye diseases are helpful to improve the awareness of DR prevention and control, reduce the incidence of DR.

[Energy metabolism characteristic with risk of secondary bacterial infection in patients with hepatitis B virus-related chronic liver disease]

Objective: To investigate and analyze the energy metabolism characteristics and the correlation between energy metabolism and the risk of secondary bacterial infection in patients with hepatitis B virus-related chronic liver disease (HBV-CLD). Methods: Data of 183 cases admitted to the Mengchao Hepatobiliary Hospital of Fujian Medical University from November 2017 to November 2020 were retrospectively analyzed. 79 cases of chronic hepatitis B, 51 cases of hepatitis B-related liver cirrhosis, and 53 cases of hepatitis B-related liver failure were collected. Among them patients with liver failure and decompensated liver cirrhosis were defined as severe liver disease group. The Quark RMR indirect calorimetry (COSMED Corporation, Italy) was used to exam the patients' energy metabolism condition, and the incidences of secondary bacterial infection of the patients during hospitalization were recorded. Shapiro-Wilk test and normal QQ plot were used to analyze the normal distribution of continuous variable data, which was consistent with the normal distribution and was described by mean ± standard deviation. In addition, if it did not conform to the normal distribution, the median and interquartile distance were used to describe it. Levene's test was used to test the homogeneity of variance of the data, which was consistent with the normal distribution. The t-test was used to compare the means of the two groups of samples. One-way analysis of variance was used to compare the mean values of the three groups of samples, and then the Tukey's test was used to compare the two groups. If the variance was uneven or did not conform to the normal distribution, the Wilcoxon rank sum test was used to compare the differences between the two groups. Kruskal-Wallis test (H test) was used to compare the differences between the three groups of samples, and then the Dunnett's test (Z test) was used for comparison between the two groups. Categorical variable data were analyzed using chi-square test. Logistic regression analysis was used to screen independent risk factors, and the criteria for variable inclusion (P < 0.05). Results: The respiratory entropy (RQ) and non-protein respiratory entropy (npRQ) of the three groups had statistically significant difference (P < 0.05). Among them, the RQ and npRQ of the chronic hepatitis B group were higher than hepatitis B-related liver cirrhosis group and hepatitis B-related liver failure group. There were statistically significant differences in fat oxidation rate (FAT%) and carbohydrate oxidation rate (CHO%) between the three groups (P < 0.05). Compared with hepatitis B-related liver cirrhosis group and hepatitis B-related liver failure group, chronic hepatitis B group (P < 0.05) had lower FAT% and higher CHO%. There were no statistically significant differences in the measured and predicted resting energy expenditure and protein oxidation rate (PRO%) between the three groups. The incidence of secondary bacterial infection in patients with severe liver disease was 48.39% (45/93). Compared with the non-infected group, the RQ and npRQ values ​​of the infected group were significantly decreased (P < 0.05), while FAT% was significantly increased (P < 0.05). Logistic regression analysis showed that glutamyltransferase, cholesterol, and npRQ were independent risk factors for secondary bacterial infections in patients with severe liver disease. Glutamyltransferase elevation, and cholesterol and npRQ depletion had suggested an increased risk of secondary bacterial infection. Subgroup analysis of patients with hepatitis B-related liver failure also showed that compared with non-infected group, RQ value and npRQ value of secondary bacterial infection group were significantly decreased (P < 0.05), while FAT% was significantly increased (P < 0.05). Conclusion: Patients with hepatitis B virus-related chronic liver disease generally have abnormal energy metabolism. Low RQ, npRQ, CHO% and high FAT% are related to the severity of the disease; while npRQ reduction is related to the risk of secondary bacterial infection in patients with severe liver disease, and thus can be used as a clinical prognostic indicator.

[Analysis of cataract surgery status in public hospitals of Shanghai from 2013 to 2015]

Objective: To analyze the reasons that restrict the growth of cataract surgery service capacity in public hospitals in Shanghai in recent years. Methods: The status of surgeries performed in public hospitals are analyzed based on the data related to cataract surgery collected from the database of Shanghai Eye Disease Treatment. Meanwhile, the surgeries performed by ophthalmologists working in the public hospitals are studied based on the National ophthalmology service capacity questionnaire. Results: The cataract surgery volume performed in public hospitals of Shanghai increased from 45 480 in 2013 to 51 941 in 2015. In 2014, the year on year growth rate of cataract surgery volume in tertiary hospitals was 8.54%, while in 2015, it was -0.21% on an annual basis. More than 70% cataract surgeries were performed in tertiary public hospitals. For those performed in tertiary public hospitals, 80% were performed in urban area. The actual surgeons in tertiary account for 70% of the actual surgeons in all public hospitals. Among all cataract surgeries performed in secondary hospitals, half were performed in urban areas. The volume of cataract surgery by cataract surgeon and the number of the ophthalmologist were higher than those in secondary hospitals. The average cataract surgery volume of tertiary hospitals in urban areas and the average annual cataract surgery volume of the actual surgeons are much higher than those of the secondary hospitals in the urban areas, but it is contrary in exurban areas. Conclusion: The excessive density of tertiary hospitals in urban area and poor ophthalmology service capacity in secondary hospitals in suburban and exurban areas have restricted the rapid growth rate of cataract surgery and even a decline in Shanghai public hospitals. (Chin J Ophthalmol, 2020, 56: 615-620).

Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data

Objective

To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH).

Design

Secondary analysis of the WHO CHAMPION trial data.

Setting

Twenty‐three hospitals in ten countries.

Population

Women from the CHAMPION trial who received uterotonics as first‐line treatment of PPH.

Methods

We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first‐line PPH treatment.

Main outcome measures

Maternal characteristics; causes of PPH.

Results

Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07–1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34–2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04–1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively.

Conclusion

Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first‐line treatment responsive PPH.

Tweetable abstract

Women with refractory postpartum haemorrhage are different from those with first‐line treatment responsive PPH.

Women with refractory postpartum haemorrhage are different from those with first‐line treatment responsive PPH.

Rectal Temperature of Corpse and Estimation of Postmortem Interval

Abstract

Measurement of corpse temperature is mainly used for estimation of early postmortem interval, and rectal temperature is often used as a representative of body's core temperature in actual work because it is simple, quick and non-invasive. At present, the rectal temperature postmortem interval estimation method internationally accepted and widely used is HENSSGE's nomogram method, while many domestic scholars also deduced their own regression equations through a large number of case data. Estimation of postmortem interval based on rectal temperature still needs further study. The nomogram method needs to be optimized and extended, and quantification of its influencing factors needs to be dealt with more scientifically. There is still a lack of consensus on the probability and duration of the temperature plateau. There is no clear understanding of the probability and extent of the change in initial temperature caused by various causes. New methods and ideas enrich methodological research, but it still lacks systemicity and practicality. This article reviews the researches on estimation of postmortem interval based on rectal temperature in order to summarize the current situation of previous researches and seek new breakthrough points. Because the decline of body temperature can be easily influenced by many factors in vitro and vivo, and the influencing factors in different regions vary greatly, regionalization research and application may be a practical exploration to improve the accuracy of postmortem interval determination.

[Analysis of intratesticular condition in micro-dissection testicular sperm extraction era]

OBJECTIVE

To summarizes the intratesticular condition of azoospermia patients, to understand azoospermia more intuitively, and improve the ability of clinical doctors to predict the success rate of microsperm extraction in azoospermia patients.

METHODS

Azoospermia patients (excluding Klinefelter's syndrome) who underwent a micro-TESE during January 2014 and January 2018 in a single center were enrolled. The types of seminiferous tubules were summarized, and the clinical characteristics of different types of seminiferous tubules compared with the success rates of sperm extraction. In this study, 472 cases of non-obstructive azoospermia (excluding Klinefelter's syndrome) were analyzed by SPSS 21.0 software package. Relevant data were expressed by median(minimum,maximum).t-test was used to compare the difference of success rate of sperm extraction between each group and the group with the lowest rate (a type).

RESULTS

The 472 patients with non-obstructive azoospermia underwent micro-TESE. The mean age of the patients was 31 (23, 46) years, the mean testicular size was 10 (1, 20) mL, the mean FSH was 15.4 (1.21, 68.4) IU/L, the mean T was 8.34 (0.69, 30.2) nmol/L, and totally 202 patients achieved success in micro-TESE (42.7%, 202/472). According to the seminiferous tubules seen during the operation, they were divided into the following six types: Class a, seminiferous tubules developed well and uniformly; Class b, seminiferous tubules developed well, occasionally slightly thick; Class c, seminiferous tubules were generally thin; Class d, seminiferous tubules basically atrophied, occasionally well-developed seminiferous tubules; Class e, all seminiferous tubules atrophied; Class f, seminiferous tubules were infiltrated by yellow substances. The success rate of micro-TESE varied greatly among different types of the patients. A total of 78 patients with type a were 29 (24, 40) years old, FSH 11.1 (1.21, 15.8) IU/L, T 10.2 (3.29, 26.5) nmol/L), and testicular size 12 (12, 20) mL. The successful rate of sperm extraction was 6.41%; 82 patients with type b were 31 (23, 42) years old, FSH 13.8 (3.23, 19.6) IU/L, T 9.44 (3.58, 30.2) nmol/L), and testicular size 12(8,15) mL. The successful rate of sperm extraction was 74.39%; There were 162 patients in group c, aged 31 (25, 40), FSH 19.6 (9.28, 26.6) IU/L, T 8.75 (5.66, 18.6) nmol/L, and testicular size 8 (5, 12) mL. The successful rate of sperm extraction was 45.06%. There were 36 patients in group d, aged 25 (23,38) years and FSH 28.5 (19.3, 45.6) IU/L, T 6.52 (2.12, 9.83) nmol/L, and testicular size 5 (3, 8) mL, and the success rate of sperm extraction was 94.44%. 26 patients with type e were 28(23, 46) years old, FSH 31.3 (18.5, 68.4) IU/L, T 6.72 (0.69, 18.2) nmol/L, and testicular size 5 (1, 8) mL. The success rate of sperm extraction was 45.38%. 88 patients with type f were 29 (24, 38) years old, FSH 18.5 (5.23, 31.6) IU / L, T 8.32 (3.58, 16.5) nmol/L, and testicular size 12 (6, 20) mL. The success rate of sperm extraction was 28.41%.

CONCLUSION

The success rate of micro-TESE in different types of seminiferous tubules in testis can be helpful to the judgement of the surgeon during the operation.

[Analysis of cataract surgery cases from 2013 to 2015 in Shanghai]

Objective: To analyze the changes of cataract surgery volume and related influencing factors in Shanghai during 2013 and 2015. Methods: The information of Cataract patients during the period of 2013 and 2015 was collected from Shanghai Cataract Operations Database. The cataract surgery volume and CSR of Shanghai residents and non-registered ones were compared. The cataract surgery volume and CSR of registered Shanghai residents in urban, suburban and exurban areas were calculated, respectively. In addition, the sources of surgery cost, hospitals where surgeries were performed were analyzed. Results: In Shanghai, the cataract surgery volume grew from 63 915 to 114 688 and the total CSR grow from 2 686 to 4 729 during the years between 2013 and 2015. In this period, the cataract surgery volume of registered Shanghai residents in urban, suburban and exurban areas increased from 27 203, 21 921, 8 847 to 46 415, 40 463, 18 171, respectively. The CSR1 (CSR of registered Shanghai residents) grew rapidly from 4 081 to 7 363, while the CSR2 (CSR of non-registered Shanghai residents) grew slowly from 619 to 949. According to statistics, 93.08% of the registered Shanghai residents paid the medical expenses with their medical insurance, while more than 80% non-registered Shanghai residents afforded it at their own expenses. The number of total CSR in urban, suburban and exurban areas increased from 5 085, 3 600, 3 205 to 3 600, 6 588, 6 513 respectively. In 2015, the number of cataract surgery cases in non-public hospitals exceeded that in public hospital, accounting for 54.71% of the total cataract surgeries. In the same year, 55.44% of the total cases come from suburban and exurban residents. Conclusions: From 2013 to 2015, there had been a dramatic increase in cataract surgery volume in nonpublic hospitals and exurban area in Shanghai, which effectively solved the problem of low CSR in suburban and exurban area, however the 1ow level of CSR of non-registered Shanghai residents was the key factor that significantly reduced the total CSR in Shanghai. (Chin J Ophthalmol, 2018, 54:580-585).

Disconnect Between Genes Associated With Ischemic Heart Disease and Targets of Ischemic Heart Disease Treatments

Background

Development of pharmacological treatments to mitigate ischemic heart disease (IHD) has encompassed disappointing results and expensive failures, which has discouraged investment in new approaches to prevention and control. New treatments are most likely to be successful if they act on genetically validated targets. We assessed whether existing pharmacological treatments for IHD reduction are acting on genetically validated targets and whether all such targets for IHD are currently being exploited.

Methods

Genes associated with IHD were obtained from the loci of single nucleotide polymorphisms reported in either of two recent genome wide association studies supplemented by a gene-based analysis (accounting for linkage disequilibrium) of CARDIoGRAMplusC4D 1000 Genomes, a large IHD case (n = 60,801)-control (n = 123,504) study. Treatments targeting the products of these IHD genes and genes with products targeted by current IHD treatments were obtained from Kyoto Encyclopedia of Genes and Genomes and Drugbank. Cohen's kappa was used to assess agreement.

Results

We identified 173 autosomal genes associated with IHD and 236 autosomal genes with products targeted by current IHD treatments, only 8 genes (PCSK9, EDNRA, PLG, LPL, CXCL12, LRP1, CETP and ADORA2A) overlapped, i.e. were both associated with IHD and had products targeted by current IHD treatments. The Cohen's kappa was 0.03. Interventions related to another 29 IHD genes exist, including dietary factors, environmental exposures and existing treatments for other indications.

Conclusions

Closer alignment of IHD treatments with genetically validated physiological targets may represent a major opportunity for combating a leading cause of global morbidity and mortality through repurposing existing interventions.

•

Pharmacological treatments for ischemic heart disease (IHD) target < 5% (8/173) of genes strongly predicting IHD.

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Treatments or nutraceuticals targeting products of another 17% (29/173) of genes strongly predicting IHD exist.

•

Repurposing represents a major opportunity to prevent and treat a leading cause of global morbidity and mortality.

Development of drugs to mitigate ischemic heart disease, a leading cause of global morbidity and mortality, has stalled. We examined the relation between the physiological targets of current drugs for ischemic heart disease and the genetic predictors of ischemic heart disease. We found little correspondence between the genes with products targeted by current ischemic heart disease drugs and the genes associated with ischemic heart disease, but found several drugs for other purposes relevant to ischemic heart disease genes. Refocusing ischemic heart disease drug development on genetically valid targets and repurposing existing drugs represents a major opportunity to improve population health.

A Case of Neurologically Intact Survival after Compression-Only Cardiopulmonary Resuscitation by Two Bystanders

Conventional cardiopulmonary resuscitation (CPR) requires chest compression and mouth-to-mouth breathing. We report a 55-year-old man in cardiac arrest who received immediate chest compression but without assisted ventilation by two bystanders for 28 minutes until the arrival of the emergency medical team. His consciousness recovered completely on the third hospital day. According to the literature review, “28 minutes” may possibly be the longest period of time of compression-only CPR in out-of-hospital cardiac arrest patients with neurologically intact survival. Thus, this case supports the present CPR guideline that recommends effective chest compression without assisted ventilation by laypersons for patients in cardiac arrest.

A Randomized, Double-Blind, Placebo-Controlled Phase 2 Study of Brodalumab in Patients With Moderate-to-Severe Crohn's Disease

OBJECTIVES

To assess the safety and efficacy of brodalumab, a human anti-interleukin-17 receptor monoclonal antibody, in patients with moderate-to-severe Crohn's disease (CD).

METHODS

Phase 2, randomized, double-blind, placebo-controlled, dose-ranging study in patients with moderate-to-severe CD and evidence of active inflammation. Patients were randomized 1:1:1:1 to receive brodalumab (210, 350, or 700 mg at baseline and week 4) or placebo. The primary end point was proportion of patients achieving Crohn's disease activity index (CDAI) remission (≤150) at week 6. Secondary end points included proportion of patients with CDAI response (reduction from baseline of ≥100) at week 6 and change from baseline in CDAI at week 6.

RESULTS

The study was terminated early based on an imbalance in worsening CD in active treatment groups. At the time of termination, 130 patients had been randomized. At week 6, remission rates were 3% (210 mg), 15% (350 mg), 9% (700 mg), and 3% (placebo) and CDAI response occurred in 16% (210 mg), 27% (350 mg), 15% (700 mg), and 13% (placebo) of patients. Mean change in CDAI at week 6 was -8.7 (95.3) (210 mg), -35.4 (105.6) (350 mg), -0.6 (105.9) (700 mg), and -28.2 (86.0) (placebo). Besides worsening of CD, overall incidences of adverse events were similar across treatment groups.

CONCLUSIONS

Treatment with brodalumab resulted in a disproportionate number of cases of worsening CD in patients with active CD and no evidence of meaningful efficacy. These analyses did not suggest additional safety risks of brodalumab beyond worsening of CD symptoms in patients with active CD.

The effect of hematocrit and hemoglobin on the risk of ischemic heart disease: A Mendelian randomization study

Hematocrit and hemoglobin affect viscosity, and have been considered as risk factors for ischemic heart disease (IHD), although observations are inconsistent; randomized controlled trials targeting hematocrit or hemoglobin have not been definitive. To clarify their role, the risk of IHD was assessed according to genetically determined hematocrit and hemoglobin. We applied single nucleotide polymorphisms (SNPs) strongly determining hematocrit and hemoglobin, from a genome wide association study, to a large case (64,746) control (130,681) study of coronary artery disease, CARDIoGRAMplusC4D, to obtain unconfounded estimates using instrumental variable analysis by combining the Wald estimators for each SNP taking into account any correlation between SNPs using weighted generalized linear regression. Hematocrit was positively associated with IHD, odds ratio (OR) 1.07 per %, 95% confidence interval (CI) 1.03 to 1.11, before and after excluding SNPs from gene regions directly functionally relevant to IHD. However, hematocrit was not associated with IHD (OR 0.99, 0.94 to 1.04) after also excluding SNPs associated with lipids at genome wide significance. Hemoglobin was not associated with IHD (OR 1.06 per g/dL, 0.97 to 1.15) which was similar (OR 1.02, 0.94 to 1.11) after excluding SNPs from gene regions directly functionally relevant to IHD. Hemoglobin was negatively associated with IHD after also excluding SNPs associated with lipids at genome wide significance (OR 0.86, 0.78 to 0.94). In conclusion, hematocrit shares genetic determinants with IHD, but whether the genes contribute to IHD via hematocrit or other mechanisms is not entirely clear. Higher Hemoglobin is unlikely to cause IHD.

A Study to Evaluate the Safety, Tolerability, and Efficacy of Brodalumab in Subjects with Rheumatoid Arthritis and an Inadequate Response to Methotrexate

Objective.

To evaluate the efficacy and safety of brodalumab, a human monoclonal antibody inhibitor of the interleukin 17 receptor, in subjects with rheumatoid arthritis (RA).

Methods.

Patients (n = 252) with inadequate response to methotrexate (MTX) were randomized to receive subcutaneous injections of brodalumab (70 mg, 140 mg, or 210 mg) or placebo. The primary endpoint was the American College of Rheumatology 50% response (ACR50) at Week 12.

Results.

Demographics and baseline characteristics were generally balanced among treatment groups. At Week 12, ACR50 occurred in 16% (70 mg), 16% (140 mg), 10% (210 mg), and 13% (placebo; all nonsignificant vs placebo) of subjects. No significant treatment effects were observed for the secondary endpoints, including ACR20, ACR70, and Disease Activity Score in 28 joints. Incidences of all adverse events (AE), including serious AE (SAE), were similar across treatment groups. A total of 7 subjects reported SAE during the study (2 in the placebo group and 5 in the brodalumab groups), none of which was treatment related. There was 1 death (cardiopulmonary failure) ∼1 week after the last dose in the 140 mg group.

Conclusion.

Our study failed to find evidence of meaningful clinical efficacy with brodalumab treatment in subjects with RA who had an inadequate response to MTX. These preliminary results do not support further evaluation of brodalumab as a treatment for RA. Clinicaltrials.gov number: NCT00950989.

Design of a phase 2 clinical trial of an ASK1 inhibitor, GS-4997, in patients with diabetic kidney disease

BACKGROUND

Most patients with diabetic kidney disease (DKD) experience disease progression despite receiving standard care therapy. Oxidative stress is associated with DKD severity and risk of progression, but currently approved therapies do not directly attenuate the pathologic consequences of oxidative stress. GS-4997 is a once daily, oral molecule that inhibits Apoptosis Signal-regulating Kinase 1 (ASK1), which is a key mediator of the deleterious effects of oxidative stress.

METHODS

We describe the rationale and design of a Phase 2 placebo-controlled clinical trial investigating the effects of GS-4997 in patients with T2DM and stage 3/4 DKD receiving standard of care therapy. Approximately, 300 subjects will be randomized in a stratified manner, based on the estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio, to one of four arms in this dose-ranging study. The primary endpoint is change in eGFR at 48 weeks, and the key secondary endpoint is change in albuminuria.

CONCLUSION

Guided by the biology of oxidative stress signaling through ASK1, the biology of DKD pathogenesis, and solid statistical methods, the decisions made for this Phase 2 study regarding delineating study population, efficacy outcomes, treatment period and statistical methods represent innovative attempts to resolve challenges specific to DKD study design.

Oral GS-5806 activity in a respiratory syncytial virus challenge study

BACKGROUND

Respiratory syncytial virus (RSV) is a common cause of infant hospitalizations and is increasingly recognized as a cause of considerable morbidity and mortality. No accepted antiviral treatment exists.

METHODS

We conducted a double-blind, placebo-controlled study of GS-5806, an oral RSV-entry inhibitor, in healthy adults who received a clinical challenge strain of RSV intranasally. Participants were monitored for 12 days. At the time of a positive test for RSV infection or 5 days after inoculation, whichever occurred first, participants were randomly assigned to receive GS-5806 or placebo in one of seven sequential cohorts. Cohorts 1 to 4 received a first dose of 50 mg of GS-5806 and then 25 mg daily for the next 4 days, cohort 5 received a first dose of 50 mg and then 25 mg daily for the next 2 days, cohort 6 received one 100-mg dose, and cohort 7 received a first dose of 10 mg and then 5 mg daily for the next 4 days. Dose selection for cohorts 5, 6, and 7 occurred after an interim analysis of data for cohorts 1 to 4. The primary end point was the area under the curve (AUC) for the viral load, which was assessed after administration of the first dose through the 12th day after inoculation. Secondary end points were mucus weight and symptom scores.

RESULTS

Among the 54 participants in cohorts 1 to 4 who were infected with RSV, active treatment was associated with a lower viral load (adjusted mean, 250.7 vs. 757.7 log10 plaque-forming-unit equivalents [PFUe] × hours per milliliter; P<0.001), lower total mucus weight (mean, 6.9 g vs. 15.1 g; P=0.03), and a lower AUC for the change from baseline in symptom scores (adjusted mean, -20.2 vs. 204.9 × hours; P=0.005). The results were similar in cohorts 5, 6, and 7. Adverse events, including low neutrophil counts and increased levels of alanine aminotransferase, were more common among participants receiving GS-5806.

CONCLUSIONS

Treatment with GS-5806 reduced the viral load and the severity of clinical disease in a challenge study of healthy adults. (Funded by Gilead Sciences; ClinicalTrials.gov number, NCT01756482.).

Effects of dietary selenium deficiency on mRNA levels of twenty-one selenoprotein genes in the liver of layer chicken

Selenium (Se) is an essential trace element in many life forms due to its occurrence as selenocysteine (Sec) residue in selenoproteins. However, little is known about the expression pattern of selenoproteins in the liver of layer chicken. To investigate the effects of Se deficiency on the mRNA expressions of selenoproteins in the liver tissue of layer chickens, 1-day-old layer chickens were randomly allocated into two groups (n=120/group). The Se-deficient group (-Se) was fed a Se-deficient corn-soy basal diet; the Se-adequate group as control (+Se) was fed the same basal diet supplemented with Se at 0.15 mg/kg (sodium selenite). The liver tissue was collected and examined for mRNA levels of 21 selenoprotein genes at 15, 25, 35, 45, 55, and 65 days old. The data indicated that the mRNA expressions of Gpx1, Gpx2, Gpx3, Gpx4, Sepn1, Sepp1, Selo, Sepx1, Selu, Txnrd1, Txnrd2, Txnrd3, Dio1, Dio2, SPS2, Selm, SelPb, Sep15, and Sels were decreased (p<0.05), but not the levels of Dio3 and Seli (p>0.05). The results showed that the mRNA levels of 19 selenoprotein (except Seli and Dio3) genes in the layer chicken liver were regulated by diet Se level. The present study provided some compensated data about the roles of Se in the regulation of selenoproteins.

The relationship between asthma, asthma control and economic outcomes in the United States

OBJECTIVE

Asthma, a serious chronic lung disease affecting approximately 26 million Americans, remains clinical and economic burdens on the healthcare system. Although associations between uncontrolled asthma and poor health outcomes is known, the extent of this impact of uncontrolled asthma on economic outcomes in the United States (US) is unknown. We sought to determine the relationship between asthma, asthma control and economic outcomes in the US.

METHODS

The 2008-2010 Medical Expenditure Panel Surveys were used to estimate the impact of uncontrolled asthma (asthma-related emergency department [ED] visit, use of >3 canisters of quick-relief inhaler in past 3 months or asthma attack in past 12 months) on medical expenditures, utilization and productivity. Estimates were generated using multivariate regression controlling for sociodemographics and comorbidity.

RESULTS

Medical expenditures attributable to asthma were up to $4423 greater for those with markers of uncontrolled asthma compared with those who did not have asthma. Frequency of hospital discharges were up to 4.6-fold greater for those with uncontrolled asthma than those without asthma (p < 0.01), while all others with asthma did not have significantly more discharges. ED visits were up to 1.8-fold greater for those with uncontrolled asthma compared with those without asthma (p < 0.01). Productivity was significantly (p < 0.01) decreased (more likely to be unemployed, more days absent from work and more activity limitations) for those with uncontrolled asthma.

CONCLUSIONS

In recent national data, individuals with asthma and markers of uncontrolled asthma had higher medical expenditures, greater utilization and decreased productivity.

Randomized, double-blind, placebo-controlled study of brodalumab, a human anti-IL-17 receptor monoclonal antibody, in moderate to severe asthma

RATIONALE

IL-17 signaling has been implicated in development and persistence of asthma. Cytokine-targeted strategies blocking IL-17 receptor signaling may be beneficial in asthma treatment.

OBJECTIVES

To determine efficacy and safety of brodalumab, a human anti-IL-17 receptor A monoclonal antibody, in subjects with inadequately controlled moderate to severe asthma taking regular inhaled corticosteroids.

METHODS

Three hundred two subjects were randomized to brodalumab (140, 210, or 280 mg) or placebo. Primary endpoint was change in Asthma Control Questionnaire (ACQ) score from baseline to Week 12. Secondary endpoints included FEV1, symptom scores, and symptom-free days. Prespecified subgroup analyses were conducted to identify potential responsive subpopulations. Analyses included randomized subjects receiving one or more doses of investigational product using last-observation-carried-forward imputation.

MEASUREMENTS AND MAIN RESULTS

Demographics and baseline characteristics were generally balanced among groups (n = 302; n = 226 brodalumab). For the overall study population, no treatment differences were observed. Nine prespecified subgroups were examined without corrections for multiple testing. In only the high-reversibility subgroup (post-bronchodilator FEV1 improvement ≥ 20%; n = 112) was an ACQ change with nominal significance noted; ACQ responses were nominally significant in the 210-mg group (estimated treatment difference, 0.53) but not significant in the higher 280-mg group (estimated treatment difference, 0.38). Adverse events, generally balanced among groups, were most commonly asthma, upper respiratory tract infection, and injection site reaction.

CONCLUSIONS

Inhibition of IL-17 receptor A did not produce a treatment effect in subjects with asthma. The results of the high-reversibility subgroup analysis are of uncertain significance, requiring further study of brodalumab in this asthma subpopulation. Clinical trial registered with www.clinicaltrials.gov (NCT01199289).

The prognostic value of P-cadherin in non-muscle-invasive bladder cancer

OBJECTIVES

This research aims to specify the prognostic value of P-cadherin on recurrence and progression in non-muscle-invasive bladder cancers (NMIBC).

METHODS

A total of 110 NMIBC cases were collected and P-cadherin protein was assessed by immunohistochemical test in these samples. Correlations between P-cadherin expression and clinicopathologic features were analyzed. For recurrence-free and progression-free survival, Kaplan-Meier log-rank test was used. Then Cox univariate and multivariate analyses were further performed.

RESULTS

P-cadherin high expression correlated with tumor progression (P = 0.031). Kaplan-Meier results showed that patients with high P-cadherin expression had worse progression-free survival (P = 0.034) but not recurrence-free survival (P = 0.133) than low-expression patients. Cox regression results showed P-cadherin expression was an independent predictor for progression (P = 0.042) but not recurrence (P = 0.139) in NMIBC.

CONCLUSIONS

Our results demonstrated that P-cadherin expression correlated with tumor progression and could be taken as an independent predictor for progression in NMIBC.

Asthma control in the United States, 2008-2010: indicators of poor asthma control

BACKGROUND

An estimated 23 million Americans have asthma, of whom at least 12 million experience an asthma exacerbation every year. Clinical practice guidelines focus on asthma control, with an emphasis on reducing both impairment and risk.

OBJECTIVE

We sought to explore broad patterns of asthma prevalence, self-reported medication use, and indicators of control in a nationally representative sample.

METHODS

The 2008, 2009, and 2010 Medical Expenditure Panel Surveys were used to examine the national prevalence of self-reported asthma, trends in medication use, and demographic characteristics of asthmatic patients. History of lifetime asthma and current diagnosis were ascertained based on self-report. Asthma management and control were examined by using patient-reported medication use.

RESULTS

Of the 102,544 subjects asked about an asthma diagnosis, 9,782 reported lifetime asthma, and 8,837 reported current asthma. Five thousand five subjects (4.8% of the population) reported experiencing an asthma exacerbation in the previous year. Four thousand five hundred twenty-one subjects used a quick-relief inhaler for asthma symptoms, and 14.6% used more than 3 canisters of this type of medication in the past 3 months. Of this group, 60% were using daily long-term control medication but still required significant use of quick-relief inhalers, whereas 28% had never used long-term control medication. Of those who had a recent exacerbation, 29% were using daily preventive medication, whereas 54% had never used long-term control medication.

CONCLUSIONS

Improvement of asthma control continues to be a US public health concern. Results suggest suboptimal asthma control with underuse of long-term control medications, overuse of quick-relief inhalers, and a significant number of self-reported asthma exacerbations.

Asthma in USA: its impact on health-related quality of life

OBJECTIVES

Given the growing prevalence of asthma in USA, it is important to understand its national burden from the patient's perspective. The objective of this research is to examine the national burden of asthma and poor asthma control on health function, health perception and preference-based health-related quality of life (HRQL).

METHODS

The Medical Expenditure Panel Survey (MEPS), a nationally representative survey, was used to estimate the impact of asthma and indicators of poor asthma control on health function, self-rated health perception and preference-based HRQL using multivariate regression methods controlling for socioeconomic, clinical and demographic characteristics. Two HRQL instruments were used: SF-12v2 Physical Component Scale (PCS-12) and Mental Component Scale (MCS-12); EQ-5D-3L index and visual analogue scale (VAS). Two multivariate regression methods were used, Censored Least Absolute Deviation [EQ-5D-3L and VAS (due to censoring)] and Ordinary Least Squares (OLS) (PCS-12 and MCS-12).

RESULTS

After controlling for covariates, asthma resulted in a statistically significant reduction in preference-based HRQL, health perception and physical and mental function (EQ-5D -0.023; VAS -2.21; PCS-12 -2.36; MCS-12 -0.96). Likewise, experiencing an exacerbation in the previous year and using more than three canisters of quick-relief medication in the previous 3 months were both associated with a statistically significant and clinically meaningful reduction in all four measures.

CONCLUSIONS

Asthma itself and especially indicators of poor asthma control were associated with a deleterious effect on health function, preference-based HRQL and self-perceived health status. Given the prevalence of asthma, poorly controlled asthma constitutes a significant national burden in USA.

Time trends in 30 day case-fatality following hospitalisation for asthma in adults in Scotland: a retrospective cohort study from 1981 to 2009

BACKGROUND

The risk of case-fatality following hospitalisation for asthma has not been well characterised. We describe trends in 30 day case-fatality following hospitalisation for asthma in adults in Scotland from 1981 to 2009.

METHODS

Using the Scottish Morbidity Record Scheme (SMR01) with all asthma hospitalisations for adults (≥18 years) with ICD9 493 and ICD10 J45-J46 in the principal diagnostic position at discharge (1981-2009). These data were linked to mortality data from the General Register Office for Scotland (GROS), with asthma case-fatality defined as death within 30 days of asthma admission (in or out of hospital). Logistic regression was used to explore the impact of age, sex, previous asthma admission (in the 12 months prior to hospitalisation), socioeconomic deprivation, year of admission and co-morbidity on 30-day case-fatality.

RESULTS

There were a total of 116,457 asthma hospitalisations; a total of 1000 (0.9%) hospitalisations resulted in a post-admission death (within 30 days of admission). Odds ratios for unadjusted and adjusted case-fatality showed a decreased risk of case-fatality from the mid-1990s onwards when compared to case-fatality in 1981. Advancing age and co-morbid diagnoses of respiratory failure, cancer, renal failure, cor pulmonale, coronary heart disease and respiratory infection were associated with increased likelihood of death.

CONCLUSIONS

30 day case-fatality has declined over the last three decades, comparable to case-fatality reported in other parts of the U.K. This decline may be in part due to improved guidelines, protocols and disease management for asthma over the last 30 years. The likelihood of death 30 days following an asthma admission increased with age group and was associated with respiratory failure, renal failure and cancer.

Lack of association between Human Oxoguanine Glycosylase 1 (hOGG1) S326C polymorphism and the risk of gastric cancer: a meta-analysis

Results from published studies on the association of Human Oxoguanine Glycosylase 1 (hOGG1) S326C genetic polymorphism with the risk of gastric cancer are inconsistent. We performed a meta-analysis to summarize the possible association. Eleven case-control studies including 2168 cases and 4058 controls were identified from electronic databases (Pubmed, Elsevier Science Direct, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), and the Chinese database, Wanfang). No significant association between hOGG1 S326C genetic polymorphism and risk of gastric cancer was observed in the overall analysis. In the stratified analysis based on ethnicity, still no significant association was observed in Europeans, Asians, or Brazilians. This meta-analysis provided evidence that hOGG1 S326C genetic polymorphism was not associated with increased risk of gastric cancer. However, additional studies with large sample size and better study designs are warranted to verify our finding.

Experiment and simulation of resistance of nanoporous dentin biomaterial to CO₂ laser irradiation

The resistance of nanoporous dentin biomaterial to CO₂ laser irradiation was investigated by experiment and simulation for potential tooth hypersensitivity treatment. The controlled parameters including laser power of 0.03-0.150 W, scanning speeds of 11.4-34.2 mm/s and focus/defocus modes were used for studying interaction between laser energy and dentin of human tooth. Most of the dentin specimens were etched after CO₂ laser irradiation with the power larger than 0.12 W at a scanning speed of 11.4 mm/s. Compared with the simulation results of temperature distribution, the maximum temperature at laser powers from 0.12 to 0.15 W is increased from 1961 to 2245°C, which exceeded the melting point (1570°C) of dentin's main content hydroxyapatite (HA). Increasing scanning speed can reduce the linear density of laser output energy for just locally melting porous microstructure of dentin surface without etching. Varying focus mode can also improve the damage of nanoporous dentin microstructure. At parameters of 0.150 W power and 34.2 mm/s scanning speed under defocus operation, laser treatment was successfully performed on the nano-HA coated dentin with well-molten sealing on tubules of porous microstructure at a simulate surface temperature of about 574°C, which was the potential for dentin hypersensitivity cure application.

Quantitative model of the relationship between dipeptidyl peptidase-4 (DPP-4) inhibition and response: meta-analysis of alogliptin, saxagliptin, sitagliptin, and vildagliptin efficacy results

Dipeptidyl peptidase-4 (DPP-4) inhibition is a well- characterized treatment for type 2 diabetes mellitus (T2DM). The objective of this model-based meta-analysis was to describe the time course of HbA1c response after dosing with alogliptin (ALOG), saxagliptin (SAXA), sitagliptin (SITA), or vildagliptin (VILD). Publicly available data involving late-stage or marketed DPP-4 inhibitors were leveraged for the analysis. Nonlinear mixed-effects modeling was performed to describe the relationship between DPP-4 inhibition and mean response over time. Plots of the relationship between metrics of DPP-4 inhibition (ie, weighted average inhibition [WAI], time above 80% inhibition, and trough inhibition) and response after 12 weeks of daily dosing were evaluated. The WAI was most closely related to outcome, although other metrics performed well. A model was constructed that included fixed effects for placebo and drug and random effects for intertrial variability and residual error. The relationship between WAI and outcome was nonlinear, with an increasing response up to 98% WAI. Response to DPP-4 inhibitors could be described with a single drug effect. The WAI appears to be a useful index of DPP-4 inhibition related to HbA1c. Biomarker to response relationships informed by model-based meta-analysis can be leveraged to support study designs including optimization of dose, duration of therapy, and patient population.

Filaggrin polymorphism P478S, IgE level, and atopic phenotypes

BACKGROUND

Whether environmental exposures may modulate the effect of the skin barrier gene on atopic dermatitis (AD) remains to be elucidated.

OBJECTIVES

To determine whether filaggrin (FLG) variants can serve as a predictor for atopic disorders in Chinese individuals and if allergen exposures may modify the effect of FLG variants on AD by total IgE levels.

METHODS

In total, 116 children aged 2-5years with AD and 212 control subjects were analysed for the FLG variants using DNA sequencing. Multiple logistic regression models were performed to estimate the association among FLG polymorphisms and atopic phenotypes. Serum total IgE level, standing for the degree of allergen exposures, was later stratified to determine the effects of FLG polymorphisms on AD.

RESULTS

A significant difference in genotype frequency was found among AD cases and controls in FLG P478S polymorphism. FLG P478S GG genotype significantly increased the risk of AD [odds ratio (OR) 4·60, 95% confidence interval (CI) 1·88-11·24]. In addition, among subjects with AD, GG genotypes also significantly increased the risk of developing asthma (OR 4·68, 95% CI 1·37-16·03). Further, a similar result was obtained for allergic rhinitis (OR 3·23, 95% CI 1·01-10·30). Interestingly, the P478S GG genotype was significantly related to AD (OR 5·67, 95% CI 1·93-16·60) in children with IgE level ≥100 kU L(-1) . However, the association was not evident when IgE level was < 100 kU L(-1) .

CONCLUSIONS

Our results suggest that the FLG P478S polymorphism may confer susceptibility to the development of AD among Chinese individuals and may be modified by IgE levels.

Population PK and IgE pharmacodynamic analysis of a fully human monoclonal antibody against IL4 receptor

PURPOSE

For AMG 317, a fully human monoclonal antibody to interleukin receptor IL-4Rα, we developed a population pharmacokinetic (PK) model by fitting data from four early phase clinical trials of intravenous and subcutaneous (SC) routes simultaneously, investigated important PK covariates, and explored the relationship between exposure and IgE response.

METHODS

Data for 294 subjects and 2183 AMG 317 plasma concentrations from three Phase 1 and 1 Phase 2 studies were analyzed by nonlinear mixed effects modeling using first-order conditional estimation with interaction. The relationship of IgE response with post hoc estimates of exposure generated from the final PK model was explored based on data from asthmatic patients.

RESULTS

The best structural model was a two-compartment quasi-steady-state target-mediated drug disposition model with linear and non-linear clearances. For a typical 80-kg, 40-year subject, linear clearance was 35.0 mL/hr, central and peripheral volumes of distribution were 1.78 and 5.03 L, respectively, and SC bioavailability was 24.3%. Body weight was an important covariate on linear clearance and central volume; age influenced absorption rate. A significant treatment effect was observable between the cumulative AUC and IgE response measured.

CONCLUSION

The population PK model adequately described AMG 317 PK from IV and SC routes over a 60-fold range of doses with two dosing strengths across multiple studies covering healthy volunteers and patients with mild to severe asthma. IgE response across a range of doses and over the sampling time points was found to be related to cumulative AMG 317 exposure.

The burden of adult asthma in the United States: evidence from the Medical Expenditure Panel Survey

BACKGROUND

It is important to have an accurate picture of the sources and extent of medical expenditures and productivity loss to understand the nature and scope of the burden of asthma in the United States (US).

OBJECTIVE

The current study aims to provide recent nationally representative estimates of direct and productivity-related costs attributable to asthma in adults in the US.

METHODS

The 2003 and 2005 Medical Expenditure Panel Surveys were used to estimate the effect of asthma on medical expenditures, use, productivity, and chronic comorbidity among adults (≥ 18 years). Productivity-related outcome variables included employment, annual wages, missed work days, days spent sick in bed, and activity limitations. Multivariate regression was conducted, controlling for sociodemographics and comorbidity.

RESULTS

Of 44,795 adults, 1,935 reported an encounter for asthma [corrected]. Compared with those without, subjects with asthma were significantly less likely to be employed (odds ratio, 0.78), spent 1.4 more days sick in bed annually, and were significantly more likely to have activity limitations or to be unable to work. Adults with asthma incurred an additional $1,907 (2008 US dollars) annually and experienced higher health care use and comorbidity. The total national medical expenditure attributable to adult asthma was $18 billion. Adults with asthma were more likely to be covered by Medicaid (30%) than the general adult population (10%). The largest contributors to medical expenditures for adults with asthma were prescription drugs, followed by inpatient hospitalizations and home health care.

CONCLUSIONS

In recent national data adult asthma is associated with a significant deleterious effect on direct and indirect costs in the US.

Clinical trial safety and mortality analyses in patients receiving etanercept across approved indications

OBJECTIVES

Assessment of associations between etanercept treatment and rare adverse events has been limited by the size of clinical trial populations. The authors examined the collective safety of etanercept in clinical trials across approved indications.

PATIENTS AND METHODS

Forty-nine U.S. and non-U.S. trials of etanercept, involving up to 13,977 patients for approved indications, with final trial reports as of May 2006, were selected from the Amgen Inc. clinical trials database. Exposure-adjusted rates of serious infections, opportunistic infections, malignancies, and deaths were reported by trial, indication, and dosage.

RESULTS

Rates of serious infections were generally similar between etanercept and controls. Overall rates of opportunistic infections and tuberculosis were low. The standardized incidence ratio (SIR) (95% CI) for malignancy was 1.00 (0.83-1.19) for all etanercept patients across all indications. The SIR for lymphoma for patients with rheumatoid arthritis was 3.45 (1.83-5.89); all other indications reported SIRs similar to those observed in the general population. The SIRs for cutaneous squamous cell carcinoma in patients with psoriasis relative to the general population with high or low sun exposure were 2.09 (1.27-3.22) and 4.96 (3.03-7.66), respectively. SIRs were less than 1.0 for all other indications regardless of sun exposure. Rates of melanoma and basal cell carcinoma were not significantly different from those in the general population. There was no increase in mortality associated with etanercept use relative to control populations.

CONCLUSION

These data support the overall tolerability of etanercept across approved indications.

Patient-derived joint counts are a potential alternative for determining Disease Activity Score

OBJECTIVE

To investigate the correlation between the Disease Activity Score using a 28-joint count (DAS28) based on physician-derived joint counts and the DAS28 based on patient-derived joint counts (Pt-DAS28) in rheumatoid arthritis (RA).

METHODS

Data from a multicenter, open-label study investigating the immunogenicity of etanercept (ETN) were analyzed. ETN-naive patients with active RA received ETN 50 mg once weekly alone or with methotrexate (MTX). Joint counts were performed at baseline, Week 12, and Week 24 by the physician and patient independently. Patients received instruction in performing joint assessments.

RESULTS

Of 447 patients enrolled (ETN, n = 218; ETN + MTX, n = 229), most were women (79%) and the mean age was 54.5 years. Correlation coefficients between DAS28 and Pt-DAS28 were > or = 0.57 at baseline, Week 12, and Week 24. At Week 24, 48%, 39%, and 12% of patients could be classified as having low, moderate, or high disease activity, respectively, using DAS28. Using Pt-DAS28, 43%, 39%, and 18% were similarly classified. Agreement in the category of disease activity classification occurred in 72% of patients (kappa = 0.55). At Week 24, 78% of patients using DAS28 and 72% of patients using Pt-DAS28 were classified as moderate or good European League Against Rheumatism responders.

CONCLUSION

These results support the possible use of patient-derived tender and swollen joint counts to aid in the assessment of disease activity and clinical response in patients with RA.

A randomized, controlled, phase 2 study of AMG 317, an IL-4Ralpha antagonist, in patients with asthma

RATIONALE

IL-4 and IL-13 share many biological functions important in the development of allergic airway inflammation and are implicated in the pathogenesis of asthma. AMG 317 is a fully human monoclonal antibody to IL-4Ralpha that blocks both IL-4 and IL-13 pathways.

OBJECTIVES

To evaluate efficacy and safety of AMG 317 in patients with moderate to severe asthma.

METHODS

In this phase 2, randomized, double-blind, placebo-controlled study, patients received weekly subcutaneous injections of placebo or AMG 317 (75-300 mg) for 12 weeks, followed by a 4-week follow-up period. The primary endpoint was change from baseline at Week 12 in Asthma Control Questionnaire (ACQ) symptom score.

MEASUREMENTS AND MAIN RESULTS

Mean ACQ change (SE) was -0.49 (0.09) in placebo (n = 74), and -0.43 (0.11), -0.58 (0.12), and -0.70 (0.09) in the AMG 317 75 mg (n = 73), 150 mg (n = 73), and 300 mg (n = 74) groups, respectively (treatment effect P = 0.25). No statistically significant differences were observed in the secondary endpoints. Numerical decreases in number of and time to exacerbations were noted in patients receiving AMG 317 150 mg and 300 mg. Preplanned analyses by tertile of baseline ACQ revealed that patients with higher baseline ACQ scores (>or=2.86) were more likely to respond to AMG 317. Serious adverse events were reported in three patients, each noted as not related to study drug.

CONCLUSIONS

AMG 317 did not demonstrate clinical efficacy across the overall group of patients. Clinically significant improvements were observed in several outcome measures in patients with higher baseline ACQ scores. AMG 317 was safe and well tolerated in this study population. Clinical trial registered with www.clinicaltrials.gov (NCT 00436670).

Water-assisted CO(2) laser ablated glass and modified thermal bonding for capillary-driven bio-fluidic application

The glass-based microfluidic chip has widely been applied to the lab-on-a-chip for clotting tests. Here, we have demonstrated a capillary driven flow chip using the water-assisted CO(2) laser ablation for crackless fluidic channels and holes as well as the modified low-temperature glass bonding with assistance of adhesive polymer film at 300 degrees Celsius. Effect of water depth on the laser ablation of glass quality was investigated. The surface hydrophilic property of glass and polymer film was measured by static contact angle method for hydrophilicity examination in comparison with the conventional polydimethylsiloxane (PDMS) material. Both low-viscosity deionized water and high-viscosity whole blood were used for testing the capillary-driving flow behavior. The preliminary coagulation testing in the Y-channel chip was also performed using whole blood and CaCl(2) solution. The water-assisted CO(2) laser processing can cool down glass during ablation for less temperature gradient to eliminate the crack. The modified glass bonding can simplify the conventional complex fabrication procedure of glass chips, such as high-temperature bonding, long consuming time and high cost. Moreover, the developed fluidic glass chip has the merit of hydrophilic behavior conquering the problem of traditional hydrophobic recovery of polymer fluidic chips and shows the ability to drive high-viscosity bio-fluids.

Measuring asthma control is the first step to patient management: a literature review

Asthma control is recognized as a critical aspect of the evaluation and management of the disease. Here we evaluate and compare existing instruments for measuring asthma control in an attempt to evaluate their clinical utility. Based on a literature review, we identified validated instruments used to assess asthma control in adults. We examined the specific measurement properties and the strengths and weaknesses of each instrument, and evaluated a single instrument, the Asthma Control Questionnaire (ACQ), more closely as an example, evaluating its applicability in the clinical setting. Our review identified five validated instruments designed to measure asthma control: the Asthma Control Questionnaire (ACQ), Asthma Control Scoring System (ACSS), Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), and the Lara Asthma Symptom Scale (LASS). None of the instruments covered all relevant control characteristics, but most were aligned with guideline definitions of control. All instruments demonstrated validity and responsiveness, with some measure of reliability. All instruments were short and easily administered, easy to interpret, and all had evidence to support their use in clinical decision making.

Alefacept (anti-CD2) causes a selective reduction in circulating effector memory T cells (Tem) and relative preservation of central memory T cells (Tcm) in psoriasis

BACKGROUND

Alefacept (anti-CD2) biological therapy selectively targets effector memory T cells (Tem) in psoriasis vulgaris, a model Type 1 autoimmune disease.

METHODS

Circulating leukocytes were phenotyped in patients receiving alefacept for moderate to severe psoriasis.

RESULTS

In all patients, this treatment caused a preferential decrease in effector memory T cells (CCR7- CD45RA-) (mean 63% reduction) for both CD4+ and CD8+ Tem, while central memory T cells (Tcm) (CCR7+CD45RA-) were less affected, and naïve T cells (CCR7+CD45RA+) were relatively spared. Circulating CD8+ effector T cells and Type 1 T cells (IFN-gamma-producing) were also significantly reduced.

CONCLUSION

Alefacept causes a selective reduction in circulating effector memory T cells (Tem) and relative preservation of central memory T cells (Tcm) in psoriasis.

Aggressive management of acute myocardial infarction: successful outcome in an older patient with cardiogenic shock

A 71-year-old man was referred to our emergency department presenting with acute inferior and right ventricular myocardial infarction with cardiogenic shock. He developed ventricular fibrillation 80 minutes after arrival. Immediate defibrillation, mechanical ventilatory support with oxygenation, and inotropic agents were instituted. Despite restoration of sinus rhythm, his hypotension persisted. He promptly received intra-aortic balloon pump (IABP) counterpulsation and cardiac catheterisation. Coronary angiography revealed a subtotal occlusion of the left anterior descending coronary artery and complete occlusion of the right coronary artery. Since the right coronary artery was considered to be the infarct-related coronary artery, percutaneous coronary intervention (PCI) was carried out to the right coronary artery only. The patient was extubated and IABP was removed on the second and third admission day, respectively. He was discharged from the hospital eight days later. A second PCI to the left anterior descending coronary artery was performed successfully three weeks later. This case illustrates that in patients with acute myocardial infarction and cardiogenic shock, prompt application of IABP and PCI of the infarct-related coronary artery may be beneficial in reducing the catastrophic morbidity and mortality, especially in older patients.

Increase in TNF-alpha and inducible nitric oxide synthase-expressing dendritic cells in psoriasis and reduction with efalizumab (anti-CD11a)

We find that CD11c(+) cells with many markers of dendritic cells (DCs) are a major cell type in the skin lesions of psoriasis. These CD11c(+) cells, which are evident in both epidermis and dermis, are the sites for the expression of two mediators of inflammation, inducible nitric oxide synthase (iNOS) and TNF-alpha in diseased skin. These cells express HLA-DR, CD40, and CD86, lack the Langerin and CD14 markers of Langerhans cells and monocytes, respectively, and to a significant extent express the DC maturation markers DC-LAMP and CD83. Treatment of psoriasis with efalizumab (anti-CD11a, Raptiva) strongly reduces infiltration by these DCs in patients responding to this agent. Disease activity after therapy was more related to DC infiltrates and iNOS mRNA levels than T cell infiltrates, and CD11c(+) cells responded more quickly to therapy than epidermal keratinocytes. Our results suggest that a type of DC, which resembles murine "Tip-DCs" that can accumulate during infection, has proinflammatory effects in psoriasis through nitric oxide and TNF-alpha production, and can be an important target for suppressive therapies.

Alefacept reduces infiltrating T cells, activated dendritic cells, and inflammatory genes in psoriasis vulgaris

Psoriasis vulgaris, a skin disease that is considered to be the result of a type 1 autoimmune response, provides an opportunity for studying the changes that occur in a target-diseased tissue during innovative immunotherapies. To gain a more comprehensive picture of the response to an approved biological therapy, we studied alfacept, which is a CD2 binding fusion protein. We examined T cells, dendritic cells (DCs), and expression of a number of inflammatory genes. In 22 patients, 55% demonstrated a clear histological remission of the disease, with a 73% reduction in lesional lymphocytes and a 79% decrease in infiltrating CD8+ cells. Only histological responders showed marked reductions in the tissue expression of inflammatory genes IFN-gamma, signal transducer and activator of transcription 1, monokine induced by IFN-gamma, inducible NO synthase, IL-8, and IL-23 subunits. Parallel decreases in CD83+ and CD11c+ DCs also were measured by immunohistochemistry. Because we observed that alefacept binds primarily to T cells and not DCs, we suggest that T cells are the primary target for therapy, but that DCs and a spectrum of type 1 inflammatory genes are coordinately suppressed.

Development of interesting step-climbing styles

OBJECTIVES

This study was to investigate the influence of stepping styles (forward, side, and cross steppings) and inclinations (25 and 45 degrees) on cardiorespiratory responses (C-R responses).

METHODS

Twenty volunteers were recruited and randomly arranged into two ten-people groups, exercising on step-climbing machines respectively of 25 and 45 degrees of inclination. C-R responses were recorded during each test which lasted for six minutes at 50 steps per minute on a step-climbing machine.

RESULTS

The group on 25-degree inclination had significantly lower C-R responses than the group on 45-degree inclination. Although only small differences, probably statistically insignificant, were found among the three step-climbing styles, these differences showed interesting trends independent of inclination.

CONCLUSIONS

Climbing stairs with the three interesting step-climbing styles in this study could be considered as an exercise of moderate intensity (60-80% HRmax ). Climbing on 25-degree inclination at 50 steps per minute is recommended for less fit individuals because of lower cardiovascular stress as compared with on 45-degree inclination.

The abundant NK cells in human secondary lymphoid tissues require activation to express killer cell Ig-like receptors and become cytolytic

Natural killer cells are important cytolytic cells in innate immunity. We have characterized human NK cells of spleen, lymph nodes, and tonsils. More than 95% of peripheral blood and 85% of spleen NK cells are CD56(dim)CD16(+) and express perforin, the natural cytotoxicity receptors (NCRs) NKp30 and NKp46, as well as in part killer cell Ig-like receptors (KIRs). In contrast, NK cells in lymph nodes have mainly a CD56(bright)CD16(-) phenotype and lack perforin. In addition, they lack KIRs and all NCR expression, except low levels of NKp46. The NK cells of tonsils also lack perforin, KIRs, NKp30, and CD16, but partially express NKp44 and NKp46. Upon IL-2 stimulation, however, lymph node and tonsilar NK cells up-regulate NCRs, express perforin, and acquire cytolytic activity for NK-sensitive target cells. In addition, they express CD16 and KIRs upon IL-2 activation, and therefore display a phenotype similar to peripheral blood NK cells. We hypothesize that IL-2 can mobilize the NK cells of secondary lymphoid tissues to mediate natural killing during immune responses. Because lymph nodes harbor 40% and peripheral blood only 2% of all lymphocytes in humans, this newly characterized perforin(-) NK cell compartment in lymph nodes and related tissues probably outnumbers perforin(+) NK cells. These results also suggest secondary lymphoid organs as a possible site of NK cell differentiation and self-tolerance acquisition.

Neuromuscular hamartoma arising in the brachial plexus

We report a case brachial plexus neuromuscular hamartoma (choristoma) in a 28-year-old man who complained of numbness of the left hand and forearm for several years. MRI revealed a circumscribed, rounded mass in the left brachial plexus. The patient is well 2 years after surgery, with no neurological deficit.