Impact of clinical symptoms and diagnosis: the electronic Person-Specific Outcome Measure (ePSOM) development programme

Introduction

Regulatory bodies recommend that outcome measures used in Alzheimer’s disease (AD) clinical trials capture clinically meaningful changes for the trial participant. However, commonly used outcome measures do not reflect the individual’s views on what matters to them individually. The aim of the electronic Person-Specific Outcome Measure (ePSOM) programme is to better understand what outcomes matter to patients in early Alzheimer’s disease.

Methods

As part of the ePSOM programme, we designed and ran an online study to understand what matters to individuals when developing new treatments for AD. The ePSOM survey ran Aug 2019–Dec 2019 (UK) and collected primarily free text responses which were analysed using Natural Language Processing (NLP) techniques. In this paper, we focus our analyses on individuals who reported having a neurodegenerative disease diagnosis (primarily Mild Cognitive Impairment (MCI) or AD), reporting the most frequent and most important brain health priorities for this group. Due to a small sample size, the Diagnosis group was analysed as a whole. Finally, we compared the Diagnosis group to an age and gender matched control group using chi-squared tests to look for any differences between the Diagnosis and control groups’ priorities.

Results

The survey was completed by 5808 respondents, of whom 167 (2.9%) (women n = 91, men n = 69, other n = 7) had received one of our pre-defined neurodegenerative disease diagnosis: most commonly MCI n = 52, 1.1% (mean age 69.42, SD = 10.8); or Alzheimer’s disease n = 48, 1.0% (mean age 71.24, SD = 9.79). Several thematic clusters were significantly more important for the target diagnostic group, e.g.: Expressing opinions; and less important, e.g., Cognitive Games.

Conclusion

We conclude there are a range of outcomes which individuals consider important and what potential new treatments should help maintain or improve, suggesting that outcomes that matter shift along the preclinical, prodromal and overt dementia continuum. This has important implications for the development of outcome measures in long term prevention studies that last several years where participants may pass through different stages of disease. In the final stage of our project, we will design an electronic outcomes app which will employ the methodology tested in the large-scale survey to capture what matters to individuals about their brain health at an individual level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00433-2.

A UK-Wide Study Employing Natural Language Processing to Determine What Matters to People about Brain Health to Improve Drug Development: The Electronic Person-Specific Outcome Measure (ePSOM) Programme

BACKGROUND

It is important to use outcome measures for novel interventions in Alzheimer's disease (AD) that capture the research participants' views of effectiveness. The electronic Person-Specific Outcome Measure (ePSOM) development programme is underpinned by the need to identify and detect change in early disease manifestations and the possibilities of incorporating artificial intelligence in outcome measures.

OBJECTIVES

The aim of the ePSOM programme is to better understand what outcomes matter to patients in the AD population with a focus on those at the pre-dementia stages of disease. Ultimately, we aim to develop an app with robust psychometric properties to be used as a patient reported outcome measure in AD clinical trials.

DESIGN

We designed and ran a nationwide study (Aug 2019 - Nov 2019, UK), collecting primarily free text responses in five pre-defined domains. We collected self-reported clinical details and sociodemographic data to analyse responses by key variables whilst keeping the survey short (around 15 minutes). We used clustering and Natural Language Processing techniques to identify themes which matter most to individuals when developing new treatments for AD.

RESULTS

The study was completed by 5,808 respondents, yielding over 80,000 free text answers. The analysis resulted in 184 themes of importance. An analysis focusing on key demographics to explore how priorities differed by age, gender and education revealed that there are significant differences in what groups consider important about their brain health.

DISCUSSION

The ePSOM data has generated evidence on what matters to people when developing new treatments for AD that target secondary prevention and therein maintenance of brain health. These results will form the basis for an electronic outcome measure to be used in AD clinical research and clinical practice.

mHealth for Pneumonia Prevention

Introduction

Pneumonia contributes to 14% of under-five mortality in Pakistan. Delayed care seeking is one of the causes of death due to this disease. One of the most impactful strategies can be timely healthcare-seeking through CHW's. We, therefore propose to develop an intervention package for educating caregivers on pneumonia by Lady Health Workers (LHWs).

Methodology

This first phase of the feasibility study comprised of a systematic review (SR) on best mobile health-based approaches for CHWs on the management of childhood illness followed by formative research (FR). In the systematic review, 6 databases were searched, and 22 articles were included. Based on findings of SR and FR along with guidelines of WHO and UNICEF, a mobile application-based intervention package will be developed in the second phase. Recruited LHWs will use the mobile application in their monthly visits for 6 months. Text and voice messages will be sent to each caregiver. Pre and Post-intervention surveys will be conducted with the recruited caregivers to assess the impact of the intervention and FGDs with the recruited LHWs to get feedback on the intervention.

Findings

Findings of the systematic review suggest that the most common approaches of mobile health for community health workers is the use of a customized application for disease management and data collection. Findings of formative research suggest that the majority of the caregivers were not aware of the danger signs of pneumonia. Respondents agreed to the importance of an educational intervention package on pneumonia and its prevention by LHWs through mHealth.

Acknowledgment

This research was commissioned by the National Institute of Health Research using Official Development Assistance (ODA) funding. The views expressed in this publication are those of author(s) and not necessarily those of NHS, the National Institute of Health Research, or the development of Health.

Key messages

mHealth intervention employing community health workers can be a useful mode of improving healthcare services. Use of technology to raise awareness and delivered health-related information at community level can prove tremendously helpful for illness management.

Melioidosis in Singapore: Clinical, Veterinary, and Environmental Perspectives

Melioidosis is a notifiable infectious disease registered with the Ministry of Health (MOH) and Agri-Food & Veterinary Authority (AVA), Singapore. From a clinical perspective, increased awareness of the disease has led to early detection and treatment initiation, thus resulting in decreasing mortality rates in recent years. However, the disease still poses a threat to local pet, zoo and farm animals, where early diagnosis is a challenge. The lack of routine environmental surveillance studies also makes prevention of the disease in animals difficult. To date, there have been no reports that provide a complete picture of how the disease impacts the local human and animal populations in Singapore. Information on the distribution of Burkholderia pseudomallei in the environment is also lacking. The aim of this review is to provide a comprehensive overview of both published and unpublished clinical, veterinary and environmental studies on melioidosis in Singapore to achieve better awareness and management of the disease.

MicroRNAs as biomarkers of resilience or vulnerability to stress

Identifying novel biomarkers of resilience or vulnerability to stress could provide valuable information for the prevention and treatment of stress-related psychiatric disorders. To investigate the utility of blood microRNAs as biomarkers of resilience or vulnerability to stress, microRNAs were assessed before and after 7days of chronic social defeat in rats. Additionally, microRNA profiles of two important stress-regulatory brain regions, the medial prefrontal cortex (mPFC) and basolateral amygdala (BLA), were assessed. Rats that displayed vulnerability to subsequent chronic stress exhibited reductions in circulating miR-24-2-5p, miR-27a-3p, miR-30e-5p, miR-3590-3p, miR-362-3p, and miR-532-5p levels. In contrast, rats that became resilient to stress displayed reduced levels of miR-139-5p, miR-28-3p, miR-326-3p, and miR-99b-5p compared to controls. In the mPFC, miR-126a-3p and miR-708-5p levels were higher in vulnerability compared to resilient rats. In the BLA, 77 microRNAs were significantly altered by stress but none were significantly different between resilient and vulnerable animals. These results provide proof-of-principle that assessment of circulating microRNAs is useful in identifying individuals who are vulnerable to the effects of future stress or individuals who have become resilient to the effects of stress. Furthermore, these data suggest that microRNAs in the mPFC but not in the BLA are regulators of resilience/vulnerability to stress.

Short-term and long-term effects of repeated social defeat during adolescence or adulthood in female rats

Accumulating evidence suggests that adolescence represents a sensitive period during which social stressors influence adult behavior and stress reactivity. However, relatively little is known about the impact of social stress in adolescence on behaviors or stress reactivity in females. In this study, we exposed adolescent or adult female rats to the repeated social stress of defeat for seven consecutive days. Repeated defeat resulted in distinctly different behavioral repertoires during defeat in adolescent compared to adult female rats. Adolescent females exhibited more play and avoidant behaviors and adult females exhibited more active and aggressive behaviors toward the resident female. Examination of the short-term effects of social defeat using the Porsolt forced swim test (FST) indicated that adolescents, regardless of their exposure to social defeat, showed increased time immobile and decreased time swimming compared to adults. Adolescent rats exposed to defeat also exhibited increased climbing compared to their age-matched naïve counterparts. These effects dissipated with age. Interestingly, no effects of defeat were observed in adult females, however, when these females were re-assessed in the FST 30 days after the end of defeat, we observed increased swimming at the expense of climbing. Using exposure to a novel restraint to assess stress reactivity, we found that stress during adolescence and adulthood led to lower basal adrenocorticotropic hormone concentrations and that both stressed and control adolescent groups exhibited a delay in recovery in adulthood compared to stressed and control adult groups. Fos protein analysis further suggested that cortical/thalamic structures serve as potential substrates that mediate these long-term impacts of stress during adolescence. Thus, repeated social stress during adolescence produces different patterns of effects as compared with repeated social stress during adulthood.

A central role for venom in predation by Varanus komodoensis (Komodo Dragon) and the extinct giant Varanus (Megalania) priscus

The predatory ecology of Varanus komodoensis (Komodo Dragon) has been a subject of long-standing interest and considerable conjecture. Here, we investigate the roles and potential interplay between cranial mechanics, toxic bacteria, and venom. Our analyses point to the presence of a sophisticated combined-arsenal killing apparatus. We find that the lightweight skull is relatively poorly adapted to generate high bite forces but better adapted to resist high pulling loads. We reject the popular notion regarding toxic bacteria utilization. Instead, we demonstrate that the effects of deep wounds inflicted are potentiated through venom with toxic activities including anticoagulation and shock induction. Anatomical comparisons of V. komodoensis with V. (Megalania) priscus fossils suggest that the closely related extinct giant was the largest venomous animal to have ever lived.

Environmental dissemination of group A rotavirus: P-type, G-type and subgroup characterization

Rotaviruses A (RV-A) infection is the most common cause of acute diarrheal diseases in infants and the dissemination of these viruses in the environment represents a public health hazard. The present study aims to evaluate reverse transcription-polymerase chain reaction (RT-PCR) based protocols for the detection of RV-A genes in different types of environmental samples. RV-A were concentrated by the adsorption-elution method using negatively charged membranes associated with a Centriprep Concentrator 50. The RV-A VP4, VP7 and VP6 genes were detected using RT-PCR in river water from the Amazon Hydrographic basin (Northern region) and from wastewater in a sewage treatment plant in Rio de Janeiro (Southeast region), Brazil. RV-A were successfully detected in water environmental samples by the methods used. The detection of the VP6 gene by RT-PCR was the most sensitive for detecting RV-A in environmental samples (44.0%), when compared to the detection of the VP4 (33.3%) and VP7 (25.3%) genes. Based on nucleotide sequence and phylogenetic analysis of the partial VP6 gene, 22 environmental samples were determined to be subgroup II (Wa-like). These results indicate that analysis of environmental samples could possibly make a valuable contribution to studies on the epidemiology of RV-A.

The treatment of spasticity with Delta9-tetrahydrocannabinol in persons with spinal cord injury

STUDY DESIGN

Open label study to determine drug dose for a randomized double-blind placebo-controlled parallel study.

OBJECTIVES

To assess the efficacy and side effects of oral Delta(9)-tetrahydrocannabinol (THC) and rectal THC-hemisuccinate (THC-HS) in SCI patients.

SETTING

REHAB Basel, Switzerland.

METHOD

Twenty-five patients with SCI were included in this three-phase study with individual dose adjustment, each consisting of 6 weeks. Twenty-two participants received oral THC open label starting with a single dose of 10 mg (Phase 1, completed by 15 patients). Eight subjects received rectal THC-HS (Phase 2, completed by seven patients). In Phase 3, six patients were treated with oral THC and seven with placebo. Major outcome parameters were the spasticity sum score (SSS) using the Modified Ashworth Scale (MAS) and self-ratings of spasticity.

RESULTS

Mean daily doses were 31 mg with THC and 43 mg with THC-HS. Mean SSS for THC decreased significantly from 16.72 (+/-7.60) at baseline to 8.92 (+/-7.14) on day 43. Similar improvement was seen with THC-HS. We observed a significant improvement of SSS with active drug (P=0.001) in the seven subjects who received oral THC in Phase 1 and placebo in Phase 3. Major reasons for drop out were increase of pain and psychological side effects.

CONCLUSION

THC is an effective and safe drug in the treatment of spasticity. At least 15-20 mg per day were needed to achieve a therapeutic effect.

Newly synthesized and preformed acetylcholine are released from Torpedo synaptosomes by different pathways

In this study, we investigated the mechanisms underlying the release of preformed and of newly synthesized acetylcholine (ACh) from isolated Torpedo nerve terminals (synaptosomes). This was pursued by examining and comparing the effects of anticytoskeletal and anticalmodulin drugs and of activating the presynaptic muscarinic ACh receptors on the release of preformed endogenous ACh and of newly synthesized radiolabeled ACh. The anticytoskeletal drugs vinblastine, cytochalasin B, and colchicine inhibit the Ca2+-dependent K+-mediated release of newly synthesized radiolabeled ACh, but have no effect on the release of preformed ACh. By contrast, the muscarinic agonist oxotremorine markedly inhibits the release of preformed ACh, but has little effect on the release of newly formed ACh. Treatment of the synaptosomes with the calmodulin antagonist trifluoperazine inhibits the release of both ACh pools concomitantly. These findings show that preformed and newly synthesized ACh are released by different routes and suggest that their secretion is mediated by converging pathways. The significance of these results in view of the previously demonstrated preferential release of newly synthesized ACh is discussed.

Differential inhibition of the release of endogenous and newly synthesized acetylcholine from Torpedo synaptosomes by presynaptic muscarinic receptors

Activation of Torpedo presynaptic muscarinic acetylcholine (ACh) receptors with the agonist oxotremorine (20 microM) results in the inhibition of Ca2+-dependent release of endogenous ACh from Torpedo synaptosomes. This effect is reversed by the muscarinic antagonist atropine (1 microM) which, by itself, has no effect. In contrast, under the same conditions the amount of newly synthesized radiolabeled [3H]ACh released is not affected by muscarinic ligands. These findings suggest that presynaptic muscarinic inhibition in the Torpedo is due to interference with the mobilization of ACh from a storage pool.