The Cardiac Amyloidosis Registry Study (CARS): Rationale, Design and Methodology

BACKGROUND

CARS (Cardiac Amyloidosis Registry Study) is a multicenter registry established in 2019 that includes patients with transthyretin (ATTR, wild-type and variant) and light chain (AL) cardiac amyloidosis (CA) evaluated at major amyloidosis centers between 1997 and 2025. CARS aims to describe the natural history of CA with attention to clinical and diagnostic variables at the time of diagnosis, real-world treatment patterns, and associated outcomes of patients in a diverse cohort that is more representative of the at-risk population than that described in CA clinical trials.

METHODS AND RESULTS

This article describes the design and methodology of CARS, including procedures for data collection and preliminary results. As of February 2023, 20 centers in the United States enrolled 1415 patients, including 1155 (82%) with ATTR and 260 (18%) with AL CA. Among those with ATTR, wild-type is the most common ATTR (71%), and most of the 305 patients with variant ATTR have the p.V142I mutation (68%). A quarter of the total population identifies as Black. More individuals with AL are female (39%) compared to those with ATTR (13%).

CONCLUSIONS

CARS will answer crucial clinical questions about CA natural history and permit comparison of different therapeutics not possible through current clinical trials. Future international collaboration will further strengthen the validity of observations of this increasingly recognized condition.

Patient Focus: Moving Beyond Step Count: An Explanation of Real-World Walking Behaviors Are Associated With Early-Stage Heart Failure: A Project Baseline Health Study

In this issue of the Journal of Cardiac Failure, Dr. Sooyoon Shin and colleagues look at whether information from wearable devices, or activity trackers, could improve how a medical team monitors activity limitations for people who are at risk of developing heart failure symptoms.

Associations of Cumulative Perceived Stress with Cardiovascular Risk Factors and Outcomes: Findings from The Dallas Heart Study

Background

Data remain sparse regarding the impact of chronic stress on cardiovascular disease (CVD) risk factors and outcomes. Prior work has been limited by incomplete assessments of perceived stress and focus on single stress domains. We evaluated the association between a composite measure of perceived stress and CVD risk factors and outcomes.

Methods

Participants from the Dallas Heart Study phase 2 (2007-2009) without prevalent CVD who completed questionnaire assessments of perceived stress were included (n=2685). Individual perceived stress subcomponents (generalized stress, psychosocial, financial, and neighborhood stress) were standardized and integrated into a single cumulative stress score (CSS) with equal weighting for each component. Associations between CSS and demographics, psychosocial variables and cardiac risk factors were assessed in univariable and multivariable analyses. Cox proportional hazards models were used to determine associations of the CSS with atherosclerotic CVD (ASCVD) and Global CVD (ASCVD, heart failure, and atrial fibrillation) after adjustment for demographics and traditional risk factors.

Results

Median age of the study population was 48 years, 55% were female, 49% Black and 15% Hispanic/Latinx. CSS was higher among participants who were younger, female, Black or Hispanic, and those with lower income and educational attainment (p<.0001 for each). Higher CSS was associated with self-report of racial/ethnic discrimination, lack of health insurance and last medical contact > one year previously (p<.0001 for each). In multivariable regression models adjusting for age, gender, race/ethnicity, income and education, higher CSS associated with hypertension, smoking, and higher body mass index, waist circumference Hemoglobin A1C, hs-CRP and sedentary time (p< 0.01 for each). Over a median follow-up of 12.4 years, higher CSS associated with ASCVD (adjusted HR 1.22 per SD, 95% CI 1.01-1.47) and Global CVD (HR 1.20, 95% CI 1.03-1.40). No interactions were seen between CSS, demographic factors, and outcomes.

Conclusion

Composite multidimensional assessments of perceived stress may help to identify individuals at risk for CVD who may be targeted for stress mitigation or enhanced prevention strategies. These approaches may be best focused on vulnerable populations, given the higher burden of stress in women, Black and Hispanic individuals, and those with lower income and education.

WHAT IS NEW?

A novel measure of cumulative stress was created that integrates generalized, psychosocial, financial, and neighborhood perceived stress.Cumulative stress was higher among women, Black and Hispanic participants, younger individuals and persons with lower income and educational attainment and was associated with adverse health behaviors and increased burden of cardiovascular disease (CVD) risk factors.In a diverse cohort, higher cumulative stress associated with incident CVD after adjustment for demographics and traditional risk factors. No interactions were seen based on demographic factors.

CLINICAL IMPLICATIONS

Although associations of chronic stress with CVD were similar across demographic subgroups, the higher burden of stress among younger individuals, women, Black and Hispanic participants, and those with lower SES suggests that CVD risk associated with higher stress affects marginalized groups disproportionately.Cumulative Stress is associated with modifiable risk factors and health behaviors. Future studies should explore targeting behavioral modification and risk factor reduction programs, as well as stress reduction strategies, to individuals with high cumulative stress.Additional research is needed to uncover mechanisms that underly the association between chronic stress and cardiovascular disease.

Glucagon-like peptide-1 secretion in people with versus without type 2 diabetes: a systematic review and meta-analysis of cross-sectional studies

AIMS/HYPOTHESIS

The aim of this systematic review was to synthesise the study findings on whether GLP-1 secretion in response to a meal tolerance test is affected by the presence of type 2 diabetes (T2D). The influence of putative moderators such as age, sex, meal type, meal form, and assay type were also explored.

METHODS

A literature search identified 32 relevant studies. The sample mean and SD for fasting GLP-1TOTAL and GLP-1TOTAL iAUC were extracted and used to calculate between-group standardised mean differences (SMD), which were meta-analysed using a random-effects model to derive pooled estimates of Hedges' g and 95 % prediction intervals (PI).

RESULTS

Pooled across 18 studies, the overall SMD in GLP-1TOTAL iAUC between individuals with T2D (n = 270, 1047 ± 930 pmol·L-1·min) and individuals without T2D (n = 402, 1204 ± 937 pmol·L-1·min) was very small, not statistically significant and heterogenous across studies (g = -0.15, p = 0.43, PI: -1.53, 1.23). Subgroup analyses demonstrated an effect of assay type whereby Hedges' g for GLP-1 iAUC was greater in individuals with, versus those without T2D when using ELISA or Mesoscale (g = 0.67 [moderate], p = 0.009), but not when using RIA (g = -0.30 [small], p = 0.10). Pooled across 30 studies, the SMD in fasting GLP-1TOTAL between individuals with T2D (n = 580, 16.2 ± 6.9 pmol·L-1) versus individuals without T2D (n = 1363, 12.4 ± 5.7 pmol·L-1) was small and heterogenous between studies (g = 0.24, p = 0.21, PI: -1.55, 2.02).

CONCLUSIONS

Differences in fasting GLP-1TOTAL and GLP-1TOTAL iAUC between individuals with, versus those without T2D were generally small and inconsistent between studies. Factors influencing study heterogeneity such as small sample sizes and poor matching of groups may help to explain the wide prediction intervals observed. Considerations to improve comparisons of GLP-1 secretion in T2D and potential mediating factors more important than T2D diagnosis per se are outlined.

PROSPERO ID

CRD42020195612.

Impact of wideband cardiac magnetic resonance on diagnosis, decision-making and outcomes in patients with implantable cardioverter defibrillators

AIMS

Although myocardial scar assessment using late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging is frequently indicated for patients with implantable cardioverter defibrillators (ICDs), metal artefact can degrade image quality. With the new wideband technique designed to mitigate device related artefact, CMR is increasingly used in this population. However, the common clinical indications for CMR referral and impact on clinical decision-making and prognosis are not well defined. Our study was designed to address these knowledge gaps.

METHODS AND RESULTS

One hundred seventy-nine consecutive patients with an ICD (age 59 ± 13 years, 75% male) underwent CMR using cine and wideband pulse sequences for LGE imaging. Electronic medical records were reviewed to determine the reason for CMR referral, whether there was a change in clinical decision-making, and occurrence of major adverse cardiac events (MACEs). Referral indication was the most common evaluation of ventricular tachycardia (VT) substrate (n = 114, 64%), followed by cardiomyopathy (n = 53, 30%). Overall, CMR resulted in a new or changed diagnosis in 64 (36%) patients and impacted clinical management in 51 (28%). The effect on management change was highest in patients presenting with VT. A total of 77 patients (43%) experienced MACE during the follow-up period (median 1.7 years), including 65 in patients with evidence of LGE. Kaplan-Meier analysis showed that ICD patients with LGE had worse outcomes than those without LGE (P = 0.006).

CONCLUSION

The clinical yield from LGE CMR is high and provides management changing and meaningful prognostic information in a significant proportion of patients with ICDs.

Biomarker-Based Assessment for Infectious Risk Before and After Heart Transplantation

Purpose of Review

Survival outcomes for heart transplant recipients have improved in recent decades, but infection remains a significant cause of morbidity and mortality. In this review, we discuss several biological markers, or biomarkers, that may be used to monitor immunologic status in this patient population.

Recent Findings

While modest, data on the utility of immune biomarkers in heart transplant recipients suggest correlation between low level of immune response and increased infection risk. More novel assays, such as the detection of circulating levels of pathogen cell-free DNA in plasma and the use of Torque teno virus load as a surrogate for net state of immunosuppression, have potential to be additional important biomarkers.

Summary

Biomarker approaches to individualize immunosuppression therapy among heart transplant recipients is a promising area of medicine. However, additional studies are needed to inform the optimal protocol in which to incorporate these biomarkers into clinical practice.

Differential relationships between parent-child DXA and pQCT bone measures: Results from the Southampton Women's Survey

AIM

To investigate the associations between indices of bone health in childhood and corresponding parental measures.

METHODS

The Southampton Women's Survey characterised 12,583 non-pregnant women aged 20-34 years; 3158 subsequently had singleton live births. In a subset, dual-energy X-ray absorptiometry (DXA) measurements of bone area (BA), bone mineral content (BMC) and areal bone mineral density (aBMD) lumbar spine and total hip were obtained in the parent/offspring (aged 8-9 years) trios. Another subset of children (aged 6-7 years), and their parents, had peripheral quantitative computed tomography (pQCT; 4% and 38% tibia) measures. Using multivariable linear regression we examined relationships between mother/father and offspring, adjusting for parental age, habitual walking speed and education; offspring age and sex; and the corresponding bone measure in the other parent (β-coefficients (95%CI) unit/unit for each bone measure).

RESULTS

Data were available for 260 trios with DXA and 99 with pQCT. There were positive associations for BA, BMC and aBMD between either parent and offspring. Mother-child associations were of greater magnitude than father-child; for example, mother-child aBMD (β = 0.26 g·cm-2/g·cm-2 (0.21,0.32)) and father-child aBMD (β = 0.16 g·cm-2/g·cm-2 (0.11,0.21)), P-difference in β = 0.007. In the subset with pQCT there was a positive association for mother-offspring 4% tibial total area (β = 0.33 mm2/mm2 (0.17,0.48)), but little evidence of a father-offspring association (β = -0.06 mm2/mm2 (-0.17,0.06)). In contrast offspring 38% cortical density was more strongly associated with this measure in fathers (β = 0.48 mg·cm-3/mg·cm-3 (0.15,0.82)) than mothers (β = 0.27 mg·cm-3/mg·cm-3 (-0.03,0.56)). In general mother-father differences were attenuated by adjustment for height.

CONCLUSIONS

Whilst offspring bone measures are independently associated with those of either parent, the magnitude of the association is often greater for maternal than paternal relationships. These findings are consistent with an in utero influence on offspring growth but might also reflect genetic and/or epigenetic parent of origin effects.

SUMMARY

In an established parent-offspring cohort, associations between parent and offspring bone indices were generally greater in magnitude for mother-offspring than father-offspring relationships.

Testing a Generalizable Machine Learning Workflow for Aquatic Invasive Species on Rainbow Trout (Oncorhynchus mykiss) in Northwest Montana

Biological invasions are accelerating worldwide, causing major ecological and economic impacts in aquatic ecosystems. The urgent decision-making needs of invasive species managers can be better met by the integration of biodiversity big data with large-domain models and data-driven products. Remotely sensed data products can be combined with existing invasive species occurrence data via machine learning models to provide the proactive spatial risk analysis necessary for implementing coordinated and agile management paradigms across large scales. We present a workflow that generates rapid spatial risk assessments on aquatic invasive species using occurrence data, spatially explicit environmental data, and an ensemble approach to species distribution modeling using five machine learning algorithms. For proof of concept and validation, we tested this workflow using extensive spatial and temporal hybridization and occurrence data from a well-studied, ongoing, and climate-driven species invasion in the upper Flathead River system in northwestern Montana, USA. Rainbow Trout (RBT; Oncorhynchus mykiss), an introduced species in the Flathead River basin, compete and readily hybridize with native Westslope Cutthroat Trout (WCT; O. clarkii lewisii), and the spread of RBT individuals and their alleles has been tracked for decades. We used remotely sensed and other geospatial data as key environmental predictors for projecting resultant habitat suitability to geographic space. The ensemble modeling technique yielded high accuracy predictions relative to 30-fold cross-validated datasets (87% 30-fold cross-validated accuracy score). Both top predictors and model performance relative to these predictors matched current understanding of the drivers of RBT invasion and habitat suitability, indicating that temperature is a major factor influencing the spread of invasive RBT and hybridization with native WCT. The congruence between more time-consuming modeling approaches and our rapid machine-learning approach suggest that this workflow could be applied more broadly to provide data-driven management information for early detection of potential invaders.

Patient experiences with hidradenitis suppurativa: the Hidradenitis Patient Experience survey

BACKGROUND

Better understanding of the experience of people living with hidradenitis suppurativa (HS) is essential to identify gaps in current patient care and inform healthcare decision-making.

AIM

To describe the patient experience of individuals with HS, including their path to diagnosis, symptom control, treatments, healthcare utilization, patient needs and impact on quality of life.

METHODS

The Hidradenitis Suppurativa Patient Experience survey was created, extensively reviewed and disseminated through engaging HS-related patient organizations, physician groups and social media groups.

RESULTS

In total, 537 respondents completed the survey; the mean age was 38 years (range 14-73 years) and 95% (510 of 537) were female. The mean number of treatment types per respondent was 15, and included antibacterial soaps (93.3%; 431 of 462), avoidance of tight clothing (90.9%; 419 of 462), use of oral antibiotics (79.7%; 368 of 462), nonprescription drugs (79.7%; 368 of 462) and topical antibiotics (77.1%; 356 of 262). Pain was poorly controlled in 46% of respondents (184 of 401). HS had a negative impact on the ability to work and attend school for 81% of respondents (337 of 415), with 59% (245 of 415) missing at least 2 days of work a month and 16% (66 of 415) missing > 11 days of work. The mean number of misdiagnoses per respondent was three and the median time to diagnosis was 10 years.

CONCLUSION

Individuals with HS experience a delay in diagnosis and have suboptimal control of the disease. We propose 11 recommendations to improve diagnosis, treatment and quality of life for individuals living with HS.

Angiotensin Receptor-Neprilysin Inhibitors and the Natriuretic Peptide Axis

PURPOSE OF THE REVIEW

The purpose of this review is to describe the effects of angiotensin receptor neprilysin inhibitor (ARNI) therapy on the natriuretic peptide axis (NPA), with a particular focus on B-type natriuretic peptide (BNP), atrial natriuretic peptide (ANP), and C-type natriuretic peptide (CNP) to better understand the biology behind the improved outcomes in patients with heart failure with reduced ejection fraction (HFrEF).

RECENT FINDINGS

BNP, ANP, and CNP are the three main natriuretic peptides (NP); they share a common structure and ultimately mediate their actions by activating cyclic guanosine monophosphate (cGMP). ARNI therapy results in a decrease of N-terminal pro-BNP (NT-proBNP) and increase of BNP levels respectively. It is been questioned whether these changes may result from unique laboratory assays characteristics rather than actual biological implications. It appears to be that the prognostic accuracy of BNP for cardiovascular outcomes remains independent and comparable to that of NT-proBNP while on ARNI therapy. ANP levels also increase with ARNI therapy, but no consistent change has been described for CNP levels. There is evidence that the changes in BNP and NT-proBNP correlate with improvement in echocardiographic parameters of volume and function. The dual effect of neprilysin inhibition and angiotensin receptor blockade has substantial implications on the natriuretic peptide axis (NPA). The changes seen in BNP and NT-proBNP specifically have shown to correlate with improvement in echocardiographic parameters. Further results exploring the biologic effects of ARNI therapy on other NPs are still pending and likely will provide further insights in the mechanisms behind the improvement in cardiac function and clinical outcomes.

Changes in fecal microbiota with CFTR modulator therapy: A pilot study

Studies have demonstrated that people with CF with pancreatic insufficiency (PI) have fecal dysbioses. Evidence suggests the causes of these dysbioses are multifactorial, and that important drivers include antibiotic exposure, dietary intake, and CF gastrointestinal tract dysfunction, including nutrient malabsorption. In this pilot study, we tested whether initiation of the CFTR modulator treatments ivacaftor (in a cohort of pancreatic sufficient (PS) people with CF and an R117H CFTR variant) or lumacaftor/ivacaftor (in a cohort of PI people with CF and an F508del variant) changed fecal measures of malabsorption or fecal microbiomes. While we identified no statistically significant fecal changes with either treatment, we detected trends in the PI cohort when initiating lumacaftor/ivacaftor towards decreased fecal fat content and towards fecal microbiomes that more closely resembled the fecal microbiota of people without PI. While these findings support a model in which nutrient malabsorption resulting from CF-induced PI drives fecal dysbiosis, they must be validated in future, larger studies of fecal microbiome and malabsorption outcomes with highly effective CFTR modulator therapies.

Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry

BACKGROUND

Obesity may contribute to adverse outcomes in coronavirus disease 2019 (COVID-19). However, studies of large, broadly generalizable patient populations are lacking, and the effect of body mass index (BMI) on COVID-19 outcomes- particularly in younger adults-remains uncertain.

METHODS

We analyzed data from patients hospitalized with COVID-19 at 88 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease Registry with data collection through July 22, 2020. BMI was stratified by World Health Organization obesity class, with normal weight prespecified as the reference group.

RESULTS

Obesity, and, in particular, class III obesity, was overrepresented in the registry in comparison with the US population, with the largest differences among adults ≤50 years. Among 7606 patients, in-hospital death or mechanical ventilation occurred in 2109 (27.7%), in-hospital death in 1302 (17.1%), and mechanical ventilation in 1602 (21.1%). After multivariable adjustment, classes I to III obesity were associated with higher risks of in-hospital death or mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.57 [1.29-1.91], 1.80 [1.47-2.20], respectively), and class III obesity was associated with a higher risk of in-hospital death (hazard ratio, 1.26 [95% CI, 1.00-1.58]). Overweight and class I to III obese individuals were at higher risk for mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.54 [1.29-1.84], 1.88 [1.52-2.32], and 2.08 [1.68-2.58], respectively). Significant BMI by age interactions were seen for all primary end points (P-interaction<0.05 for each), such that the association of BMI with death or mechanical ventilation was strongest in adults ≤50 years, intermediate in adults 51 to 70 years, and weakest in adults >70 years. Severe obesity (BMI ≥40 kg/m²) was associated with an increased risk of in-hospital death only in those ≤50 years (hazard ratio, 1.36 [1.01-1.84]). In adjusted analyses, higher BMI was associated with dialysis initiation and with venous thromboembolism but not with major adverse cardiac events.

CONCLUSIONS

Obese patients are more likely to be hospitalized with COVID-19, and are at higher risk of in-hospital death or mechanical ventilation, in particular, if young (age ≤50 years). Obese patients are also at higher risk for venous thromboembolism and dialysis. These observations support clear public health messaging and rigorous adherence to COVID-19 prevention strategies in all obese individuals regardless of age.

Atraumatic Restorative Treatments in Australian Aboriginal Communities: A Cluster-randomized Trial

INTRODUCTION

The management of early childhood caries (ECC) is challenging.

OBJECTIVES

A model of care based on Atraumatic Restorative Treatment and the Hall Technique (ART-HT) to manage ECC was evaluated among remote Aboriginal communities in Australia.

METHODS

Aboriginal communities in the North-West of Western Australia were invited to participate and consenting communities were randomized into early or delayed intervention for the management of ECC. Children were examined at baseline and at the 11-mo follow-up. The early intervention group (test) was provided with the ART-based dental care at baseline while the delayed intervention group (control) was advised to seek care through the usual care options available within the community. At follow-up, both groups were examined by calibrated examiners, and were offered care using the ART-HT approach. Changes from baseline to follow-up in caries experience were tested using paired tests. Multivariate analysis after multiple imputation of missing data used generalised estimating equation (GEE) controlling for clustering within communities.

RESULTS

A total of 25 communities and 338 children (mean age = 3.6 y, SD 1.7) participated in the study (test = 177). At follow-up, 231 children were examined (68% retention, test = 125). At follow-up, children in the test group had more filled teeth (test filled teeth = 1.2, control filled teeth = 0.2, P < 0.001) and decreased levels of decayed teeth (mean test = 0.7 fewer teeth with decay, mean control = 1.0 more tooth with decay, P < 0.001). GEE analysis controlled for baseline caries experience, age, sex, and community water fluoride levels found increased rates of untreated decayed teeth (RR = 1.4, P = 0.02) and decreased rates of filled teeth (RR = 0.2, P < 0.001) at follow-up among the control group.

CONCLUSION

A model of care relying on the principles of minimally invasive atraumatic approaches enabled the delivery of effective dental services to young children (<6 y) in remote Aboriginal Australian communities resulting in increased levels of care and improved oral health.

KNOWLEDGE TRANSFER STATEMENT

This cluster-randomized trial tested a multi-component model of dental care to young children with ECC in remote Aboriginal communities in Australia. The intervention, based on the atraumatic approaches using minimally invasive techniques encompassing preventive care, Atraumatic Restorative Treatment and the Hall Technique (ART-HT), delivered more restorative care and reduced the incidence of caries. This model of care was more effective than available standard care and should be incorporated into mainstream service delivery programs.

Self-perceived Fracture Risk in the Global Longitudinal Study of Osteoporosis in Women: Its Correlates and Relationship with Bone Microarchitecture

The purpose of this study is to examine correlates of self-perceived fracture risk (SPR) and relationships between SPR and subsequent bone density and microarchitecture in the UK arm of the Global Longitudinal Study of Osteoporosis in Women. 3912 women completed baseline questionnaires detailing medical history and SPR; 492 underwent HRpQCT scans of the radius and tibia and DXA scans of total body, hip, femoral neck and lumbar spine a median of 7.5 years later. Correlates of SPR were examined and a cluster analysis of potential predictors of SPR performed. SPR in relation to HRpQCT and aBMD parameters was examined using linear regression with and without adjustment for anthropometric, demographic and lifestyle covariates. Mean (SD) baseline age was 69.0 (9.0) years; 56.6% reported a similar SPR; 28.6% lower SPR; 14.9% higher SPR compared to women of similar age. In mutually-adjusted analysis, higher SPR was associated (p < 0.05) with: lower physical activity and educational attainment; use of anti-osteoporosis medications (AOM) and calcium supplements; greater number of falls in the previous year; history of fracture since aged 45; family history of hip fracture; and increased comorbidity. Higher SPR, history of fracture, and use of AOM, calcium and vitamin D clustered together. Even after adjustments that included AOM use, higher SPR was associated with: lower radial trabecular volumetric density and number, and higher trabecular separation; lower tibial cortical area and trabecular volumetric density; and lower aBMD at the femoral neck. Despite greater AOM use, women with higher baseline SPR had poorer subsequent bone health.

Innovation in Fischer–Tropsch: Developing Fundamental Understanding to Support Commercial Opportunities

In this contribution we provide details of the BP-Johnson Matthey proprietary Fischer–Tropsch technology and the advanced CANS reactor and catalyst system. The advanced CANS catalyst carrier reactor provides superior heat transfer, reduced pressure drop and higher productivity that lead to major economic savings. Fundamental understanding of catalyst behaviour is also key to obtaining a catalyst that is stable over the lifetime of its use. Synthesis, calcination and reduction steps introduce changes in the catalyst properties prior to syngas introduction. In particular, the presence of water can affect the final catalyst performance. The activity of a good catalyst can be significantly reduced by a sub-optimal activation or start-up. Similarly, stable operation and minimising deactivation are vital for long and stable catalyst life, with years of operation without requiring regeneration. In this report we also share a fundamental study on the catalyst activation across different catalyst supports. This combines advanced in situ techniques with reactor testing to explore the role of the support on catalyst performance. The results illustrate the critical need for a logical and systematic catalyst development programme to explore these effects to optimise the whole FT process. The combination of a joint approach in development plays a key role in a long term success in a process. The fundamental catalyst understanding, optimisation and improvements in combination with the novel CANS reactor design maximise their potential and offer the potential for a world leading technology.

Flash glucose monitoring for the safe use of a 2-day intermittent energy restriction in patients with type 2 diabetes at risk of hypoglycaemia: An exploratory study

AIMS

Two medication change protocols were tested, both based on haemoglobin A1c (HbA1c), with one protocol also accounting for hypoglycaemic events. The aim was to compare the two protocols during intermittent energy restriction (5:2 diet).

METHODS

Forty-two adults with type 2 diabetes (HbA1c ≥ 7% [53 mmol/mol], BMI of ≥27 kg/m²) treated with sulphonylureas and/or insulin were recruited and randomised 1:1 to fixed or adjusted medication protocols. Participants experiencing hypoglycaemia during a 2-week usual diet period then followed the 5:2 diet for 2 weeks (2 non-consecutive very-low-calorie days [500-600 kcal] and 5 habitual eating days/week), following the allocated medication protocol. The primary outcome was to determine if the adjusted protocol was superior to the fixed protocol at reducing hypoglycaemic events during the 5:2 diet. Flash glucose monitoring was used throughout to detect hypoglycaemia.

RESULTS

There was a significant difference in change in the number of hypoglycaemic events between fixed and adjusted protocols (-1.0 vs. -3.5; P = 0.04). Over 60% of participants on the adjusted protocol had no hypoglycaemic events.

CONCLUSIONS

This pilot study demonstrates the importance of assessing the risk of hypoglycaemia before starting a 5:2 diet and that the adjusted medication protocol is likely the best option for patients at risk.

CLINICAL TRIAL REGISTRY

This study has been registered with the Australia New Zealand Clinical Trial Registry (ANZCTR) www.anzctr.org.au and given the registration number ACTRN12617000512325.

The effect of intermittent compared with continuous energy restriction on glycaemic control in patients with type 2 diabetes: 24-month follow-up of a randomised noninferiority trial

AIMS

We investigated the effects of intermittent compared to continuous energy restriction on glycaemic control in patients with type 2 diabetes mellitus.

METHODS

Adults (N = 137) with type 2 diabetes (mean [SD] HbA1c level, 7.3% (56 mmol/mol) [1.3%] [14.2 mmol/mol]) were randomised to one of two diets for 12 months. The intermittent group (n = 70) followed a 2100-2500 kJ (500-600 kcal) diet 2 non-consecutive days/week and their usual diet for 5 days/week. The continuous group (n = 67) followed a 5000-6300 kJ (1200-1500 kcal) diet for 7 days/week. Follow-up occurred at 24 months, 12 months after the completed intervention. The primary outcome was change in HbA1c and the secondary outcome was weight loss.

RESULTS

Intention-to-treat analysis showed an increase in mean [SEM] HbA1c level at 24 months in both the continuous and intermittent groups (0.4% [0.3%] vs 0.1% [0.2%] respectively; P = 0.32) (4.4 [3.3 mmol/mol] vs 1.1 [2.2 mmol/mol]; P = 0.32), with a between-group difference of 0.3% (90% CI, -0.31 to 0.83%) (3.3 mmol/mol [90% CI, -3.2 to 9.1 mmol/mol]) outside the prespecified boundary of ± 0.5% (5.5 mmol/mol), so statistical equivalence was not shown. Weight loss was maintained (P < 0.001) at -3.9 kg [1.1 kg] in both groups at 24 months, with a between-group difference of 0.07 kg (90% CI, -2.5 to 2.6 kg) outside the prespecified boundary of ±2.5 kg. There were no significant differences between groups in body composition, fasting glucose levels, lipid levels, or total medication effect score at 24 months, which remained less than baseline.

CONCLUSIONS

In this prospective analysis weight loss was maintained but despite this HbA1c increased to above baseline levels in both groups.

The Importance of Consistent Global Forest Aboveground Biomass Product Validation

Several upcoming satellite missions have core science requirements to produce data for accurate forest aboveground biomass mapping. Largely because of these mission datasets, the number of available biomass products is expected to greatly increase over the coming decade. Despite the recognized importance of biomass mapping for a wide range of science, policy and management applications, there remains no community accepted standard for satellite-based biomass map validation. The Committee on Earth Observing Satellites (CEOS) is developing a protocol to fill this need in advance of the next generation of biomass-relevant satellites, and this paper presents a review of biomass validation practices from a CEOS perspective. We outline the wide range of anticipated user requirements for product accuracy assessment and provide recommendations for the validation of biomass products. These recommendations include the collection of new, high-quality in situ data and the use of airborne lidar biomass maps as tools toward transparent multi-resolution validation. Adoption of community-vetted validation standards and practices will facilitate the uptake of the next generation of biomass products.

Dietary weight loss in insulin-resistant non-obese humans: Metabolic benefits and relationship to adipose cell size

BACKGROUND AND AIMS

Overweight and obesity increase risk for diabetes and cardiovascular disease, largely through development of insulin resistance. Benefits of dietary weight loss are documented for obese individuals with insulin resistance. Similar benefits have not been shown in overweight individuals. We sought to quantify whether dietary weight loss improves metabolic risk profile in overweight insulin-resistant individuals, and evaluated potential mediators between weight loss and metabolic response.

METHODS AND RESULTS

Healthy volunteers with BMI 25-29.9 kg/m2 underwent detailed metabolic phenotyping including insulin-mediated-glucose disposal, fasting/daylong glucose, insulin, triglycerides, FFA, and cholesterol. Subcutaneous fat biopsies were performed for measurement of adipose cell size. After 14 weeks of hypocaloric diet and 2 weeks of weight maintenance, cardiometabolic measures and biopsies were repeated. Changes in weight, % body fat, waist circumference, adipose cell size and FFA were evaluated as predictors of change in insulin resistance. Weight loss (4.3 kg) yielded significant improvements in insulin resistance and all cardiovascular risk markers except glucose, HDL-C, and LDL-C. Improvement in insulin sensitivity was greater among those with <2 vs >2 cardiovascular risk factors at baseline. Decrease in adipose cell size and waist circumference, but not weight or body fat, independently predicted improvement in insulin resistance.

CONCLUSIONS

Weight loss yields metabolic health benefits in insulin-resistant overweight adults, even in the absence of classic cardiovascular risk factors. Weight loss-related improvement in insulin sensitivity may be mediated through changes in adipose cell size and/or central distribution of body fat. The insulin-resistant subgroup of overweight individuals should be identified and targeted for dietary weight loss.

CLINICAL TRIALS IDENTIFIER

NCT00186459.

16S rRNA amplicon sequencing reveals a polymicrobial nature of complicated claw horn disruption lesions and interdigital phlegmon in dairy cattle

Lameness represents an intractable problem for the dairy industry. Complicated claw horn disruption lesions, interdigital hyperplasia, and interdigital phlegmon are important lameness causing foot lesions. Their aetiology is multifactorial, but infectious processes are likely implicated in disease pathogenesis. Our aim was to investigate the bacterial profiles of these lesions using 16S rRNA gene sequencing of samples obtained from 51 cattle across ten farms in the UK. In this study, interdigital hyperplasia, interdigital hyperplasia with signs of interdigital dermatitis, interdigital phlegmon, complicated sole ulcers, complicated toe ulcers lesions, and complicated white line lesions were investigated; corresponding healthy skin control samples were also analysed. All diseased tissues displayed reduced microbial richness and diversity (as described by Chao1, Shannon, and Simpson alpha-diversity indices) compared to their healthy skin control samples. Our results confirm the association of Treponema spp with some of these disorders. Other anaerobic bacteria including Fusobacterium spp., Fastidiosipila spp. and Porphyromonas spp. were implicated in the aetiology of all these lesions with the exception of interdigital hyperplasia. Complicated claw horn disruption lesions, and interdigital phlegmon were found to have similar bacterial profiles. Such sharing of bacterial genera suggests many of the infectious agents detected in these foot lesions are acting opportunistically; this finding could contribute towards future treatment and control strategies.

Abstract OT2-06-01: Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery

Background: Brain metastases occur in up to 25-40% of HER2+ breast cancer patients. Standard treatment is limited to surgery or stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT), with high levels of recurrence or progression, limiting survival and quality of life in most patients. Our group has demonstrated that low doses of temozolomide (TMZ) administered in a prophylactic, metronomic fashion can significantly prevent development of brain metastases in murine models of breast cancer. Based on these findings, we propose a secondary-prevention clinical trial.

Trial Design: Phase I/II open label study. Phase I will follow a standard 3+3 design: T-DM1 3.6 mg/kg IV every 21 days plus TMZ 30, 40 or 50 mg/m2 daily. Phase II: randomization T-DM1 3.6 mg/kg versus T-DM1 3.6mg/kg plus TMZ at recommended phase 2 dose (RP2D). Patients will undergo radiology guided lumbar puncture at baseline and after 6 weeks of treatment (C3D1) for correlative studies, brain MRI, systemic restaging CTs, and questionnaires for evaluation of symptoms and quality of life (MDASI-BT and PROMIS®) every 6 weeks.

Eligibility: HER2+ breast cancer with ≤3 brain metastases, treated with SRS and/or resection ≤6 weeks before enrollment, no leptomeningeal metastases, no previous WBRT, able to complete brain MRI with contrast evaluations, willing to undergo lumbar puncture, ECOG ≤2 and adequate organ and marrow function. HBV, HCV or HIV-positive patients are ineligible.

Specific Aims: Phase I: to identify the maximum tolerated dose (MTD) of TMZ combined with T-DM1. Phase II: to determine if the combination regimen of T-DM1 and TMZ improves the recurrence-free incidence from distant new brain metastases at one year as compared to T-DM1 alone. Biomarkers, including cell free DNA sequencing from CSF, serum and tumor block, serum markers for neuroinflammation, and patient reported outcomes, will be analyzed in an exploratory fashion.

Statistical Methods: Phase I, MTD will be identified based on the dose level at which 0 or 1 patient in 6 has a DLT. Phase II, to test whether TMZ will increase RFS from 50% to 65% at 12 months. RFS Kaplan-Meier curves will be created for each of the randomized arms and compared using a one-tailed log-rank test, with a one-sided 0.10 significance level of interest to be detected. Patients will be stratified for number of brain lesions and status of systemic metastases (controlled or not).

Target Accrual: 49 evaluable patients per arm (total 98), plus 9 to 18 patients during phase I. Trial will open in Summer 2017, at NIH in Bethesda, MD.

Contact Information: Principal Investigator: Alexandra S Zimmer, MD alexandra.zimmer@nih.gov

Citation Format: Zimmer AS, Gril B, Steinberg S, Smart D, Gilbert M, Armstrong T, Xiao L, Houston N, Biassou N, Brastianos P, Carter S, Lyden DC, Lipkowitz S, Steeg P. Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-06-01.

The effects of intermittent compared to continuous energy restriction on glycaemic control in type 2 diabetes; a pragmatic pilot trial

AIMS

Weight loss improves glycaemic control in type 2 diabetes mellitus (T2DM). However, as achieving and maintaining weight loss is difficult, alternative strategies are needed. Our primary aim was to investigate the effects of intermittent energy restriction (IER) compared to continuous energy restriction (CER) on glycated haemoglobin A1c (HbA1c). Secondary aims were to assess effects on weight loss, body composition, medication changes and subjective measures of appetite. Using a 2-day IER method, we expected equal improvements to HbA1c and weight in both groups.

METHOD

Sixty-three overweight or obese participants (BMI 35.2±5kg/m²) with T2DM (HbA1c 7.4±1.3%) (57mmol/mol) were randomised to a 2-day severe energy restriction (1670-2500kJ/day) with 5days of habitual eating, compared to a moderate CER diet (5000-6500kJ/day) for 12weeks.

RESULTS

At 12weeks HbA1c (-0.7±0.9% P<0.001) and percent body weight reduction (-5.9±4% P<0.001) was similar in both groups with no group by time interaction. Similar reductions were also seen for medication dosages, all measures of body composition and subjective reports of appetite.

CONCLUSIONS

In this pilot trial, 2days of IER compared with CER resulted in similar improvements in glycaemic control and weight reduction offering a suitable alternative treatment strategy.

Management of sarcomas possibly involving the knee joint when to perform extra-articular resection of the knee joint and is it safe?

We reviewed the oncological and functional outcomes of patients treated for a primary sarcoma possibly involving the knee joint and present an algorithm to guide treatment. The records of 76 patients who had a primary bone or soft tissue sarcoma possibly invading the knee between 1996 and 2012 were identified. Mean age and follow-up was 32 years (9-74) and 64 months (12-195), respectively. Patients were grouped according to the resection (Intra-articular [IAR] vs. Extra-articular [EAR] vs. Amputation/rotationplasty) for survival and functional outcomes. Overall 5 and 10 year survival was 61% and 53%, respectively. No differences in survival were found between the 3 groups (p = 0.55). Sixteen patients developed local recurrence with no difference between the groups. Mean MSTS score was 24.5 (12-30). Mean flexion at final follow-up was 106° (70-130°). We conclude that EAR of the knee allows for good oncologic and functional outcomes but with an increased risk of complications compared to IAR. Intra-operative assessment of joint involvement can be done in patients where joint infiltration by the tumour is not clear to avoid an unnecessary EAR. For chondrosarcoma patients with joint involvement, an EAR should be carefully considered because they present a significantly higher local recurrence risk.