Why restrict medical effective altruism?

In a challenge trial, research subjects are purposefully exposed to some pathogen in a controlled setting, in order to test the efficacy of a vaccine or other experimental treatment. This is an example of medical effective altruism (MEA), where individuals volunteer to risk harms for the public good. Many bioethicists rejected challenge trials in the context of Covid-19 vaccine research on ethical grounds. After considering various grounds of this objection, I conclude that the crucial question is how much harm research subjects can permissibly risk. But we lack a satisfying way of making this judgment that does not appeal simply to the intuitions of doctors or bioethicists. I consider one recent and structurally plausible approach to critically evaluating the harm question. Alex London defends a social consistency test for research risks: we should compare the risks undertaken by research subjects to relevantly similar risks which are accepted in other spheres of society. I argue there is no good reason not to consider volunteer military service as a relevant social comparison. This implies there is essentially no cap on acceptable risks on the social consistency rationale. In short, if soldiers can be heroes, why can't research volunteers?

757 ASSESSING THE READMISSION RATES OF THE OLDER PERSON’S ASSESSMENT AND LIAISON ACUTE FRAILTY TEAM AT GOOD HOPE HOSPITAL

Introduction

The Older Person’s Assessment and Liaison (OPAL) team at Good Hope Hospital (GHH), part of the University Hospitals Birmingham NHS Foundation Trust, provides multidisciplinary, patient-centred comprehensive assessment to patients presenting to the hospital front door. The team takes a ‘home first’ approach and where possible aims to discharge patients home with support by community teams. The service is part of the Birmingham wide Early Intervention programme. A front door OPAL service therefore enables early discharge for frail patients who would otherwise be likely to have a prolonged hospital admission. This has to be balanced against ensuring readmission rates do not exceed that of a comparable hospital inpatient population.

Method

We measured the 7 and 28-day readmission rate of all patients who received OPAL input and were discharged from A&E, the Medical Admissions Unit or the Acute Medical unit from July 2020—January 2021. This was compared with an inpatient short stay frailty unit however data was not available beyond November 2020 due to changes in response to the Covid-19 pandemic.

Results

2096 patients were discharged by OPAL with a 7-day readmission rate of 9.2% (95% CI 4.6–13.7%) and a 28-day readmission rate of 20.2% (95% CI 14.0–26.4%). From July—October 2020 the short stay frailty unit at GHH had a 7-day readmission rate of 9.7% (95% CI 3.1–16.3%) and a 28-day readmission rate of 25.2% (95% CI 8.2–42.2%). In the same period OPAL had a 7-day readmission rate of 8.7% (95% CI 3.2–14.2%) and a 28-day readmission rate of 19.9% (95% CI 13.3–26.5%).

Conclusion

The OPAL service enabled the early discharge of patients without compromising readmission rates. The readmission rates for patients discharged by the OPAL team were better than the inpatient frailty unit with over 20% fewer 28 day readmissions.

3 UTI Diagnosis and Management in the Over 65s According to Public Health England Guidelines

Introduction

The diagnosis of urinary tract infections (UTI) becomes increasingly difficult with age. Dipsticks are unreliable and with the prevalence of asymptomatic bacteriuria increasing to 17% in females over 75 even urine culture results can be unreliable. Public Health England (PHE) released new guidelines in November 2018 with criteria for diagnosing UTIs in the over 65s.

Methods

Identify patients over 65 who are diagnosed with a UTI in Solihull acute medical unit. Collect data on presenting symptoms, dipstick and culture results and antibiotic use. Aim to improve guideline adherence and decrease dipstick use through education of medical and nursing staff via presentations and posters.

Results

Prior to the educational intervention guideline adherence when diagnosing UTIs in over 65s was 55%. This rose to 82% following the educational intervention. Dipstick usage decreased from 49% to 28% following the intervention. Dipsticks were shown to be unreliable as 21.6% of dipstick positive urine samples sent for culture had a normal (0-80) white cell count in the laboratory, whilst 43.8% of dipstick negative urine samples sent for culture had a raised white cell count in the laboratory. On retrospective analysis 16.1% of patients treated for a UTI appeared to have had an asymptomatic bacteriuria. Co-amoxiclav was initially used for 51% of patients however there was resistance to Co-amoxiclav in 31% of samples where an organism was cultured.

Conclusions

The educational intervention was able to increase PHE guideline adherence for diagnosing UTIs in the over 65s. There was also a decrease in the use of dipsticks which were shown to be unreliable in this age group. Prescribers remained reliant on broad-spectrum antibiotics with Co-Amoxiclav being most commonly used. This is likely to be ineffective in a significant number of patients given the common resistance seen in urine culture sensitivities.

Abstract B101: Safety, tolerability, and pharmacokinetics of IPI-493, an oral Hsp90 inhibitor, in patients with advanced cancers

Background: Inhibition of the Hsp90 chaperone protein is associated with clinical activity in selected patients (pts). IPI-493, an oral Hsp90 inhibitor, was assessed in advanced solid and hematologic malignancies in two phase 1 studies. Study objectives included determination of the following: maximum tolerated dose (MTD), dose-limiting toxicities (DLTs), recommended phase 2 dose, safety/tolerability, pharmacokinetics (PK)/pharmacodynamics (PD), and clinical activity.

Methods: Pts with advanced cancers received oral IPI-493 for 21-day cycles in a routine 3+3, sequential dose escalation design with three unique schedules: three times weekly for 2 weeks + 1 week rest (TIW), twice weekly for 2 weeks + 1 week rest (BIW), and once weekly continuously (QW). PK and PD samples were obtained in Cycle 1 during Weeks 1 and 3. CT scans were performed at baseline and every 2 cycles thereafter.

Results: IPI-493 (TIW n=14, BIW n=21 and QW n=22) at doses from 50 to 250 mg was administered to 57 pts (53 with solid tumors, 4 with hematologic malignancies) with a median age of 58 years (range 21–86), ECOG score 0–1, and a median of 5 previous chemotherapy agents (range 1–16). The most common tumor types were colorectal cancer (10 pts) and gastrointestinal stromal tumor (6 pts). The median time on study was 65 days (range 15–544). Fourteen total DLTs were observed in 4 pts on the TIW (200 mg and 150 mg) schedule and 1 pt on the BIW (125 mg) schedule, which were primarily elevations in aspartate aminotransferase (AST), alanine aminotransferase, and alkaline phosphatase (ALP). No DLTs were observed on the QW schedule. DLTs of metabolic acidosis and acute renal failure were fatal in a single pt; all other DLTs were reversible. A maximum tolerated dose was not determined. The most common treatment-related adverse events were fatigue (35%), diarrhea (30%), elevated AST (28%), elevated ALP (25%), and nausea (21%). Maximal plasma concentrations occurred approximately 2–3 hours following single and repeat oral administration. Across all doses and schedules, the mean terminal elimination half life was approximately 14 hours, with no drug accumulation observed upon repeat dosing. Systemic exposure increased with dose across the 50–150 mg dose levels and demonstrated a plateau at 150 mg with no further increases in mean exposure at doses up to 250 mg.

Conclusions: IPI-493 tolerability was schedule dependent, with increasing toxicity identified on the TIW schedule. Development of IPI-493 is no longer being pursued due to the lack of increased exposure with increasing doses.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr B101.

Risk factors for the introduction and within-herd transmission of Mycobacterium avium subspecies paratuberculosis (MAP) infection on 59 Irish dairy herds

Since 1994, Irish cattle have been exposed to greater risks of acquiring Mycobacterium avium subspecies paratuberculosis (MAP) infection as a consequence of the importation of over 70,000 animals from continental Europe. In recent years, there has been an increase in the number of reported clinical cases of paratuberculosis in Ireland. This study examines the prevalence of factors that promote the introduction and within-herd transmission of Mycobacterium avium subspecies paratuberculosis (MAP) on selected Irish dairy farms in the Cork region, and the association between these factors and the results of MAP screening tests on milk sock filter residue (MFR). A total of 59 dairy farms, selected using non-random methods but apparently free of endemic paratuberculosis, were enrolled into the study. A questionnaire was used to collect data about risk factors for MAP introduction and transmission. The MFR was assessed on six occasions over 24 months for the presence of MAP, using culture and immunomagnetic separation prior to polymerase chain reaction (IMS-PCR). Furthermore, blood samples from all entire male and female animals over one year of age in 20 herds were tested by ELISA. Eighteen (31%) farms had operated as closed herds since 1994, 28 (47%) had purchased from multiple sources and 14 (24%) had either direct or indirect (progeny) contact with imported animals. Milk and colostrum were mixed on 51% of farms, while 88% of farms fed pooled milk. Thirty (51%) herds tested negative to MFR culture and IMS-PCR, 12 (20%) were MFR culture positive, 26 (44%) were IMS-PCR positive and seven (12%) were both culture and IMS-PCR positive. The probability of a positive MFR culture was significantly associated with reduced attendance at calving, and with increased use of individual calf pens and increased (but not significantly) if mulitiple suckling was practised. There was poor agreement between MFR culture and MFR IMS-PCR results, but moderate agreement between MFR culture and ELISA test results. This study highlights a lack of awareness among Irish dairy farmers about the effect of inadequate biosecurity on MAP introduction. Furthermore, within-herd transmission will be facilitated by traditional calf rearing and waste management practices. The findings of viable MAP in the presence of known transmission factors in non-clinically affected herds could be a prelude to long-term problems for the Irish cattle and agri-business generally.

Phase II study of the antiangiogenic agent SU5416 in patients with advanced soft tissue sarcomas

PURPOSE

SU5416 (semaxanib) is a small molecule inhibitor of the vascular endothelial growth factor (VEGF) receptor-2 and KIT receptor tyrosine kinases. This Phase II study was conducted to investigate the safety and efficacy of SU5416 for patients with soft tissue sarcomas.

EXPERIMENTAL DESIGN

Thirteen patients with locally advanced or metastatic soft tissue sarcomas were treated with SU5416 via intravenous infusion at a dose of 145 mg/m(2) twice weekly. In selected cases tumor biopsies were taken before and after 2 months of treatment.

RESULTS

The median progression-free survival was 1.8 months. Median overall survival was 22.8 months. No objective tumor responses were observed. There was evidence of shorter survival among patients with high baseline urine VEGF levels (P = 0.04). No grade 4 toxicities were observed. The most common grade 3 toxicities were headache and thrombosis. Other less serious toxicities included fatigue, nausea, and abdominal pain. The median systolic blood pressure increased from 118 mmHg at baseline to 133 after 1 month of treatment (P = 0.01). Post-treatment tumor biopsies showed no significant decreases in VEGF receptor phosphorylation compared with baseline in 3 evaluable patients. One patient with gastrointestinal stromal tumor who had rapid progression during SU5416 treatment was subsequently treated with another KIT inhibitor, imatinib mesylate, and had a partial response lasting >36 months.

CONCLUSIONS

SU5416 was relatively well tolerated but did not demonstrate significant antitumor activity against advanced soft tissue sarcoma. Correlative studies suggest that VEGF receptor or KIT inhibition was incomplete in at least some cases, providing a possible explanation for the observed lack of activity.

Acute gastroenteritis in northern Ireland and the Republic of Ireland: a telephone survey

Most people with acute gastroenteritis do not seek medical care and are therefore not captured by routine surveillance. For this reason, population-based studies are needed to measure the burden of illness. A study of acute gastroenteritis in Northern Ireland and the Republic of Ireland surveyed 9,903 people by telephone over the 12-month period from December 2000 to November 2001. The rate of acute gastroenteritis was 0.60 episodes per person per year. A general practitioner was consulted by 29.2% of those reporting illness, and 2.0% submitted a stool sample. The use of antibiotics was reported by 7.4% of ill respondents and 14.8% took anti-diarrhoeals. Taking days off work due to illness, was reported by 17.4% of respondents. Acute gastroenteritis causes a large amount of illness in the community. There are established and effective measures to prevent this condition and the challenge is to find new ways of promoting these precautions.

A phase II and pharmacokinetic study of ecteinascidin 743 in patients with gastrointestinal stromal tumors

PURPOSE

To assess the efficacy, tolerability, and pharmacokinetics of ecteinascidin 743 (ET-743) in patients with advanced gastrointestinal stromal tumors (GISTs).

PATIENTS AND METHODS

The study was confined to adult patients with radiographically measurable GISTs. ET-743 was administered as a 24-hour continuous i.v. infusion at a dose of 1.5 mg/m(2) repeated every 3 weeks. Pharmacokinetic blood sampling was performed during the first cycle of therapy. Tumors were restaged after every second cycle of therapy.

RESULTS

A total of 20 patients was enrolled in the study, 19 of whom were treated with 47 cycles of ET-743 (median 2, range 1-10). Severe toxicities were limited to reversible grade 3 transaminitis in 10 patients and grade 3 fatigue in one patient. There were no objective responses, and disease stabilization occurred in two patients lasting for periods of 4 and 10 months. The 1-year survival rate was 71.1%. Mean +/- standard deviation values of the maximum plasma concentration and total plasma clearance were 1.1 +/- 0.4 ng/ml and 44 +/- 16 l/h/m(2), respectively, for 19 of the 20 patients.

CONCLUSION

This study is the first report of a prospective phase II trial to evaluate a cytotoxic agent in patients with GISTs. This study underscores the primary resistance of GISTS to chemotherapy and stands in stark contrast to the encouraging results recently achieved with STI571. The lack of response may be associated with a therapeutically ineffective exposure to the drug based upon the lower incidence of severe toxicities and greater clearance than described in phase I and II trials of ET-743.

Screening performance of functional and structural measurements of neural damage in open-angle glaucoma: a case-control study from the Baltimore Eye Survey

PURPOSE

To compare the sensitivity and specificity of four approaches to glaucoma screening.

METHODS

Case patients were persons with possible, probable, or definite glaucomatous optic nerve damage, as judged by a glaucoma specialist using Humphrey 24-2 threshold findings and clinical assessment of disc and nerve fiber layer, identified in the population-based Baltimore Eye Survey Follow-up Study. Control patients were participants in the same study, frequency-matched for age, without evidence of glaucomatous optic nerve damage. Participants underwent optic disc photography (Topcon ImageNet), disc imaging (GlaucomaScope), scanning laser polarimetry (Nerve Fiber Analyzer), and suprathreshold field testing (Dicon).

RESULTS

A total of 100 case patients with open-angle glaucoma and 149 control patients were included. Objective imaging had the best screening performance. For the GlaucomaScope, a criterion of cup-to-disc ratio of -0.68 had a sensitivity of 72% and specificity of 82% for detecting eyes with definite or probable glaucomatous optic nerve damage. For the nerve fiber layer, a criterion of The Number as > or = 20 had a sensitivity of 69% and specificity of 77% for detecting eyes with definite or probable glaucomatous optic nerve damage. Usable data could be obtained in 93% of participants with the Dicon and the Nerve Fiber Analyzer and in 82% and 87% of participants with the GlaucomaScope and Topcon instruments, respectively.

CONCLUSIONS

Vertical cup-to-disc ratio, as measured by the GlaucomaScope or Topcon instruments, and the Nerve Fiber Layer neural network Number had the best combination of sensitivity and specificity among the instruments tested. The Nerve Fiber Analyzer had the highest percentage of participants with usable data.

Symptomatic gastroesophageal reflux in acutely hospitalized patients

Patients admitted acutely to hospital may be at risk of increased morbidity and mortality as a result of gastroesophageal reflux and its complications. The recognized association of gastroesophageal reflux with cardiac and respiratory disease, the use of drugs that reduce lower esophageal sphincter pressure, and the supine position in which many patients are nursed may increase the risk of gastroesophageal reflux. This study aimed to determine the prevalence and severity of refluxlike symptoms in a series of consecutive unselected patients admitted acutely through the accident and emergency department of a district general hospital and to study the effect of hospitalization on these symptoms. Patients were interviewed by questionnaire on two occasions: immediately following admission and again 7-10 days later. The frequency of symptoms of heartburn, acid regurgitation, dysphagia, nausea, and belching were recorded on a 6-point scale, in addition to whether these symptoms occurred at night. Medication history, the number of days spent on bed rest, nasogastric intubation, and operation history were also recorded. In all, 275 patients were interviewed, of whom 229 had a second interview; 27% (62) had symptoms at least once a week (49% reported symptoms at least once a month) prior to admission, of whom 4% (9) had daily heartburn and/or acid regurgitation. Following admission to hospital there was a significant (P < 0.001) fall in the prevalence and frequency of refluxlike symptoms. There was a significant association of refluxlike symptoms with number of days spent in bed (P < 0.05) and with the use of nonsteroidal antiinflammatory drugs in hospital (P < 0.0001). Logistic regression analysis confirmed the association of NSAIDs with refluxlike symptoms. Nasogastric intubation and surgery were not associated with heartburn. In conclusion, symptoms of heartburn and acid regurgitation become less frequent following admission to hospital. This probably relates to a reduction in physical exertion following hospital admission but may reflect a reduction in anxiety levels or treatment of underlying disease. Patients on prolonged bed rest and those given non-steroidal anti-inflammatory drugs are at increased risk of refluxlike symptoms and may require antireflux measures.

Relationship of antral gastrin cells and serum gastrin to thyroid function in the rat

Using a quantitative immunocytochemical technique, antral gastrin cell populations in the rat were studied in various states of thyroid function. Simultaneous determinations of circulating serum gastrin were made by RIA. Rats made hypothyroid by ingestion of methimazole (0.01% solution in drinking water for 30 days) demonstrated a significant 32% decrease in gastrin cell density (306 +/- 9/cm vs. 207 +/- 11/cm for controls) associated with a significant 50% decrease in serum gastrin (143 +/- 12 vs. 307 +/- 20 pg/ml for controls). Induction of hypothyroidism and hypoparathyroidism by surgical thyroparathyroidectomy resulted in similarly significant decreases in gastrin cell numbers (229 +/- 12/cm) and serum gastrin (169 +/- 14 pg/ml). Animals that underwent thyroparathyroidectomy followed by T4 replacement (2.5 micrograms/100 g X day, ip) for 30 days had a mean gastrin cell density that was not significantly different from that of controls; serum gastrin was decreased to 207 +/- 11 pg/ml. The administration of excess T4 (200 micrograms/100 g X day, ip) for either 15 or 30 days was associated with a significant increase in gastrin cell numbers (413 +/- 23/cm at 15 days; 352 +/- 21/cm at 30 days). Mean serum gastrin was increased by 82% after 15 days of T4 administration (558 +/- 51 pg/ml) and by 65% at 30 days (506 +/- 36 pg/ml). We conclude that T4 is trophic for gastrin cells in the rat.