Placental expression of leptin: fetal sex-independent relation with human placental growth

OBJECTIVES

Leptin (LEP) is a vital placental hormone that is known to affect different aspects of placental function and fetal development. The present study aimed to determine the association of placental LEP transcript abundance with maternal, placental, and newborn parameters.

SUBJECTS/METHODS

In this retrospective case-control study, placental samples (n = 105) were collected from small (SGA) and appropriate (AGA) for gestational age full-term singleton pregnancies (n = 44 SGA and n = 61 AGA). Placental transcript abundance of LEP was assessed by real-time quantitative PCR after normalization to a reference gene panel. LEP methylation was measured using a quantitative MethyLight assay in a subset of samples (n = 54).

RESULTS

Placental LEP transcript abundance was negatively and significantly associated with placental weight (β = -3.883, P = 0.015). This association continued to be significant in the SGA group (β = -10.332, P = 0.001), both in female (β = -15.423, P = 0.021) and male births (β = -10.029, P = 0.007). LEP transcript abundance was not associated with LEP methylation levels (Spearman's ρ = 0.148, P = 0.287).

CONCLUSION

We conclude that placental upregulation of LEP is an integral and fetal sex-independent component of placental growth restriction, which can be potentially targeted through maternal dietary modifications to improve fetoplacental growth.

Changing patterns in the epidemiology and outcomes of inflammatory bowel disease in the United Kingdom: 2000-2018

BACKGROUND

Data regarding incidence, prevalence and long-term outcomes of inflammatory bowel diseases in the UK are limited or outdated.

AIMS

To investigate incidence and prevalence of Crohn's disease and ulcerative colitis and risk of colorectal cancer and all-cause mortality in these diseases.

METHODS

Inflammatory bowel disease cases between 2000 and 2018 were identified from a national primary care database. Inflammatory bowel disease prevalence was forecast until 2025. The association between inflammatory bowel disease and colorectal cancer and all-cause mortality was investigated using age/sex-matched retrospective cohort studies. Hazard ratios were adjusted for age, sex, deprivation, comorbidity, smoking status and body mass index.

RESULTS

Ulcerative colitis prevalence increased from 390 to 570 per 100 000 population from 2000 to 2017. Prevalence of Crohn's disease increased from 220 to 400 per 100 000. In 2017 male Crohn's disease prevalence was 0.35% (95% confidence interval 0.34-0.36); female prevalence was 0.44% (0.43-0.45). Prevalence of inflammatory bowel disease is predicted to be 1.1% by 2025. Incidence of ulcerative colitis and Crohn's disease was 23.2 (22.8-23.6) and 14.3 (14.0-14.7) per 100 000 person-years respectively. Subjects with ulcerative colitis were more likely to develop colorectal cancer than controls (adjusted Hazard Ratio 1.40 [1.23-1.59]). Colorectal cancer rates remained stable in inflammatory bowel diseases over time. Ulcerative colitis and Crohn's disease were associated with increased risk of all-cause mortality (1.17 [1.14-1.21] and 1.42 [1.36-1.48] respectively).

CONCLUSIONS

The UK prevalence of inflammatory bowel disease is greater than previous reports suggest and we predict an 11% increase in prevalence by the year 2025. Mortality risk in inflammatory bowel disease and colorectal cancer risk in ulcerative colitis are increased compared to matched controls.

Alternative and complementary therapies in osteoarthritis and cartilage repair

Osteoarthritis (OA) is the most common joint condition and, with a burgeoning ageing population, is due to increase in prevalence. Beyond conventional medical and surgical interventions, there are an increasing number of ‘alternative’ therapies. These alternative therapies may have a limited evidence base and, for this reason, are often only afforded brief reference (or completely excluded) from current OA guidelines. Thus, the aim of this review was to synthesize the current evidence regarding autologous chondrocyte implantation (ACI), mesenchymal stem cell (MSC) therapy, platelet-rich plasma (PRP), vitamin D and other alternative therapies. The majority of studies were in knee OA or chondral defects. Matrix-assisted ACI has demonstrated exceedingly limited, symptomatic improvements in the treatment of cartilage defects of the knee and is not supported for the treatment of knee OA. There is some evidence to suggest symptomatic improvement with MSC injection in knee OA, with the suggestion of minimal structural improvement demonstrated on MRI and there are positive signals that PRP may also lead to symptomatic improvement, though variation in preparation makes inter-study comparison difficult. There is variability in findings with vitamin D supplementation in OA, and the only recommendation which can be made, at this time, is for replacement when vitamin D is deplete. Other alternative therapies reviewed have some evidence (though from small, poor-quality studies) to support improvement in symptoms and again there is often a wide variation in dosage and regimens. For all these therapeutic modalities, although controlled studies have been undertaken to evaluate effectiveness in OA, these have often been of small size, limited statistical power, uncertain blindness and using various methodologies. These deficiencies must leave the question as to whether they have been validated as effective therapies in OA (or chondral defects). The conclusions of this review are that all alternative interventions definitely require clinical trials with robust methodology, to assess their efficacy and safety in the treatment of OA beyond contextual and placebo effects.

Risk of Cardiometabolic Disease and All-Cause Mortality in Female Survivors of Domestic Abuse

Background Domestic abuse (DA) against women is a global public health problem. Although the possible health burden could be substantial, the associations between DA and subsequent cardiometabolic disease (cardiovascular disease, hypertension, and type 2 diabetes mellitus) and all-cause mortality are poorly understood. Methods and Results This retrospective cohort study consisted of UK-based primary care patients between January 1, 1995, to December 1, 2017. Overall, 18 547 women exposed to DA were matched to 72 231 unexposed women by age and lifestyle factors. The main outcomes, presented as adjusted incidence rate ratios (IRRs), were the risk of developing cardiovascular disease, hypertension, type 2 diabetes mellitus, and all-cause mortality. In total, 181 exposed women experienced a cardiovascular disease event compared with 644 of the unexposed control group, relating to an increased adjusted IRR of 1.31 (95% CI, 1.11-1.55; P=0.001). There was also an increased risk of subsequent type 2 diabetes mellitus (adjusted IRR: 1.51; 95% CI, 1.30-1.76; P<0.001) and all-cause mortality (adjusted IRR: 1.44; 95% CI, 1.24-1.67; P<0.001) following exposure to DA. This observation was not seen with hypertension (adjusted IRR: 0.99; 95% CI, 0.88-1.12; P=0.873). Conclusions There is an increased risk of subsequent cardiovascular disease, type 2 diabetes mellitus, and all-cause mortality in female survivors of DA. However, there is no association with the development of hypertension in this group, in keeping with previous literature. Considering the high prevalence of DA, clinicians should be made aware of the disproportionally increased risk and thus are encouraged to manage modifiable risk factors actively in this group.

Epidemiology, morbidity and mortality in Behçet’s disease: a cohort study using The Health Improvement Network (THIN)

Objectives

The epidemiology of Behçet’s disease (BD) has not been well characterized in the UK. Evidence on the risk of cardiovascular disease, thromboembolic disease and mortality in patients with BD compared with the general population is scarce.

Methods

We used a large UK primary care database to investigate the epidemiology of BD. A retrospective matched cohort study was used to assess the following outcomes: risk of cardiovascular, thromboembolic disease and mortality. Controls were selected at a 1:4 ratio (age and gender matched). Cox proportional hazard models were used to derive adjusted hazard ratios (aHR).

Results

The prevalence of BD was 14.61 (95% CI 13.35–15.88) per 100 000 population in 2017. A total of 1281 patients with BD were compared with 5124 age- and gender-matched controls. There was significantly increased risk of ischaemic heart disease [aHR 3.09 (1.28–7.44)], venous thrombosis [aHR 4.80 (2.42–9.54)] and mortality [aHR 1.40 (1.07–1.84)] in patients with BD compared with corresponding controls. Patients with BD were at higher risk of pulmonary embolism compared with corresponding controls at baseline [adjusted odds ratio 4.64 (2.66–8.09), P &lt; 0.0001]. The majority of patients with pulmonary embolism and a diagnosis of BD had pulmonary embolism preceding the diagnosis of BD, not after (87.5%; n = 28/32).

Conclusion

BD has a higher prevalence than previously thought. Physicians should be aware of the increased risk of developing ischaemic heart disease, stroke/transient ischaemic attack and deep venous thrombosis in patients with BD at an earlier age compared with the general population. Risk of embolism in patients with BD might vary across the disease course.

Arbuscular mycorrhizal fungi improve the growth and disease resistance of the invasive plant Wedelia trilobata

AIMS

Arbuscular mycorrhizal fungi (AMF) are symbiotic partners of many invasive plants, however, it is still unclear how AMF contribute to traits that are important for the successful invasion of their host and how environmental factors, such as nutrient conditions, influence this. This study was to explore the effects of Glomus versiforme (GV) and Glomus mosseae (GM) on the growth and disease resistance of the invasive plant Wedelia trilobata under different nutrient conditions.

METHODS AND RESULTS

We found that GV and GM had higher root colonization rates resulting in faster W. trilobata growth under both low-N and low-P nutrient conditions compared to the normal condition. Also, the colonization of W. trilobata by GV significantly reduced the infection area of the pathogenic fungus Rhizoctonia solani under low-N conditions.

CONCLUSIONS

These results demonstrated that AMF can promote the growth and pathogenic defence of W. trilobata in a nutrient-poor environment, which might contribute to their successful invasion into certain type of habitats.

SIGNIFICANCE AND IMPACT OF THE STUDY

In this study, we report for the first time that AMF can promote growth and disease resistance of W. trilobata under nutrient-poor environment, which contribute to a better understanding of plant invasion.

Determination of Ochratoxin A in Currants, Raisins, Sultanas, Mixed Dried Fruit, and Dried Figs by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatographic (LC) method for the determination of ochratoxin A in a variety of dried fruit at European regulatory limits. To ensure homogeneity before analysis, laboratory samples are normally slurried with water in the ratio of 5 parts fruit to 4 parts water, and test materials in this form were used in the study. The test portion was extracted with acidified methanol. The extract was filtered, diluted with phosphate-buffered saline, and applied to an affinity column. The column was washed and ochratoxin A was eluted with methanol. Ochratoxin A was quantified by reversed-phase LC. The use of post-column pH shift to enhance the fluorescence of ochratoxin A by the addition of 1.1M ammonia solution to the column eluant is optional. Determination was by fluorescence. Currants, sultanas, raisins, figs, and mixed fruit (comprising dried pineapple, papaya, sultanas, prunes, dates, and banana chips), both naturally contaminated and blank (very low level), were sent to 24 collaborators in 7 European countries. Participants were asked to spike test portions of all test samples at a level equivalent to 5 ng/g ochra toxin A. Average recoveries ranged from 69 to 74%. Based on results for 5 naturally contaminated test samples (blind duplicates) the relative standard deviation for repeatability (RSDr) ranged from 4.9 to 8.7%, and the relative standard deviation for reproducibility (RSDR)rangedfrom14to28%. The method showed acceptable within-and be-tween-laboratory precision for all 5 matrixes, as evidenced by HORRAT values &lt;1.3.

The burden of mental ill health associated with childhood maltreatment in the UK, using The Health Improvement Network database: a population-based retrospective cohort study

BACKGROUND

Childhood maltreatment is a global public health, human rights, and moral issue that is associated with a substantial mental health burden. We aimed to assess the association between childhood maltreatment and the development of mental ill health and the initiation of new prescriptions for mental ill health.

METHODS

In this population-based, retrospective, open cohort study, we used a dataset from individuals in The Health Improvement Network (THIN) database. THIN database comprises UK electronic medical records taken from 787 general practices throughout the UK. We used read codes in these records to identify exposed patients (those with a read code identifying officially confirmed childhood maltreatment or a maltreatment-related concern) and up to two unexposed patients (those without such read codes) from the same general practice, who were matched by age and sex. We evaluated the risk of developing depression, anxiety, or serious mental illness (a composite mental ill health outcome) or initiation of a prescription drug used to treat mental ill health, and the odds ratio of these events at baseline, in the exposed versus unexposed patients.

FINDINGS

The first possible date for cohort entry (the study start date) was Jan 1, 1995, and patients could enter the cohort until the study end date, Dec 31, 2018. During the study period, 11 831 850 patients were eligible to participate. Of these patients, we identified 217 758 (1·8%) patients with any recorded childhood maltreatment. These patients were matched to 423 410 unexposed control patients with no recorded exposure to childhood maltreatment. The exposed group were followed up for a median of 1·8 years (IQR 0·6-4·3) versus 3·2 years (1·3-6·1) in the unexposed group. During the study period, 11 665 (5·9%) new diagnoses of mental ill health were made in the exposed group, giving an incidence rate of 16·8 events per 1000 person-years versus 15 301 (3·7%) new recorded diagnoses at an incidence rate of 8·3 events per 1000 person-years in the unexposed cohort, giving an adjusted IRR of 2·14 (95% CI 2·08-2·19). 30 911 (14·8%) patients in the exposed group received a new prescription for any type of mental ill health (incidence rate 46·5 events per 1000 person-years) versus 36 390 (8·9%) patients in the unexposed group (20·5 per 1000 person-years) resulting in an adjusted IRR of 2·44 (95% CI 2·40-2·48).

INTERPRETATION

Childhood maltreatment is thought to affect one in three children globally; therefore, a doubled risk of developing mental ill health among these individuals represents a substantial contribution to the mental ill health burden in the UK. It is imperative that public health approaches, including those aimed at preventing and detecting childhood maltreatment and its associated negative consequences, are implemented to prevent mental ill health.

FUNDING

None.

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF)

Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions.

INTRODUCTION

Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication.

METHODS

A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken.

RESULTS

Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it.

CONCLUSION

These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.

Early clinical exposure through a vertical integration programme in physiology

Background

Early clinical exposure is likely to be beneficial during the preclinical year. This pilot programme aimed to define a learning framework of introducing first year medical students to early clinical exposure through a vertical integration programme in the physiology course. The intent was to enhance the understanding of theoretical concepts and practical applications of physiology. Student and faculty perceptions were evaluated.

Methods

First year MBBS students (n = 60) had bedside clinics conducted by 5 clinical departments, where the clinical context and applied physiological concepts were emphasized. Clinical sessions were synchronized with pedagogic highlights on related physiological concepts. The student's perceptions were recorded through a semi-structured questionnaire, while qualitative feedback was obtained from the faculty.

Results

All students ( 100%) reported that the programme was relevant and did not interfere with their physiology course. Most (91%) appreciated the synchronization of classroom knowledge with clinical exposures, and thought that integrated teaching helped in better understanding of practical applications of physiology (94%) with adequate discussions during the sessions (91 %). Fifty-nine (98%) students preferred integrated teaching over the isolated traditional classroom teaching. The clinicians involved also felt that the early clinical exposure was relevant. The students achieved a mean (SD) score of 13 (2.98) of 25 in the quiz consisting of multiple-choice questions that attempted to test their learning through early clinical exposures.

Conclusion

This pilot exercise showed the utility of early clinical exposure integrated into the physiology course. It will be worthwhile to replicate this exercise at other institutions and among a larger student strength.

Increased risk of non-alcoholic fatty liver disease in women with gestational diabetes mellitus: A population-based cohort study, systematic review and meta-analysis

AIMS

Non-Alcoholic Fatty Liver Disease (NAFLD) is one of the leading causes of liver transplantation in the West. This study seeks to examine whether women with gestational diabetes mellitus (GDM) are at increased risk of developing NAFLD compared to women without GDM.

METHODS

We conducted a population-based retrospective matched-controlled cohort study utilising The Health Improvement Network (THIN), a large primary care database representative of the United Kingdom population, between 01/01/1990 to 31/05/2016 followed by systematic review of available literature. The study population included 9640 women with GDM and 31,296 controls without GDM, matched for age, body mass index (BMI) and time of pregnancy. All study participants were free from NAFLD diagnosis at study entry. Patients with GDM and patients developing NAFLD were identified by clinical codes.

RESULTS

The median (range) follow-up duration was similar in women with and without GDM (2.95 (1.21-6.01) vs 2.85 (1.14-5.75) years respectively). Unadjusted incidence rate ratio (IRR) for NAFLD development in women with vs without GDM was 3.28 (95% CI 2.14-5.02), which remained significant after adjustment for wide range of potential confounders (IRR 2.70; 95% CI 1.744-4.19). The risk of NAFLD in GDM remained high (IRR 2.46: 95% CI 1.51-4.00) despite women being censored after they developed type 2 diabetes. The meta-analysis of 3 studies (including the current study) showed increased NAFLD risk in women with vs without GDM (OR 2.60; 95% CI 1.90-3.57, I₂ = 0%). As our study is based on routine clinical diagnosis of NAFLD, this study could potentially have underestimated the risk of NAFLD development.

CONCLUSIONS

Women with GDM are at increased risk of developing NAFLD in their later life compared to women without GDM regardless of the development of type 2 diabetes. Clinicians should have a low threshold to investigate women with history of GDM for the presence of NAFLD. Further studies to identify screening strategies are needed.

Global smoking trends in inflammatory bowel disease: A systematic review of inception cohorts

Background and aims

The effect of smoking on the risk of developing inflammatory bowel diseases (IBD) may be heterogeneous across ethnicity and geography. Although trends in smoking for the general population are well described, it is unknown whether these can be extrapolated to the IBD cohort. Smoking prevalence trends specific to the global IBD cohort over time have not been previously reported. This is a systematic review of smoking prevalence specific to the IBD cohort across geography.

Methods

A systematic literature search was conducted on Medline and Embase from January 1^st 1946 to April 5^th 2018 to identify population-based studies assessing the prevalence of smoking at diagnosis in inception cohorts of Crohn’s disease(CD) or ulcerative colitis(UC). Studies that did not report smoking data from time of diagnosis or the year of IBD diagnosis were excluded. Prevalence of smoking in IBD was stratified by geography and across time.

Results

We identified 56 studies that were eligible for inclusion. Smoking prevalence data at diagnosis of CD and UC was collected from twenty and twenty-five countries respectively. Never-smokers in the newly diagnosed CD population in the West has increased over the last two decades, especially in the United Kingdom and Sweden; +26.6% and +11.2% respectively. Never-smokers at CD diagnosis in newly industrialised nations have decreased over the 1990s and 2000s; China (-19.36%). Never-smokers at UC diagnosis also decreased in China; -15.4%. The former-smoker population at UC diagnosis in China is expanding; 11%(1990–2006) to 34%(2011–2013).

Conclusion

There has been a reduction in the prevalence of smoking in the IBD cohort in the West. This is not consistent globally. Although, smoking prevalence has decreased in the general population of newly industrialised nations, this remains an important risk factor with longer term outcomes awaiting translation in both UC and CD.

Measuring Gratitude in Children

Gratitude is a rich socioemotional construct that emerges over development beginning in early childhood. Existing measures of children's gratitude as a trait or behavior may be limited because they do not capture different aspects of gratitude moments (i.e., awareness, thoughts, feelings, and actions) and the way that these facets appear in children. The current study evaluates a battery of new measures assessing children's gratitude to address these limitations. Parent-child dyads (N=101; children aged 6-9) completed a lab-based assessment followed by a 7-day online parental diary and 18-month follow-up survey. In addition to newly developed measures of children's gratitude, the battery included indicators of convergent, concurrent, divergent, and predictive validity. Results demonstrate the complexity of gratitude as a construct and the relative benefits and limits of various assessment modalities. Implications for the measurement of children's gratitude and suggestions for future research on the development of gratitude are discussed.

Outcomes following feeding gastrostomy (FG) insertion in patients with learning disability: a retrospective cohort study using the health improvement network (THIN) database

OBJECTIVES

To measure the rates of lower respiratory tract infection (LRTI) and mortality following feeding gastrostomy (FG) placement in patients with learning disability (LD). Following this to compare these rates between those having LRTI prior to FG placement and those with no recent LRTI.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The study population included patients with LD undergoing FG placement in the 'The Health Improvement Network' database. Patients with LRTI in the year prior (LYP) to their FG placement were compared with patients without a history of LRTI in the year prior (non-LYP) to FG placement. FG placement and LD were identified using Read codes previously developed by an expert panel.

MAIN OUTCOME MEASURES

Incidence rate ratio (IRR) of developing LRTI and mortality following FG, comparing patients with LRTI in the year prior to FG placement to patients without a history of LRTI.

RESULTS

214 patients with LD had a FG inserted including 743.4 person years follow-up. 53.7% were males and the median age was 27.6 (IQR 19.6 to 38.6) years. 27.1% were in the LYP patients. 18.7% had a LRTI in the year following FG, with an estimated incidence rate of 254 per 1000-person years. Over the study period the incidence rate of LRTI in LYP patients was 369 per 1000-person years, in non-LYP patients this was 91 per 1000-person years (adjusted IRR 4.21 (95% CI 2.68 to 6.63) p<0.001). 27.1% of patients died during study follow-up. Incidence rate of death was 80 and 45 per 1000-person year for LYP and non-LYP patients, respectively (adjusted IRR 1.80 (1.00 to 3.23) p=0.05).

CONCLUSION

In LD patients, no clinically meaningful reduction in LRTI incidence was observed following FG placement. Mortality and LRTI were higher in patients with at least one LRTI in the year preceding FG placement, compared with those without a preceding LRTI.

Placental expression of ENG, VEGF, and FLT: Gender-specific associations with maternal vitamin B12 status

OBJECTIVES

Adequate vitamin B₁₂ is a requisite during pregnancy and its deficiency is linked with increased risk for adverse outcomes, likely mediated by impaired placental angiogenesis. Thus, we aimed to test associations of maternal vitamin B₁₂ status with the placental expression of angiogenesis-associated genes ENG, VEGF, and FLT.

SUBJECTS/METHODS

In this retrospective case-control study, placental and maternal trimester 1 blood samples (n = 104) were collected from small for gestational age (SGA) and appropriate for gestational age (AGA) full-term singleton pregnancies. Maternal trimester 1 vitamin B₁₂ status was measured. Placentae and neonates were weighed at birth. Realtime quantitative PCR was performed to assess placental transcript abundance of ENG, VEGF, and FLT normalized to a panel of reference genes. Associations of placental transcript abundance of the genes with maternal trimester 1 vitamin B₁₂ status were evaluated.

RESULTS

Placental ENG transcript abundance associated negatively with maternal trimester 1 vitamin B₁₂ status (β = -0.461, P = 0.017, n = 104). This association was specific to the female births (β = -0.590, P = 0.014, n = 60). Placental VEGF transcript levels were negatively associated with maternal trimester 1 vitamin B₁₂ status only in the female births (β = -1.995, P = 0.029). Placental FLT transcript levels were not associated with maternal trimester 1 vitamin B₁₂ status.

CONCLUSION

Maternal trimester 1 vitamin B₁₂ status was associated negatively with placental ENG and VEGF expression predominantly in the female births. Therefore, we hypothesize that the placenta adapts to low maternal vitamin B₁₂ status by up-regulating angiogenic pathways in a gender-specific manner.

Incidence, morbidity and mortality of patients with achalasia in England: findings from a study of nationwide hospital and primary care data

BACKGROUND

Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited.

METHODS

Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality.

RESULTS

There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years.

CONCLUSION

The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.

The Risk of Inflammatory Bowel Disease in Subjects Presenting With Perianal Abscess: Findings From the THIN Database

BACKGROUND

Perianal abscess [PA] is associated with inflammatory bowel disease [IBD]. The incidence of IBD after a diagnosis of PA and potential predictors of a future diagnosis of IBD are unknown.

METHODS

The Health Improvement Network [THIN] is a primary care database representative of the UK population. Incident cases of PA were identified between 1995 and 2017. Subjects with PA were matched to controls within the same general practice. The primary outcome was a subsequent diagnosis of Crohn's Disease [CD] or ulcerative colitis [UC]. A Cox regression model was used to assess potential predictors of a new diagnosis of CD or UC following PA.

RESULTS

The risk of CD was higher in the PA cohort compared with controls; adjusted hazard ratio [HR] 7.51 (95% confidence interval [CI] 4.86-11.62), p < 0.0001. The risk of UC was also higher in the PA cohort compared with controls; adjusted HR 2.03 [1.38-2.99], p < 0.0001. Anaemia in men (HR 2.82 [1.34-5.92], p = 0.002), and use of antidiarrhoeal medications (HR 2.70 [1.71-4.25], p < 0.0001) were associated with an increased risk of CD following PA. Anaemia in men (HR 2.58 [1.09-6.07], p = 0.03), diarrhoea (HR 2.18 [1.23-3.85], p = 0.007), and use of anti-diarrhoeal medication (HR 2.27 [1.19-4.30], p = 0.012) were associated with an increased risk of UC following PA.

CONCLUSION

Subjects with PA are at an increased risk of subsequent diagnosis of CD and UC. Clinicians should strongly consider investigation for IBD in young patients presenting with diarrhoea and anaemia [in males] following PA. Future research should discern appropriate screening strategies for this high-risk cohort.

Association of Maternal Vitamin D Deficiency with Early Childhood Caries

Alaska Native (AN) children experience one of the highest reported rates of severe early childhood caries (S-ECC). Serum vitamin D concentrations in AN childbearing women in the Yukon Kuskokwim Delta (YKD) region have decreased since the 1960s to currently low levels, related to a decrease in traditional marine diet. Recent studies suggest an association between prenatal vitamin D (25(OH)D) concentrations in mothers and S-ECC in their infants. We used independent t tests to analyze the influence of prenatal 25(OH)D levels in YKD AN mothers on S-ECC in their children using data collected in the Maternal Organics Monitoring Study (MOMS). Maternal 25(OH)D levels were assessed at prenatal visits and in cord blood. We queried electronic dental records to assess early childhood caries (ECC) status using highest decayed, missing, filled, primary teeth (dmft) scores at 12 to 59 mo of age. We examined prenatal and cord blood for 76 and 57 mother/infant pairs, respectively. Children 12 to 35 mo of age with "deficient" cord blood (25(OH)D <30 nmol/L) had a mean dmft score twice as high as children who were "nondeficient" at birth (9.3 vs. 4.7; P = 0.002). There was no significant difference in mean dmft scores for children aged 36 to 59 mo with deficient versus nondeficient cord blood 25(OH)D (10.9 vs. 8.7 P = 0.14). There was no significant difference in mean dmft scores for children aged 12 to 35 mo whose mothers had "sufficient" versus "insufficient" 25(OH)D during prenatal visits (9.0 vs. 7.4; P = 0.48). In this small sample, children with deficient vitamin D levels in cord blood had a dmft score at 12 to 35 mo 2-fold higher than children with nondeficient cord blood. Maternal 25(OH)D may influence the primary dentition, and improving vitamin D status in pregnant women might affect ECC rates in their infants.

Review article: managing the adverse events caused by anti-TNF therapy in inflammatory bowel disease

BACKGROUND

Biological therapy is currently widely used to treat IBD. Infliximab, adalimumab and golimumab are currently licensed anti-TNF therapies. Biosimilar anti-TNF monoclonal antibodies are increasingly used. Anti-TNF therapies are widely used and their adverse effects are well characterised, and may cause significant morbidity and mortality in a small proportion of exposed patients. Gastroenterologists need to understand the mechanisms for these effects, recognise these swiftly and manage such events appropriately.

AIM

To cover the range of potential adverse reactions as a result of biologic therapy and specifically management of these events.

METHODS

A Medline and Pubmed search was undertaken. Search terms included were "anti-TNF," "infliximab" or "adalimumab" or "golimumab" combined with the keywords "ulcerative colitis" or "Crohn's disease" or "inflammatory bowel disease" and then narrowed to articles containing the keywords "complications," "side effects" or "adverse events" or "safety profile." International guidelines were also reviewed where relevant.

RESULTS

Adverse events discussed in this review include infusion reactions, blood disorders and infections (including bacterial, viral, fungal and opportunistic infections) as well as autoimmune, dermatological disorders, cardiac and neurological conditions. Malignancies including solid organ, haematological and those linked to viral disease are discussed.

CONCLUSIONS

Anti-TNF therapy has wide-ranging effects on the immune system resulting in a spectrum of potential adverse events in a small proportion of patients. Research advances are improving the understanding, recognition and management of these adverse events.

Vertebral fractures cascade: potential causes and risk factors

We performed a study to identify potential causes and risk factors of vertebral fracture cascade. Vertebral fracture cascade is a severe clinical event in patients with bone fragility. Only half of patients have an identified cause of secondary osteoporosis.

INTRODUCTION

Vertebral fracture (VF) is the most common osteoporotic fracture, and a strong risk factor of subsequent VFs leading to VF cascade (VFC). We prompted a study to identify potential causes and risk factors of VFC.

METHODS

VFC observations were collected retrospectively between January 2016 and April 2017. VFC was defined as an occurrence of at least three VFs within 1 year.

RESULTS

We included in 10 centers a total of 113 patients with VFC (79.6% of women, median age 73, median number of VFs in the cascade, 5). We observed 40.5% and 30.9% of patients with previous major fractures and a previous VF, respectively, and 68.6% with densitometric osteoporosis; 18.9% of patients were currently receiving oral glucocorticoids and 37.1% in the past. VFC was attributed by the physician to postmenopausal osteoporosis in 54% of patients. A secondary osteoporosis associated with the VFC was diagnosed in 52 patients: glucocorticoid-induced osteoporosis (25.7%), non-malignant hemopathies (6.2%), alcoholism (4.4%), use of aromatase inhibitors (3.6%), primary hyperparathyroidism (2.7%), hypercorticism (2.7%), anorexia nervosa (2.7%), and pregnancy and lactation-associated osteoporosis (1.8%). A total of 11.8% of cases were reported following a vertebroplasty procedure. A total of 31.5% patients previously received an anti-osteoporotic treatment. In six patients, VFC occurred early after discontinuation of an anti-osteoporotic treatment, in the year after the last dose effect was depleted: five after denosumab and one after odanacatib.

CONCLUSION

The results of this retrospective study showed that only half of VFC occurred in patients with a secondary cause of osteoporosis. Prospective studies are needed to further explore the determinants of this severe complication of osteoporosis.

Association between child maltreatment and central sensitivity syndromes: a systematic review protocol

INTRODUCTION

A growing body of evidence is identifying the link between a history of child maltreatment and a variety of adverse health outcomes ultimately leading to significant social and healthcare burden. Initial work has identified a potential association between child maltreatment and the development of a selection of somatic and visceral central sensitivity syndromes: fibromyalgia, chronic fatigue syndrome, temporomandibular joint disorder, chronic lower back pain, chronic neck pain, chronic pelvic pain, interstitial cystitis, vulvodynia, chronic prostatitis, tension-type headache, migraine, myofascial pain syndrome, irritable bowel syndrome and restless legs syndrome.

METHODS AND ANALYSIS

Primary electronic searches will be performed in the Embase, MEDLINE, PubMed, Scopus, PyscINFO, CINAHL and Cochrane Library databases and a number of Grey Literature sources including child protection and paediatric conference proceedings. Following independent screening of studies by two review authors, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses template will be used to aid extraction. A meta-analysis will be conducted on the included case-control and cohort studies. The Newcastle-Ottawa grading system will be used to assess the quality of included studies. Results will be expressed as pooled ORs for binary data and mean differences for continuous data.

ETHICS AND DISSEMINATION

Ethics approval will not be required. The final results of the review and meta-analysis will be submitted for peer-review publication and also disseminated at relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018089258.

Evidence of higher intramyocellular fat among normal and overweight Indians with prediabetes

BACKGROUND

The rise in prevalence rates of Type 2 Diabetes among Indians is well recognized. The research focus has been primarily to understand the changes in insulin sensitivity and beta cell dysfunction among Indians with Type 2 Diabetes. However, no data are available on the role of peripheral tissue, in particular intramyocellular lipid (IMCL) content and its impact on glucose homeostasis among Indians with prediabetes.

METHODS

28 male subjects (20-40 year) were studied. 13 with prediabetes (BMI ranging from 25.4 ± 2.9 kg/m²) and 15 controls (BMI ranging from 24.6 ± 2.8 kg/m²) were recruited. Body composition by dual energy X-ray absorptiometry (DXA), insulin sensitivity, insulin secretion rates were derived using the minimal model of C-peptide secretion and kinetics rates and skeletal muscle strength of the lower limb (quadriceps) was assessed using Isokinetic dynamometry. From muscle biopsy samples of the vastus lateralis, IMCL fat content (Oil red O staining) was determined.

RESULTS

The prediabetes group were older compared to controls (P < 0.01), but had similar BMI. The muscle to fat ratio, plasma Insulin, C peptide, HOMA-IR and HOMA % B were also comparable between the groups. IMCL fat content (%) was significantly higher in the prediabetes group compared to controls (7.0 ± 0.7% vs. 2.0 ± 0.3%, P < 0.01). This difference persisted even after controlling for age. Overall the IMCL fat content (%) was positively and significantly associated with HbA1c (r = 0.76, P < 0.01). HOMA-IR was significantly correlated with central (android, trunk) adiposity (kg) (r = 0.71, P < 0.01) but not with IMCL (%).

CONCLUSIONS

This is the first direct evidence of existence of significantly higher lipid levels within skeletal muscle cells among normal and overweight young Indians with prediabetes. However, there was no association between IMCL and HOMA-IR among the prediabetes group.

ZEB1 Is a Transcription Factor That Is Prognostic and Predictive in Diffuse Gliomas

Objective: To address the unmet medical need to better prognosticate patients with diffuse gliomas and to predict responses to chemotherapy regimens.

Methods: ZEB1 alterations were retrospectively identified from a cohort of 1,160 diffuse glioma patients. Epigenome-wide association scans (EWAS) were performed on available data. We determined the utility of ZEB1 as a prognostic indicator of patient survival in diffuse gliomas and assessed the value of ZEB1 to predict the efficacy of treating diffuse glioma patients with procarbazine, CCNU, and vincristine along with radiation at diagnosis. Decision curve analysis (DCA) was used to determine if ZEB1 added benefit to clinical decision-making over and above conventional methods.

Results: Fifteen percent of diffuse glioma patients had a ZEB1 deletion. ZEB1 deletion was associated with poor overall survival (OS) with and without adjustment for age and tumor grade (adjusted HR: 4.25; 95% CI: 2.35 to 7.66; P < 0.001). Decision curve analysis confirmed that ZEB1 status with or without IDH1 was more beneficial to clinical decision making than conventional information such as age and tumor grade. We showed that ZEB1 regulates TERT expression, and patients with ZEB1 deletions likely subsume patients with mutant TERT expression in diffuse gliomas. ZEB1 influenced clinical decision making to initiate procarbazine, CCNU, and vincristine treatment.

Conclusion: We demonstrate the prognostic value of ZEB1 in diffuse glioma patients. We further determine ZEB1 to be a vital and influential molecular marker in clinical decisions that exceed conventional methods regarding whether to treat or not treat patients with diffuse glioma.

The Curious Case of ZEB1

The Zinc Finger E-box binding homeobox (ZEB1/TCF8 or DeltaEF1) is at the forefront of transcription factors involved in controlling epithelial-to-mesenchymal transitions (EMT). Essentially, EMT allows for the reorganization of epithelial cells to become migratory cells with a mesenchymal phenotype.  In addition to ZEB1 being involved in embryonic development, ZEB1 has also been linked to processes involving micro-RNAs, long non-coding RNAs and stem cells. In recent years there has been an accumulation of evidence with regard to ZEB1 in various cancers. Although increased ZEB1 expression has largely been associated with EMT, cancer invasion, and tumorigenicity, there have been some episodic reports that have gone against the traditional reporting of the role of ZEB1. Indicating that the function of ZEB1 and the mechanisms by which ZEB1 facilitates its activities is more complex than was once appreciated. This complexity is further exacerbated by the notion that ZEB1 can act not only as a transcriptional repressor but a transcriptional activator as well. This review seeks to shed light on the complexity of ZEB1 with respect to cancer.

Measuring the shielding properties of flexible or rigid enclosures for portable electronics

Heaviside, in volume 1 of Electromagnetic theory, considered shielding of conducting materials in the form of attenuation. This treatment is still significant in the understanding of shielding effectiveness. He also considered propagation of electromagnetic waves in free-space. What Heaviside (1850-1925) could never have imagined is that 125 years later, there would be devices we know as mobile phones (or cell phones, handies, etc.) with capabilities beyond the dreams of the great science fiction writers of the day like H. G. Wells (1866-1949) or Jules Verne (1828-1905). More than this, that there would be a need for law enforcement agencies, among others, to use electromagnetically shielded enclosures to protect electronic equipment from communicating with the 'outside world'. Nevertheless, Heaviside's work is still fundamental to the developments discussed here. This paper provides a review of Heaviside's view of shielding and propagation provided in volume 1 of Electromagnetic theory and develops that to the design of new experiments to test the shielding of these portable enclosures in a mode-stirred reverberation chamber, a test environment that relies entirely on reflections from conducting surfaces for its operation.This article is part of the theme issue 'Celebrating 125 years of Oliver Heaviside's 'Electromagnetic Theory''.

Fetal sex modifies the effect of maternal macronutrient intake on the incidence of small-for-gestational-age births: a prospective observational cohort study

Background

Maternal macronutrient intake is likely to play a pivotal role in fetoplacental growth. Male fetuses grow faster and their growth is more responsive to maternal size.

Objective

We assessed the role of fetal sex in modifying the effect of maternal macronutrient intake on the risk of small-for-gestational-age (SGA) birth.

Design

This was a prospective, observational cohort study of 2035 births from an urban South Asian Indian population. Maternal intakes of total energy and macronutrients were recorded by validated food-frequency questionnaires. The interaction of trimester 1 macronutrient intake with fetal sex was tested on the outcome of SGA births.

Results

The prevalence of SGA was 28%. Trimester 1 macronutrient composition was high in carbohydrate and low in fat (means ± SDs-carbohydrate: 64.6% ± 5.1%; protein: 11.5% ± 1.1%; and fat: 23.9% ± 4.4% of energy). Higher carbohydrate and lower fat consumption were each associated with an increased risk of SGA [adjusted OR (AOR) per 5% of energy (95% CI): carbohydrate: 1.15 (1.01, 1.32); fat: 0.83 (0.71, 0.97)] specifically among male births (males: n = 1047; females: n = 988). Dietary intake of >70% of energy from carbohydrate was also associated with increased risk (AOR: 1.67; 95% CI: 1.00, 2.78), whereas >25% of energy from fat intake was associated with decreased risk (AOR: 0.61; 95% CI: 0.41, 0.90) of SGA in male births.

Conclusions

Higher carbohydrate and lower fat intakes early in pregnancy were associated with increased risk of male SGA births. Therefore, we speculate that fetal sex acts as a modifier of the role of maternal periconceptional nutrition in optimal fetoplacental growth.

Transversus abdominis plane block supplementation during iliac crest bone graft harvesting - Effect on postoperative pain

BACKGROUND AND AIMS

Transversus abdominis plane (TAP) block is a technique proposed to minimise pain after anterior iliac crest bone harvesting. This study aims to evaluate the postoperative pain in patients who receive ultrasound-guided TAP block to supplement routine wound infiltration.

MATERIAL AND METHODS

A total of 143 patients aged between 6 and 22 years were randomised into two groups. Patients in group A received supplemental TAP block on the same side. Patients in group B received local anesthetic wound infiltration alone. Pain scores were compared at the first and 24th postoperative hours.

RESULTS

TAP block significantly reduced pain and delirium in the immediate postoperative period. The mean FLACC (Face, Legs, Activity, Cry, Consolability) score after 10 min was 0.8 in group A versus 1.8 in group B (P = 0.001). The mean Watcha scale at 10 min was 1.0 in group A versus 1.2 in group B (P = 0.001). After 24 h, 81.7% of patients in group A had no pain versus 59.7% in group B (P = 0.004). The incidence of intolerable pain at 24 h was 5.6% in group B versus 0% in group A (P = 0.04). Cumulative ambulation scores were significantly better in group A (P < 0.05). There was a strong and positive correlation between the analgesia and ability to ambulate comfortably at 24 h postop (Pearson's coefficient 0.95).

CONCLUSION

Supplemental ultrasound-guided TAP block given intraoperatively reduces the postoperative pain. The incidence of emergence delirium was low. These patients were also able to ambulate earlier.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Bioelectrical impedance analysis (BIA)-derived phase angle (PA) is a practical aid to nutritional assessment in hospital in-patients

BACKGROUND

Nutritional status can be difficult to assess. Bioelectrical impedance analysis (BIA)-derived phase angle (PA), and the plasma markers citrulline and transthyretin (pre-albumin) have the potential to assist, but the protocol of fasting and resting for BIA renders the investigation impractical for routine use, especially so in populations at high risk of malnutrition.

AIMS

1 To clarify whether starving and resting are necessary for reliable measurement of PA. 2 To identify whether PA, citrulline and transthyretin correlate with nutritional status.

METHODS

Eighty consenting adult in-patients were recruited. Nutritional status was determined by subjective global assessment (SGA) used as gold standard. The Malnutrition Universal Screening Tool (MUST) was used and anthropometric measurements were performed. Serum was analysed for citrulline and transthyretin. PA was measured using Bodystat 4000. The PA was considered to define malnutrition when lower than reference ranges for sex and age, and severe malnutrition if more than 2 integers below the lower limit. Anthropometric measurements were categorised according to WHO reference centiles. Ordinal logistic regression estimated the strength of association of PA, citrulline and transthyretin with SGA. PA values in the different metabolic states were compared using paired t tests.

RESULTS

All 80 subjects completed the BIA and the nutritional assessments in the 3 different states; 14 declined to provide blood samples for the biochemical assays. Malnutrition was identified in 32 cases, severe malnutrition in 14 cases, the remaining 34 cases were deemed not to be malnourished. PA was strongly inversely associated with SGA (Odds Ratio [OR] per unit increase = 0.21, CI 0.12-0.37, p < 0.001). PA was not influenced by exercise (p = 0.134) or food intake (p = 0.184). Transthyretin was inversely associated with malnourished/severely malnourished states (OR = 0.98, 95% CI 0.97-0.99, p = 0.001), but had poorer predictive values than PA. There was no significant association between citrulline concentration and SGA (OR = 1.01, 95% CI 0.99-1.04, p = 0.348).

CONCLUSIONS

The BIA-derived PA reliably identifies malnutrition. It is strongly associated with SGA but requires less skill and experience, and out-performs circulating transthyretin, rendering it a promising and less operator-dependent tool for assessing nutritional status in hospital patients. Our novel demonstration that fasting and bed-rest are unnecessary consolidates that position.

Maternal intake of milk and milk proteins is positively associated with birth weight: A prospective observational cohort study

BACKGROUND

A striking number of low birth weight (LBW) Indian babies are born annually. Previous studies have confirmed the positive association between milk intake and birth weight. However, the relations between protein and vitamin B₁₂ from milk and birth weight have not been systematically explored.

AIMS

We examined the relations between birth weight and maternal intake of milk, protein from milk and vitamin B₁₂ from milk.

METHODS

This prospective, observational cohort study was conducted in an urban South Indian hospital. The dietary intakes of milk and milk products were assessed using validated food frequency questionnaire and at delivery birth outcomes were measured. The relations between milk products, milk protein, and vitamin B₁₂ from milk with birth weight and gestational weight gain were assessed in 2036 births with first trimester dietary and delivery data.

RESULTS

Median consumption of milk products in the first trimester was 310 g·day^-1 and average birth weight was 2876 g. Birth weight was positively associated with intake of milk products and of % protein from milk products (%milk protein) in the first trimester [β = 86.8, 95% confidence interval (CI): 29.1, 144.6; β = 63.1, 95% CI: 10.8, 115.5; P < 0.001 for both]. Intake of milk products and of %milk protein in the third trimester was positively associated with gestational weight gain (GWG) between the second and third trimester (One-way ANOVA, P < 0.001 and = 0.001, respectively). Neither birth weight nor GWG were associated with %vitamin B₁₂ from milk products.

CONCLUSIONS

These findings indicate that intake of milk products in the first trimester and especially, protein from milk products is positively associated with birth weight in this South Asian Indian population.

Protracted severe systemic cytomegalovirus disease in an immunosuppressed patient with ulcerative colitis

A 33-year-old man with ulcerative colitis presented with 5-day history of fever, night sweats, abdominal pain and increased stool frequency. He was on mesalazine M/R 1 g once daily, 6-mercaptopurine (6-MP) 75 mg once daily and prednisolone 40 mg once daily. Examination revealed fever and tachycardia. Blood examinations identified a persistent leucopenia, C reactive protein of 23 mg/L and an initial alanine transaminase of 855 IU/L. Flexible sigmoidoscopy revealed well-demarcated, punched-out ulcers in the proximal rectum and distal sigmoid, with histology pathognomonic of cytomegalovirus (CMV). CMV DNA PCR was 51 140 copies/mL. Despite prompt withdrawal of 6-MP, steroids and initiation of intravenous ganciclovir on day 2 of admission, his systemic illness, diarrhoea and fever persisted until day 19 of antiviral therapy. Other copathogens and lymphoma were ruled out on serology and CT scan, respectively. After an unusually prolonged course of antiviral therapy, the patient made a full clinical recovery, bloods normalised and there were two consecutive undetectable CMV DNA PCRs.

The association between idiopathic thrombocytopenic purpura and cardiovascular disease: a retrospective cohort study

Essentials We estimated the cardiovascular risk of patients with idiopathic thrombocytopenic purpura (ITP). The risk of cardiovascular disease was 38% higher in ITP patients compared with controls. Among the ITP patients, splenectomy was associated with higher cardiovascular disease. Clinicians should consider cardiovascular risk when managing ITP patients.

SUMMARY

Background Idiopathic thrombocytopenic purpura (ITP) is classically characterized by a transient or persistent decrease of platelet count. Mortality is higher in the ITP population than the general population, with a possible association with increased cardiovascular disease (CVD). Objectives The objective was to assess the strength of the association between ITP and CVD, with a secondary aim to assess the impact of splenectomy on CVD. Methods A population-based retrospective, open cohort study using clinical codes was performed using data from 6591 patients with ITP and 24 275 randomly matched controls (up to 1:4 ratio matched by age, sex, body mass index and smoking status). The main outcome was the risk of CVD, which included ischemic heart disease, stroke, trans-ischemic attack and heart failure. Adjusted incidence rate ratios were calculated using Poisson regression. Results During a median 6-year observation period there was a CVD diagnosis recorded in 392 (5.9%) ITP patients and 1114 (4.5%) control patients. There was an increased risk of developing CVD in the ITP cohort (incidence rate ratio [IRR], 1.38; 95% confidence interval [CI], 1.23-1.55), which remained robust even after a sensitivity analysis only including incident cases of ITP. Findings suggested that patients who had undergone splenectomy were at even further increased risk of developing CVD when compared with the ITP population who had not undergone splenectomy (adjusted IRR, 1.69; 95% CI, 1.22-2.34). Conclusion There is an increased risk of developing CVD in patients with ITP and even further increased risk for those patients with ITP who underwent splenectomy.

Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS

This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture.

METHODS

Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture.

RESULTS

Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types.

CONCLUSIONS

Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.

Genomic Correlates of Response to Everolimus in Aggressive Radioiodine-refractory Thyroid Cancer: A Phase II Study

Purpose: Targeting mutations leading to PI3K/mTOR/Akt activation are of interest in thyroid cancer. We evaluated the efficacy of everolimus in aggressive, radioactive iodine-refractory (RAIR) thyroid cancer and correlated tumor mutational profiling with response. Exploratory medullary and anaplastic thyroid cancer cohorts were included.Experimental Design: This single-arm, multi-institutional phase II study was conducted from 2009 to 2013 in patients with incurable RAIR thyroid cancer who had radiographic progression six months prior to enrollment. The primary endpoint was progression-free survival (PFS) with a median follow-up of 31.8 months. The study is closed to enrollment but treatment and follow-up are ongoing. A targeted next-generation sequencing platform was used for mutational analysis.Results: Thirty-three patients with differentiated thyroid cancer (DTC), 10 with medullary thyroid cancer (MTC), and 7 with anaplastic thyroid cancer (ATC) enrolled. For the DTC cohort, median PFS was 12.9 months (95% CI, 7.3-18.5) with a 2-year PFS of 23.6% (95% CI, 10.5-39.5). Median OS was not reached; 2-year OS was 73.5% (95% CI, 53.8-85.8). Among ATC patients, 1 had a partial response and was progression-free until 17.9 months after study entry and one had disease stability for 26 months, respectively. The genomically profiled cohort enriched for PI3K/mTOR/Akt alterations. PI3K/mTOR/Akt-mutated ATC subgroups appeared to benefit from everolimus. Treatment-related adverse events were as anticipated.Conclusions: Everolimus has significant antitumor activity in thyroid cancer. While genomic profiling does not currently guide therapeutic selection in thyroid cancer patients, these data have important implications when considering the use of an mTOR inhibitor in an era of precision medicine. Clin Cancer Res; 24(7); 1546-53. ©2018 AACR.

Management of oral bisphosphonates treatment by rheumatologists and determinants of therapeutic changes: a case-vignette-based study

Using case vignette methodology, this study shows that only 4% of patients are maintained on oral bisphosphonates over 5 years, and prescribers switch or stop the treatment in 20-30% of cases at each visit. There are few determinants of these changes. More information on appropriate follow-up could help in patients' management.

INTRODUCTION

Persistence to oral bisphosphonates, the most commonly prescribed anti-osteoporotic treatments, is low. The aim of this study was to evaluate the role of rheumatologists on the treatment patterns, and to assess the determinants of treatment changes.

METHODS

We used the methodology of case vignettes with the participation of 142 rheumatologists. Three baseline clinical vignettes were presented: (1) the physician was asked to indicate the most appropriate period to schedule the next visit over 5 years, (2) the physician was tested about parameters for follow-up (including traps), and (3) various results (both clinical, biological, densitometric, and radiological) were given by random and analyzed as determinants of treatment changes.

RESULTS

The study allowed assessment of 426 virtual clinical cases. Clinical examinations, patient's height, inquiries about falls, and adherence to treatment were deemed necessary in > 90% of cases. Bone mineral density was measured in 22, 40, and 71% of cases at 2, 3, and 5 years, respectively. Dental follow-up was recommended in less than 25% of cases. Only 4.2% of patients were maintained on the same treatment at 5 years, and a change of treatment (stop or switch) occurs in 20-30% of cases at each visit. Significant determinants were adherence to treatment, serum C-terminal crosslinking telopeptide of type 1 collagen (CTX) value, change in patient's height, and the occurrence of an incident vertebral fracture.

CONCLUSION

Our study shows that maintenance of oral bisphosphonate in postmenopausal women managed by rheumatologists is low; there are few determinants of these changes and more information on appropriate follow-up could help in patients' management.

Comparative Analysis of MicroRNA Expression among Benign and Malignant Tongue Tissue and Plasma of Patients with Tongue Cancer

Background

Identification of a microRNA (miRNA) pattern to be used as a biomarker for HNSCC is challenging given the heterogeneity of the disease and different methodologies used. To better define the field, we performed a prospective analysis of blood, tumor, and paired benign tissues in tongue squamous cell carcinoma (SCC) patients.

Methods

Plasma samples were collected prior to surgery, and paired tumor and benign tissue blocks were collected from tongue cancer resections. Circulating free and exosomal miRNA, and paired tumor and benign tissues miRNA were analyzed. TaqMan-based miRNA arrays were used to quantitate the expression of 747 human miRNAs. The comparative Ct method assessed the miRNA profile results, and Student’s t-test determined statistical significance between tumor and benign samples.

Results

Sixteen of 359 miRNAs detected were differentially expressed between paired tumor and benign tissue. Nine were upregulated, and seven downregulated in tumor tissue. All nine upregulated and six of seven downregulated tumor miRNAs were expressed in circulating exosomes. In contrast, eight of nine upregulated and four of seven downregulated tumor miRNAs were circulating free in the plasma.

Conclusion

An aberrantly expressed pattern of miRNA was identified in both tumor and plasma of patients with tongue SCC, suggesting this may be a biomarker for SCC of the oral tongue. Circulating exosomes appear to be a more reliable method for evaluation of circulating tumor-miRNA expression. Further studies with a larger cohort of patients and serial blood samples are needed to validate our findings.