Standardized approach to extract candidate outcomes from literature for a standard outcome set: a case- and simulation study

AIMS

Standard outcome sets enable the value-based evaluation of health care delivery. Whereas the attainment of expert opinion has been structured using methods such as the modified-Delphi process, standardized guidelines for extraction of candidate outcomes from literature are lacking. As such, we aimed to describe an approach to obtain a comprehensive list of candidate outcomes for potential inclusion in standard outcome sets.

METHODS

This study describes an iterative saturation approach, using randomly selected batches from a systematic literature search to develop a long list of candidate outcomes to evaluate healthcare. This approach can be preceded with an optional benchmark review of relevant registries and Clinical Practice Guidelines and data visualization techniques (e.g. as a WordCloud) to potentially decrease the number of iterations. The development of the International Consortium of Health Outcome Measures Heart valve disease set is used to illustrate the approach. Batch cutoff choices of the iterative saturation approach were validated using data of 1000 simulated cases.

RESULTS

Simulation showed that on average 98% (range 92-100%) saturation is reached using a 100-article batch initially, with 25 articles in the subsequent batches. On average 4.7 repeating rounds (range 1-9) of 25 new articles were necessary to achieve saturation if no outcomes are first identified from a benchmark review or a data visualization.

CONCLUSION

In this paper a standardized approach is proposed to identify relevant candidate outcomes for a standard outcome set. This approach creates a balance between comprehensiveness and feasibility in conducting literature reviews for the identification of candidate outcomes.

Fingernail form as a post-extraction guide for selecting the maxillary central incisor tooth form in the Saudi Arabian population: A novel application of CAD software

Background

Human teeth and nails have demonstrated similar factors genetically, embryologically, and morphologically. The fingernail form may be used as a post-extraction guide for selecting the tooth form.

Aim

To evaluate the correlation between the maxillary left central incisor tooth form with the left index, middle, and ring fingernails in the Saudi Arabian population.

Materials and Methods

A descriptive cross-sectional study with purposive sampling was done among 200 Saudi participants. The maxillary left central incisor and the left index, middle, and ring fingernail were scanned using an intraoral scanner. The 3D digital images were converted to 3D models. The tooth form (tooth length, tooth width, and tooth shape) and nail form (nail length, nail width, and nail shape) were measured using the CAD software. Pearson's correlation coefficient and T-test were used for statistical analysis (P < 0.05).

Result

A significant correlation exists between tooth length and nail length, with a maximum correlation toward index nail length (P = 0.015). A significant correlation exists between tooth width and nail width, with a maximum correlation toward ring nail width (P = 0.002). A significant correlation exists between tooth length and nail length in females with a maximum correlation toward index nail length in females (P = 0.001). The mean percentage of similarity between tooth and nail shape (index, middle, and ring) in males and females shows a highly significant difference between them (P = 0.001). The results indicate that the tooth and nail shape are similar (70 to 90%) based on the criteria set by the software.

Conclusion

A definite correlation exists between maxillary central incisor tooth form and fingernail form. The fingernail form may be used as a post-extraction guide for selecting the maxillary central incisor tooth form in the Saudi Arabian population.

In patients with type 2 diabetes chronic kidney disease is a modifiable cardiovascular risk factor

Background/Introduction

Chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) is associated with an increased risk of cardiovascular (CV) events. The modifiability of CKD-associated CV risk in patients with T2D across a spectrum of CKD stages remains unknown.

Purpose

To test whether CKD, as defined jointly by estimated glomerular filtration rate (eGFR) and albuminuria (urine albumin-to-creatinine ratio [UACR]), is a modifiable CV risk factor in patients with T2D. Furthermore, to estimate the population-wide reduction in first CV events in the US if all eligible patients were treated with finerenone.

Methods

We estimated the incidence rates of CV events (composite of CV death, non-fatal stroke, non-fatal myocardial infarction, or hospitalisation for heart failure) over a median follow-up of 3.0 years in 13,026 patients with CKD and T2D, treated with finerenone or placebo, in a joint analysis by eGFR and UACR categories. Patients were from FIDELITY, a prespecified pooled analysis of two phase III trials, and had an eGFR ≥25 ml/min/1.73 m2 and UACR 30–5000 mg/g at screening.The potential impact of finerenone treatment on the US population was evaluated by simulating the number of first CV events that could be prevented per year with finerenone, using incidence rates from FIDELITY and prevalence rates of CKD in patients with T2D from the National Health and Nutrition Examination Survey (NHANES).

Results

Lower eGFR and higher UACR categories were associated with higher incidences of CV events in finerenone and placebo recipients (Figure). Finerenone reduced CV risk versus placebo (hazard ratio 0.86; 95% CI 0.78–0.95; p=0.0018) without evidence of moderation of risk reduction by combined eGFR and UACR categories (p interaction = 0.66; Figure 1). Using NHANES, a total of 6.4 million treatment-eligible individuals with CKD and T2D were identified; 75% had CKD with an eGFR ≥60 ml/min/1.73 m2 and 25% had CKD with an eGFR &lt;60 ml/min/1.73 m2. Simulations using this NHANES population projected that 1 year of finerenone treatment could prevent 38,359 CV events in US patients with CKD and T2D, with 66% of events prevented in patients with eGFR ≥60 ml/min/1.73 m2.

Conclusions

Higher albuminuria and lower eGFR are associated with increased CV risk in patients with T2D. Across a range of eGFR and albuminuria categories, CV risk is modifiable. Therefore, CKD is a modifiable CV risk factor in part mediated by mineralocorticoid receptor overactivation. UACR screening to identify patients with T2D and albuminuria with an eGFR ≥60 ml/min/1.73 m2 is likely to provide a significant opportunity for population benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer AG

Biodegradation of Natural Rubber by Fungi and Bacteria

Environmental pollution is currently one of the major problems that are threatening biodiversity, ecosystems, and human health around the world. Natural rubber, which is one of the most significant polymers due to its variety of uses, has now become a serious environmental concern. Rubber waste management poses one of the greatest problems because it is extremely resilient and persists in the environment despite several mitigation efforts. Biodegradation is an eco-friendly alternative to conventional disposal methods and has gained tremendous interest in recent years. Several studies on rubber biodegradation utilizing fungi and bacteria have been reported. However, except for a few studies on technical applications, the majority of research on these microbes has focused on the fundamentals of rubber biodegradation. The challenge with biodegradation as a potential solution for rubber waste management is that we have limited mechanistic insight into rubber biodegradation, and the complicated composition of rubber products inhibits cell growth and activity of microbes. Thus it becomes important to fully comprehend the mechanism of rubber biodegradation and continue the search for new microbial strains so that the acquired knowledge can be utilized to develop a biodegradation process suitable for scale-up. In this short review, rubber degradation using fungi and bacteria is highlighted.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Clinical Implementation of 7T MRI for the Identification of Incidental Intracranial Aneurysms versus Anatomic Variants

Most unruptured intracranial aneurysms can be adequately characterized using 1.5T and 3T MR imaging. Findings in a subgroup of patients can remain unclear due to difficulties in distinguishing aneurysms from vascular anatomic variants. We retrospectively analyzed clinical data from 30 patients with suspected incidental aneurysms on 3T MR imaging who underwent 7T MR imaging. In all 30 cases, the differentiation of an aneurysm versus a vascular variant could be achieved. In 20 cases (66%), the initial suspected diagnosis was revised. Our findings suggest that 7T MR imaging provides a clarification tool for the group of patients with suspected unruptured intracranial aneurysms and diagnostic ambiguity after standard 3T MR imaging.

Antifibrotic and anti-inflammatory effects of the selective nonsteroidal MR antagonist finerenone in preclinical pulmonary fibrosis

Background

Patients with idiopathic pulmonary fibrosis (IPF) are at increased risk of developing coronary artery disease (CAD) with a median survival of 3.5 years after diagnosis. Cardiac and pulmonary fibrosis share several common signaling pathways including TGF-β-related collagen synthesis. Pirfenidone and nintedanib were the first approved medical antifibrotic IPF therapies that inhibit TGF-β–related collagen synthesis or multiple receptor tyrosine kinases, respectively. However, the role of mineralocorticoid receptor blockade in IPF is less well understood.

Purpose

To test the hypothesis that the selective nonsteroidal MR antagonist finerenone has antifibrotic and anti-inflammatory activity in preclinical IPF.

Methods

Anti-fibrotic/anti-inflammatory efficacy was investigated in two different mouse models of pulmonary fibrosis. Lung fibrosis was induced by either intranasal application of bleomycin (1 mg/kg) or intratracheal application of silica particles (2.5 mg/mouse). Bleomycin-treated C57BL6 mice (8 weeks old male, n=10–15/group) were administered once daily orally from day 7 to 21 with vehicle (ethanol/solutol/water), finerenone (10 mg/kg) or nintedanib (60 mg/kg) in vehicle. Silica-treated C57BL6 mice (8 weeks old male, n=10–12/group) were administered once daily orally from day 7 to 30 with vehicle (ethanol/solutol/water), finerenone (1 or 10 mg/kg) or nintedanib (100 mg/kg) in vehicle, or with pirfenidone (800mg/kg/d) via chow. At day 21 and 30 respectively, histological examination of pulmonary fibrosis using immunohistochemistry (COL1A1 positive tissue area in %) and Ashcroft score as well as profibrotic and pro-inflammatory cytokine and COL1A1 protein level (ELISA) analysis in lung homogenate were performed.

Results

Bleomycin caused a significant increase in lung COL1A1 positive tissue area and Ashcroft Score and silica-induced lung pathology additionally showed elevated IL-1beta, IL-6, IL-10, IL-12p70, TNFalpha and COL1A1 protein levels in lung tissue. Therapeutic treatment with finerenone as well as nintedanib from day 7–21 significantly reduced the percentage of lung COL1A1 positive tissue and Ashcroft score in the bleomycin mice model without a significant difference between treatment groups. Furthermore, finerenone significantly reduced lung COL1A1 as well as IL-1beta, IL-6, IL-10, IL-12p70 and TNFalpha protein levels in lung homogenate after a therapeutic treatment from day 7–30 in the silica mice model, whereas nintedanib showed only a reduction in lung COL1A1 and IL-10 levels and treatment with pirfenidone was without significant effects. There was a significant difference in the reduction of lung IL-12p70 and TNFalpha protein levels between finerenone 10 mg/kg and nintedanib as well as pirfenidone treatment.

Conclusion

Nonsteroidal MR antagonism by finerenone showed anti-fibrotic/anti-inflammatory efficacy in two animal models of pulmonary fibrosis and may impact the progressive course of fibrotic diseases.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): BAYER AG

Cardiovascular protection by combination of the selective nonsteroidal MR antagonist finerenone and the SGLT2 inhibitor empagliflozin in a preclinical model of hypertension-induced end-organ damage

Background

The nonsteroidal mineralocorticoid receptor (MR) antagonist finerenone and SGLT2 inhibitors have demonstrated clinical benefits in HFrEF and CKD patients with T2D. Cardiovascular protection with finerenone and the SGLT2 inhibitor empagliflozin in combination in hypertensive cardiorenal disease is unknown.

Purpose

To test the hypothesis that the combination of finerenone with empagliflozin provides cardiovascular protection in preclinical hypertension-induced end-organ damage.

Methods

Cardiovascular morbidity and mortality was studied in hypertensive L-NAME (20 mg/L) treated renin-transgenic (mRen2)27 rats. Rats (10–11 weeks old female, n=13–17/group) were treated once daily orally for up to 7 weeks with placebo, finerenone (1 and 3 mg/kg), empagliflozin (3 and 10 mg/kg), or a combination of the respective low doses. Blood pressure (week 1, 3 and 5), urinary (week 2 and 6) and plasma parameters (week 6 and at the end of the study) were determined during the course of the study, while cardiac histology and left ventricular gene expression analysis were performed after study end.

Results

Empagliflozin induced a strong and dose-dependent increase in urinary glucose excretion which was not influenced by finerenone co-administration in the combination arm. Treatment with 3 mg/kg finerenone and the low dose combination significantly decreased systolic blood pressure (SBP) after 3 and 5 weeks as well as plasma uric acid after 6 weeks. SBP was significantly more reduced in the combination arm vs. the individual monotherapies after 3 weeks. Plasma NT-proBNP was reduced by empagliflozin, finerenone and the combination with similar efficacy. There was a dose-dependent protection from cardiac vasculopathy, cardiac and vascular fibrosis with both agents while low dose combination therapy was more efficient than the respective monotherapy dosages on these cardiac histology parameters. Placebo-treated rats demonstrated a ca. 50% survival rate over the course of 7 weeks while low dose combination provided the most prominent survival benefit (93%).

Conclusion

Non-steroidal MR antagonism by finerenone and SGLT2 inhibition by empagliflozin confer cardiovascular protection in preclinical hypertensive-induced cardiorenal disease. Combination of these two modes of action at low dosages revealed efficacious reduction in blood pressure, cardiac lesions and mortality indicating a strong potential for combined clinical use in cardiorenal patient populations.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): BAYER AG

Appendicitis in the COVID-19 era: a modern challenge for experienced hands

INTRODUCTION

The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19.

METHODS

Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system.

RESULTS

Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798).

CONCLUSIONS

Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.

AB0128 CONSTRUCTION OF THE VETERANS AFFAIRS NATIONAL RHEUMATOID ARTHRITIS DATABASE (VANRAD)

Background:

The Department of Veterans Affairs (DVA) provides comprehensive medical care at minimal or no cost to 9 million veterans annually through 170 medical centers and 1074 outpatient clinics across the United States. In 1999, the DVA established a national, fully integrated electronic health record (EHR), which now includes approximately 24 million veterans. However, few studies have used VA EHR data to examine the validity of diagnoses of rheumatoid arthritis (RA).

Objectives:

Develop a validated, national database (VANRAD) of patients with RA who received VA care since International Classification of Diseases, tenth revision (ICD-10) coding was introduced in 2015. The database will provide infrastructure for retrospective and prospective research to address the ‘real-world’ care of patients with RA.

Methods:

Patients with the following criteria were identified from the VA EHR as of October 2, 2020: (a) ≥1 ICD-10 diagnosis code of RA; (b) treatment with ≥1 disease-modifying anti-rheumatic drug (DMARD); (c) ≥2 VA rheumatology clinic visits; and (d) ≥1 rheumatoid factor (RF) or anti-cyclic citrullinated peptide (aCCP) antibody test result. From this group, 553 EHRs were randomly selected for review. The ‘gold standard’ for the diagnosis of RA was the treating rheumatologist’s diagnosis, documented in the EHR.

Results:

27,482 patients met eligibility criteria. Sociodemographic characteristics were: 85.6% male, mean age of 69.7 years (y) (SD=10.9 y; range=21.9 y to 100.5 y), 76.4% white, 17.0% African American; and mean VA care duration 14.1 y (SD=5.3 y, range=0.04 y to 20.0 y).

For patients with ≥1 RF or aCCP test, the positive predictive value (PPV) for RA ranged from 65.3% (aCCP-/RF-) to 95.8% (aCCP+/RF+); rheumatologists’ likelihood of a ‘possible’ diagnosis was higher if the aCCP test result was negative or not available (Table 1). Excluding patients with a second rheumatologic diagnosis did not improve PPV results (data not shown).

Table 1.

Proportion of patients with a valid RA diagnosis1 as a function of RF and aCCP laboratory results

Test ResultaCCPNot Available (0)2Negative (-)Positive (+)TotalRheumatoid FactorNot Available (0)(N = 1253)3N 427N 1,159N 1,586RA4 89.7%RA 98.2%RA 93.5%Poss5 RA 5.9%Poss RA 0.0%Poss RA 3.2%Negative (-)N 810N 5,308N 2,005N 8,123RA 86.3%RA 65.3%RA 94.5%RA 80.7%Poss RA 3.9%Poss RA 11.9%Poss RA 0.0%Poss RA 5.8%Positive (+)N 2,229N 2,566N 12,978N 17,773RA 94.6%RA 78.0%RA 95.8%RA 87.6%Poss RA 0.0%Poss RA 8.5%Poss RA 2.1%Poss RA 4.3%TotalN 3,039N 8.301N 16,142N 27,482RA 90.7%RA 76.1%RA 95.9%RA 85.9%Poss RA 1.9%Poss RA 9.2%Poss RA 0.5%Poss RA 4.7%

1Diagnosis given by the treating rheumatologist.

2No test results available or test results available but without normal range values.

31,253 patients without available or interpretable RF or aCCP excluded from initial cohort.

4Percent of 553 charts reviewed confirmed as RA.

5Poss RA = Possible RA. Patients met our inclusion criteria but the treating rheumatologist never made definitive diagnosis of RA or alternative diagnosis (from 553 charts reviewed).

The percentage of RA-confirmed patients with one test not available, whose complementary test was negative (RF0/aCCP- or RF-/aCCP0), was greater than of patients for whom both tests were negative (RF-/aCCP-). This suggests our data extraction methods may be incomplete or that unidentified bias may be present and warrants further study.

Conclusion:

Our methodology for constructing an RA database by selecting patients with ≥2 rheumatology clinic visits, ≥1 ICD-10 diagnosis of RA, and treatment with ≥1 DMARD, has high positive predictive value for RA. Positive RF and aCCP test results were strong predictors of rheumatologists’ diagnostic certainty for an RA diagnosis. Thus, the VANRAD database and the associated EHR provide opportunity for a wide range of retrospective observational and prospective longitudinal studies based on ‘real-world’ patient care.

References:

[1]Ng B, et al. Arthritis Care Res 2012;64:1490-6; Hanly JG, et al. Open Access Rheumatol 2015;7:69-75.

Acknowledgements:

This study was sponsored by Bristol Myers Squibb.

Disclosure of Interests:

Amy Joseph Speakers bureau: Speakers bureau in the distant past., Grant/research support from: Bristol Myers Squibb, Jodi Yanagida: None declared, Xinliang Huang: None declared, Prabha Ranganathan: None declared, Melissa Laurie Shareholder of: Bristol-Myers Squibb, Employee of: I am currently employed by Bristol Myers Squibb., Hong Xian Grant/research support from: Bristol Myers Squibb Co., Seth Eisen Grant/research support from: The effort presented in this Abstract was supported with funds provided by Bristol-Meyers Squibb.

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

A Mycobacterial Systems Resource for the Research Community

Functional characterization of bacterial proteins lags far behind the identification of new protein families. This is especially true for bacterial species that are more difficult to grow and genetically manipulate than model systems such as Escherichia coli and Bacillus subtilis To facilitate functional characterization of mycobacterial proteins, we have established a Mycobacterial Systems Resource (MSR) using the model organism Mycobacterium smegmatis This resource focuses specifically on 1,153 highly conserved core genes that are common to many mycobacterial species, including Mycobacterium tuberculosis, in order to provide the most relevant information and resources for the mycobacterial research community. The MSR includes both biological and bioinformatic resources. The biological resource includes (i) an expression plasmid library of 1,116 genes fused to a fluorescent protein for determining protein localization; (ii) a library of 569 precise deletions of nonessential genes; and (iii) a set of 843 CRISPR-interference (CRISPRi) plasmids specifically targeted to silence expression of essential core genes and genes for which a precise deletion was not obtained. The bioinformatic resource includes information about individual genes and a detailed assessment of protein localization. We anticipate that integration of these initial functional analyses and the availability of the biological resource will facilitate studies of these core proteins in many Mycobacterium species, including the less experimentally tractable pathogens M. abscessus, M. avium, M. kansasii, M. leprae, M. marinum, M. tuberculosis, and M. ulceransIMPORTANCE Diseases caused by mycobacterial species result in millions of deaths per year globally, and present a substantial health and economic burden, especially in immunocompromised patients. Difficulties inherent in working with mycobacterial pathogens have hampered the development and application of high-throughput genetics that can inform genome annotations and subsequent functional assays. To facilitate mycobacterial research, we have created a biological and bioinformatic resource (https://msrdb.org/) using Mycobacterium smegmatis as a model organism. The resource focuses specifically on 1,153 proteins that are highly conserved across the mycobacterial genus and, therefore, likely perform conserved mycobacterial core functions. Thus, functional insights from the MSR will apply to all mycobacterial species. We believe that the availability of this mycobacterial systems resource will accelerate research throughout the mycobacterial research community.

Tautomer selection through solvate formation: the case of 5-hydroxynicotinic acid

Different 5-hydroxynicotinic acid tautomers were selectively captured through solvate formation. The selectivity is lost once the memory of solvation is erased by removing the solvent from the crystal lattice.

Data on the rootability of Parkia biglobosa using pure honey, Coconut Water and Moringa Leaf Extract as an alternative hormones

The data article contains the experimental data and figures on the number of rooted cuttings, number of cuttings with callus, cutting mortality and root length of Parkia biglobosa cuttings. The investigated data are related to the research article “Effects of alternative hormones on the rootability of Parkia biglobosa.” (Dunsin et al., 2014) [1]. In the experimental data, number of rooted cuttings, number of cuttings with callus, number of cuttings with mortality, total number of roots, total root length of cuttings and length of longest root of cuttings data employing alternative hormone (Pure Honey, Coconut Water, Moringa Leaf Extract) on the semi-hardwood stem cutting of Parkia biglobosa have been exhibited. The data would be useful to researchers finding alternate growth and rooting hormones that are cost friendly and for vegetative propagation during enrichment planting program of important tree crops that are difficult to propagate via seeds.

Polymorphism in Simvastatin: Twinning, Disorder, and Enantiotropic Phase Transitions

Simvastatin is one of the most widely used active pharmaceutical ingredients for the treatment of hyperlipidemias. Because the compound is employed as a solid in drug formulations, particular attention should be given to the characterization of different polymorphs, their stability domains, and the nature of the phase transitions that relate them. In this work, the phase transitions delimiting the stability domains of three previously reported simvastatin forms were investigated from structural, energetics, and dynamical points of view based on single crystal X-ray diffraction (SCXRD), hot stage microscopy (HSM), and differential scanning calorimetry (DSC) experiments (conventional scans and heat capacity measurements), complemented with molecular dynamics (MD) simulations. Previous assignments of the crystal forms were confirmed by SCXRD: forms I and II were found to be orthorhombic ( P2₁2₁2₁, Z'/ Z = 1/4) and form III was monoclinic ( P2₁, Z'/ Z = 2/4). The obtained results further indicated that (i) the transitions between different forms are observed at 235.9 ± 0.1 K (form III → form II) and at 275.2 ± 0.2 K (form II → form I) in DSC runs carried out at 10 K min^-1 and close to these values when other types of techniques are used (e.g., HSM). (ii) They are enantiotropic (i.e., there is a transition temperature relating the two phases before fusion at which the stability order is reversed), fast, reversible, with very little hysteresis between heating and cooling modes, and occur under single crystal to single crystal conditions. (iii) A nucleation and growth mechanism seems to be followed since HSM experiments on single crystals evidenced the propagation of an interface, accompanied by a change of birefringence and crystal contraction or expansion (more subtle in the case of form III → form II), when the phase transitions are triggered. (iv) Consistent with the reversible and small hysteresis nature of the phase transitions, the SCXRD results indicated that the molecular packing is very similar in all forms and the main structural differences are associated with conformational changes of the "ester tail". (v) The MD simulations further suggested that the tail is essentially "frozen" in two conformations below the III → II transition temperature, becomes progressively less hindered throughout the stability domain of form II, and acquires a large conformational freedom above the II → I transition. Finally, the fact that these transitions were found to be fast and reversible suggests that polymorphism is unlikely to be a problem for pharmaceutical formulations employing crystalline simvastatin because, if present, the III and II forms will readily convert to form I at ambient temperature.

An Assessment of Cancer Pain Control in an LMIC Oncology Clinic

Background: Cancer has become a leading cause of morbidity and mortality in adults globally. Pain is universally one of the most commonly encountered symptoms by health and supportive care providers involved in care of cancer patients. Inadequate pain control negatively impacts the patient´s quality of life, and may slow down the healing process. Health care providers often ignore pain control as a target of treatment as they focus on reducing the tumor burden. Pain management should be considered an important target and end point in the treatment of cancer patients. Aim: To assess the prevalence of pain, oncologists´ prescribing patterns; and efficacy of pain control in the Radiotherapy Department of the Lagos University Teaching Hospital. Methods: Adult cancer outpatients were assessed using a Universal Pain Assessment Tool and followed up for 2-6 weeks thereafter. Pain scores were assessed at first interview and at the follow-up appointment within 2 weeks minimum and 6 weeks maximum. Results: 347 adult clinic attendees were recruited, assessed, and followed up with interviewer-administered questionnaires over a close-out period of 6 weeks. There was an 85% (298 respondents) prevalence of pain in the study group; with over half of respondents characterizing their pain in the moderate to severe ranges. [Figure: see text] 9 out of 10 respondents stated the cancer was the primary source of their pain. Other sources of pain were medical tests; and treatment-related such as chemotherapy and radiation therapy. 86 patients (29% of study group) were not asked about pain by their attending physician, and all respondents stated their physician had not used any pain assessment tool to determine the nature or severity of their pain. [Figure: see text] Oral nonsteroidal analgesics were the most frequently prescribed form of pain control (237 patients), with radiotherapy coming in second (69 patients). The only available strong opioid analgesics at the oncology pharmacy were oral morphine and parenteral pentazocine. Oxycodone, fentanyl pethidine, and hydromorphone were unavailable. Interventional (e.g., cordotomy) and alternative (e.g., massage) forms of pain control were not prescribed in any patients. 43 respondents (15%) despite being in pain, did not receive any form of treatment or recommendation for pain control. At follow-up appointment 2-6 weeks after; 4 out of 10 respondents had not obtained pain relief from instituted measures. [Figure: see text] Conclusion: Undertreatment of cancer pain remains a major concern. The treatment process must begin with a proper and thorough evaluation of the patient's pain; a clear pain control goal and end point target; and regular reevaluation with application of guidelines when adequate control is not achieved. Inclusion of pain assessment and management guidelines in medical training would be of benefit to reduce the prevalence of inadequately controlled pain in patients living with cancer; ultimately improving their quality of life.

Childhood Cancer in an LMIC: Navigating the Wilderness

Background and context: When a child has cancer, the entire family is affected. Parents and caregivers lose work days while caring for the child. Many parents blame themselves and wonder if some action or decision of theirs contributed to; or caused the cancer. In addition, and especially for families falling within the low socioeconomic demographic groups, there may be poor understanding of the treatment process and expectations from treatment. Aim: To assess the most common challenges or concerns faced by parents, family members, or caregivers of a child living with cancer in Nigeria. Strategy/Tactics: A series of 10 focus group sessions were held with different groups of parents, family members, or other caregivers of children being treated for cancer at 2 teaching hospitals in Nigeria. Groups consisted of a minimum 8, and maximum of 12 participants in addition to a moderator. At the beginning of every session, participants were asked to submit 2 most pressing questions. Open-ended questions were also used with every attendee given a turn to give their answer. Participants were also given a chance to ask questions or bring up issues they had difficulty with. The single most prevalent concern raised in every focus group was lack of information or understanding. The 2 most common questions were: 1. What is cancer? 2. Why does my child have cancer? Program/Policy process: Data from the sessions were painstakingly compiled. The questions and concerns the attendee raised; and the degree of understanding they had regarding the diagnosis, treatment process, and expectations bring and after treatment. This data were collated and a team of experts including oncologists, nurses, and health workers in cancer were brought together to answer the questions. A compilation was made and a plan to disseminate the information was formulated. This culminated in the publishing of a free childhood cancer handbook; the first of its kind in Nigeria; with plans to translate the handbook into the common colloquial and vernacular languages in Nigeria. Outcomes: Participants of the focus groups were given a handbook, including some whose child had passed on since the sessions were held. 29% of the original participants were unreachable or declined the handbook. They were assessed to see if the handbook provided information that could have eased their cancer journey. 91% of assessed participants responded that having the handbook at diagnosis would have significantly increased their level of information and made the cancer journey easier. [Figure: see text][Figure: see text] The most appreciated information in the handbook was contact details of an organization dedicated to supporting them financially to pay treatment fees. What was learned: Many Nigerian families go through the entire childhood cancer journey completely in the dark. No dedicated information source on child cancer exists in Nigeria. Many parent and caregiver questions remain unanswered, and concerns remain unresolved.[Figure: see text]

The Burden of Comorbidities in Cancer Patients in Southwestern Nigeria

Background: Noncommunicable diseases (NCDs) in sub-Saharan Africa are a major cause of morbidity and mortality. There is especially a paucity of data on the burden of hypertension, diabetes mellitus and other NCDs coexisting with cancer in Nigerian cancer patients. Comorbidities influence the survival of patients with cancer; lead to presentation at advanced disease stages; and result in increased risk of treatment complications, higher rates of postoperative mortality, and a greater consumption of medical resources. Aim: To determine the magnitude and pattern of comorbidities in Nigerian cancer patients. Methods: This is a retrospective study, for which data were extracted from hospital records of patients presenting for oncology care between January 2015 and December 2016 in the Departments of Radiotherapy and Oncology of two tertiary health facilities in Lagos, Nigeria. Comorbidities were identified, ranked and weighted using the Charlson Comorbidity Index (CCI). Results: Eight hundred and forty-eight (848) cancer cases were identified, with breast (50.1%) and cervical (11.1%) cancers being the most prevalent. Comorbidities were present in 228 (26.9%) patients, and the most common comorbidities were hypertension (75.9%), diabetes (25.0%), and peptic ulcer disease (7.9%). Patients with prostate (41.5%), colorectal (34.0%), cervical (25.5%), nasopharyngeal (25.0%), and breast (24.0%) cancers are most likely to have comorbidities. The mean ages of patients with comorbidities and without was 60.1 ± 11.8 years and 52.5 ± 13.7 years respectively ( P < 0.0001). Hypertension-augmented CCI scores were 0 (15.6%), 1-3 (62.1%), 4-6 (21.7%), and ≥ 7 (0.6%). Patients with lower mean CCI scores were more likely to receive chemotherapy (2.2 ± 1.6 vs. 2.5 ± 1.9; P < 0.05) and/or surgery (2.1 ± 1.5 vs. 2.4 ± 1.7; P < 0.05). Conclusion: Comorbidities occur in at least one in four Nigerian cancer patients, and significantly influence the treatment outcome and prognosis of these patients. There is a need for a high index of suspicion and routine evaluation of cancer patients for comorbidities, with the aim of instituting appropriate and immediate multidisciplinary management measures where necessary.

Breast Cancer Pathology Reporting in a LMIC: Filling in the Gaps

Background: Breast cancer biology has been studied extensively over the past 5 decades, with a deeper understanding of the epidemiologic, clinical, and prognostic value of specific pathologic features. Tumor characterization beyond histologic type has been shown to guide treatment choices and ultimately improve outcomes. Pathologic features such as tumor grade, margin involvement, hormone and growth factor receptor overexpression, are all pieces of the puzzle that a clinician must put together to adequately map out the best treatment options available to the present-day breast cancer patient. Guidelines for breast cancer pathology reporting have been published, with universal consensus regarding the basic elements required to make a breast cancer pathology report complete. Aim: The aim of this study was to assess the completeness of pathology reports of breast cancer patients at all stages of diagnosis or treatment, presenting in an oncology department of a Nigerian teaching hospital over the period of one year. Methods: Pathology reports of 981 breast cancer patients attending the oncology clinic in 2016 were analyzed. Reports originated both from within the teaching hospital and from external pathology centers all over the country. Eight parameters were selected to analyze completeness of the reports: Specimen type, histologic type, immunohistochemistry, margin involvement, lymphovascular space invasion, pathologic stage, and tumor grade. Results: Of 981 pathology reports analyzed, 20.9% originated from the hospitals' pathology department. Specimen type was documented in 86% of reports. 24% of did not specify the histologic type, and almost half (44%) of reports did not specify the grade. 72% of the pathology reports did not have immunohistochemistry results ( Fig 1 ). Presence or absence of lymphovascular space invasion was reported in 10%; margin status in 32.3% ( Fig 2 ). Tumor stage was documented in 45%. Ki-67 was not reported in 99% of the pathology reports (Fig 3). Conclusion: Breast cancer survival has improved significantly globally; however LMICs such as Nigeria continue to lag behind. The reasons for this are undoubtedly multifactorial, however inadequate pathology reporting is worth exploring in the context of assessing the consequences of clinicians making decisions, armed with limited information regarding the biology of the tumor they are treating. In general, reports originating from within the hospital's pathology department were more complete than those from referring centers, with up to 7 out of 8 parameters present in at least 50%. Pathology reporting of breast cancer must be standardized in LMICs. Hundreds of years after Cheatle and Cutler first published their pathologic findings from breast cancer specimens; clinicians should no longer be subjected to the practice of making treatment decisions using inadequate data. Perhaps this will bring us one small step closer to achieving survival rates comparable to the rest of the world.[Figure: see text]

E-Patients: Online Health Seeking Behaviour of Cancer Patients in South Western Nigeria

Background: Cancer has been reported to be one of the top three diseases that patients research on the Internet. This is because the Internet is an evolving hub of cancer information and social support for patients. With the increasing connectivity and over 92,000,000 Internet enabled devices in Nigeria, it is expected that mobile health will proliferate and this will change the way cancer patients gather health information and resources, propagating a new age of e-patients. An e-patient is a health consumer who uses the Internet as a health resource. With over 100,000 new cancer cases diagnosed yearly in Nigeria, low doctor to patient ratio, constrained consultation time and limited access to specialist care, the need to promote patients to become e-patients could efficiently empower them to become better-educated healthcare consumers. However, there is a paucity of data on how Nigerian cancer patients use the Internet. Aim: To measure the utilization rate and patient attitudes toward the Internet. Methods: This descriptive cross-sectional study was carried out among 281 cancer patients across the department of radiotherapy in three teaching hospitals in south-western Nigeria in March 2018, using a self-administered questionnaire. The analysis was done with SPSS version 20, and the level of significance was set at < 0.05. Results: The mean age for the 281 participants was 50.8±14.2 years; with the majority between 41 and 60 years (46.6%); and females (78.3%). About 67.6% owned a smartphone ( Table 1 ); and 32% possessed a personal laptop/desktop computer, or lived in households with people with smartphones (66.9%). Majority of the respondents had consistent access to the Internet (59.1%) ( Table 2 ). They also had an e-mail and social media account (52%) in order of decreasing frequency: Facebook, 52.7%; WhatsApp, 18.1%; and Instagram, 17.1% ( Fig. 1 ). At least 43.1% had searched for cancer information online with the purpose of understanding the disease better (41.6%) ( Fig. 2 ). About 45.2% of the respondents also indicated that they would be comfortable having an online medical consultation with their oncologist; however, they had not used any health/cancer app before (71.2%). Patients aged 41-60 years, married, with tertiary level of education, and monthly incomes ≤ N50,000 (∼$140) were more likely to search for cancer information online ( P < 0.05). About 56.9% of the respondents did not use the Internet for cancer information because they preferred getting information directly from doctors (43.2%), lacked the knowledge of Internet use (33.6%), and lacked access to Internet-enabled devices (20.8%). Conclusion: With more cancer patients being connected to the Internet and an increasing trend to be e-patients, there is a need to leverage technology to provide patient education, consultation, navigation and social support services.[Table: see text]

[Table: see text][Figure: see text][Figure: see text]

The PAC-SYM questionnaire for chronic constipation: defining the minimal important difference

BACKGROUND

The Patient Assessment of Constipation-Symptoms (PAC-SYM) questionnaire is frequently used in clinical trials of constipation. However, the threshold for reduction in total PAC-SYM score used to define a clinical response on this 0-4 point scale has not undergone formal appraisal, and its relationship with clinical benefit as perceived by patients has not been defined.

AIM

To determine the minimal important difference in PAC-SYM score, and the optimum cut-off value for defining responders.

METHODS

The minimal important difference was estimated using data from six international phase 3/4, double-blind, randomised controlled trials of prucalopride in patients with chronic constipation (NCT01147926, NCT01424228, NCT01116206, NCT00485940, NCT00483886, NCT00488137), with anchor- and distribution-based approaches. Five appropriate patient-reported outcomes were selected as anchors. In addition, receiver operating characteristics (ROC) curve analyses were used to investigate responder discrimination for each anchor.

RESULTS

Data from 2884 patients were included. Minimal important difference estimates ranged from -0.52 to -0.63 across the five anchors. Estimates were not affected by study location but were consistently lower for rectal symptoms than for abdominal and stool symptoms. Distribution-based estimates were considerably lower than anchor-based estimates. ROC curve analyses showed optimum cut-off scores for discriminating responders to be similar to anchor-based minimal important difference estimates.

CONCLUSIONS

Anchor-based methods gave consistent results for the minimal important difference, at approximately -0.6, and this value was close to the ROC-determined optimal cut-off scores for responder discrimination. This value could be considered in clinical practice. A slightly more conservative threshold (eg -0.75) could be used in clinical trials to reduce the placebo response rate.

Health-related quality of life and work productivity of adults with ADHD: A UK web-based survey

Introduction

European data on health-related quality of life (HRQoL) in adults with attention deficit/hyperactivity disorder (ADHD) in the general population is sparse.

Aims and objectives

To report HRQoL in UK adults with ADHD.

Methods

UK residents aged 18–55 years with a diagnosis of adult ADHD completed an online, cross-sectional survey including questions on disease history, the EuroQol Five Dimensions questionnaire with five-levels (EQ-5D-5L) and the Work productivity and activity impairment questionnaire: general health (WPAI:GH). ADHD symptom severity was assessed by telephone using ADHD rating scale version IV with adult prompts (ADHD-RS-IV).

Results

The survey was completed by 233 participants (65.2% women; 77.3% white British), mean age 32.6 years (standard deviation [SD] 9.5), mean ADHD-RS-IV total score 43.46 (SD 7.88). Their mean EQ-5D-5L utility score of 0.74 (SD 0.21) was lower than the UK population norm of 0.86 (SD 0.23).[1] WPAI:GH scores indicated that health problems resulted in impairments of 32.04% in work productivity and 45.79% in regular daily activities. Regression analyses adjusting for gender, age and comorbidities demonstrated associations between EQ-5D-5L utility scores and gender (men had lower scores, P < 0.001), work impairment due to health problems (increasing impairment was associated with lower scores, P = 0.005) and age (for each additional year of age, scores decreased by 0.007, P = 0.010).

Conclusions

These results highlight the impact on health utility, work productivity and regular daily activities, and add to the description of the disease burden of adult ADHD in the UK.

This study was funded by Shire Development LLC.

Disclosure of interest

Kings College London research support account for Asherson received honoraria for consultancy to Shire, Eli-Lilly and Novartis educational/research awards from Shire, Lilly, Novartis, Vifor Pharma, GW Pharma and QbTech speaker at sponsored events for Shire, Lilly and Novartis.

Summer Temperature and Spatial Variability of all-Cause Mortality in Surat City, India

Background:

Ample information is available on extreme heat associated mortality for few Indian cities, but scant literature is available on effect of temperature on spatial variability of all-cause mortality for coastal cities.

Objective:

To assess the effect of daily maximum temperature, relative humidity and heat index on spatial variability of all-cause mortality for summer months (March to May) from 2014 to 2015 for the urban population of Surat (coastal) city.

Materials and Methods:

Retrospective analysis of the all-cause mortality data with temperature and humidity was performed on a total of 9,237 deaths for 184 summer days (2014-2015). Climatic and all-cause mortality data were obtained through Tutiempo website and Surat Municipal Corporation respectively. Bivariate analysis performed through SPSS.

Observations:

Mean daily mortality was estimated at 50.2 ± 8.5 for the study period with a rise of 20% all-cause mortality at temperature ≥ 40°C and rise of 10% deaths per day during extreme danger level (HI: > 54°C) days. Spatial (Zone wise) analysis revealed rise of 61% all-cause mortality for Southeast and 30% for East zones at temperature ≥ 40°C.

Conclusions:

All-cause mortality increased on high summer temperature days. Presence of spatial variation in all-cause mortality provided the evidence for high risk zones. Findings may be helpful in designing the interventions at micro level.

Label free measurement of retinal blood cell flux, velocity, hematocrit and capillary width in the living mouse eye

Measuring blood cell dynamics within the capillaries of the living eye provides crucial information regarding the health of the microvascular network. To date, the study of single blood cell movement in this network has been obscured by optical aberrations, hindered by weak optical contrast, and often required injection of exogenous fluorescent dyes to perform measurements. Here we present a new strategy to non-invasively image single blood cells in the living mouse eye without contrast agents. Eye aberrations were corrected with an adaptive optics camera coupled with a fast, 15 kHz scanned beam orthogonal to a capillary of interest. Blood cells were imaged as they flowed past a near infrared imaging beam to which the eye is relatively insensitive. Optical contrast of cells was optimized using differential scatter of blood cells in the split-detector imaging configuration. Combined, these strategies provide label-free, non-invasive imaging of blood cells in the retina as they travel in single file in capillaries, enabling determination of cell flux, morphology, class, velocity, and rheology at the single cell level.

Dynamic spin interchange in a tridentate Fe(iii) Schiff-base compound

The thermosalient effect is still a rare and poorly understood phenomenon, where crystals suddenly jump, bend, twist or explode upon undergoing a thermally activated phase transition. The synthesis and characterisation of the new spin transition Fe(iii) compound [Fe(5-Br-salEen)2][ClO4] (salEen = N-ethyl-N-(2-aminoethyl)salicylaldiminate) is described and its thermosalient behaviour reported. It is the first example of a thermosalient effect with a spin transition and magnetic, calorimetric, diffraction, microscopy and computational studies are used to characterise these effects. Both thermosalient effect and spin transition occur around 320 K upon heating and are accompanied by an anisotropic unit cell change with conservation of crystal symmetry that causes a large enough stress of the crystal lattice to induce crystal explosion. This stress can ultimately be traced back to a diffusionless and distortive structural perturbation resulting in a coupled spin transition-thermosalient effect.