Real-world evidence study finds no new-onset diabetes or drug-related hyperglycemia in Pompe disease patients treated with avalglucosidase alfa

Avalglucosidase alfa therapy for Pompe disease is diluted in dextrose 5% solution in water (D5W) for infusion, which raises questions about the potential for hyperglycemia or worsening diabetes. Using United States insurance claims data, we assessed the impact of biweekly infusions on hyperglycemia, new-onset diabetes mellitus, insulin resistance, and prediabetes in patients with Pompe disease. After starting avalglucosidase alfa treatment, 1 of 26 patients had one claim for hyperglycemia, which was attributed to acute pancreatitis.

Matrix-bound nanovesicle-associated IL-33 supports functional recovery after skeletal muscle injury by initiating a pro-regenerative macrophage phenotypic transition

Injuries to skeletal muscle are among the most common injuries in civilian and military populations, accounting for nearly 60% of extremity injuries. The standard of care for severe extremity injury has been focused upon limb salvage procedures and the utilization of tissue grafts or orthotics in conjunction with rehabilitation to avoid amputation. Nonetheless, many patients have persistent strength and functional deficits that permanently impact their quality of life. Preclinical and clinical studies have shown that partial restoration of functional skeletal muscle tissue following injury can be achieved by the implantation of a biologic scaffold composed of extracellular matrix (ECM). These favorable outcomes are mediated, at least in part, through local immunomodulation. The mechanisms underlying this immunomodulatory effect, however, are poorly understood. The present study investigates a potential mechanistic driver of the immunomodulatory effects; specifically, the effect of selected ECM components upon inflammation resolution and repair. Results show that the host response to skeletal muscle injury is profoundly altered and functional recovery decreased in il33-/- mice compared to age- and sex-matched wildtype counterparts by 14 days post-injury. Results also show that IL-33, contained within matrix-bound nanovesicles (MBV), supports skeletal muscle regeneration by regulating local macrophage activation toward a pro-remodeling phenotype via canonical and non-canonical pathways to improve functional recovery from injury compared to untreated il33-/- counterparts. Taken together, these data suggest that MBV and their associated IL-33 cargo represent a novel homeostatic signaling mechanism that contributes to skeletal muscle repair.

Combined sequence and copy number analysis improves diagnosis of limb girdle and other myopathies

OBJECTIVE

Clinical and genetic heterogeneities make diagnosis of limb-girdle muscular dystrophy (LGMD) and other overlapping disorders of muscle weakness complicated and expensive. We aimed to develop a comprehensive next generation sequence-based multi-gene panel ("The Lantern Focused Neuromuscular Panel") to detect both sequence variants and copy number variants in one assay.

METHODS

Patients with clinical diagnosis of LGMD or other overlapping muscular dystrophies in the United States were tested by PerkinElmer Genomics in 2018-2021 via "The Lantern Project," a sponsored diagnostic testing program. Sixty-six genes related to LGMD subtypes- and other myopathies were investigated. Main outcomes were diagnostic yield, gene-variant spectrum, and LGMD subtypes' prevalence.

RESULTS

Molecular diagnosis was established in 19.6% (1266) of 6473 cases. Major genes contributing to LGMD were identified including CAPN3 (5.4%, 68), DYSF (4.0%, 51), GAA (3.7%, 47), ANO5 (3.6%, 45), and FKRP (2.7%, 34). Genes of other overlapping MD subtypes identified included PABPN1 (10.5%, 133), VCP (2.2%, 28), MYOT (1.2% 15), LDB3 (1.0%, 13), COL6A1 (1.5%, 19), FLNC (1.1%, 14), and DNAJB6 (0.8%, 10). Different sizes of copy number variants including single exon, multi-exon, and whole genes were identified in 7.5% (95) cases in genes including DMD, EMD, CAPN3, ANO5, SGCG, COL6A2, DOK7, and LAMA2.

INTERPRETATION

"The Lantern Focused Neuromuscular Panel" enables identification of LGMD subtypes and other myopathies with overlapping clinical features. Prevalence of some MD subtypes was higher than previously reported. Widespread deployment of this comprehensive NGS panel has the potential to ensure early, accurate diagnosis as well as re-define MD epidemiology.

High unrecognized SARS-CoV-2 exposure of newly admitted and hospitalized psychiatric patients

BACKGROUND

Patients with pre-existing mental disorders are at higher risk for SARS-CoV-2 infection and adverse outcomes, and severe mental illness, including mood and psychosis spectrum disorders, is associated with increased mortality risk. Despite their increased risk profile, patients with severe mental illness have been understudied during the pandemic, with limited estimates of exposure in inpatient settings.

OBJECTIVE

The aim of this study was to describe the SARS-CoV-2 seroprevalence and antibody titers, and pro-inflammatory cytokine concentrations of newly admitted or hospitalized psychiatric inpatients without known history of COVID-19 infection, using robust quantitative multi-antigen assessments, and compare patients' exposure to that of hospital staff.

METHODS

This multi-centric, cross-sectional study compared SARS-CoV-2 seroprevalence and titers of 285 patients (University Psychiatric Centre Duffel [UPCD] N = 194; Assistance-Publique-Hopitaux de Paris [AP-HP] N = 91), and 192 hospital caregivers (UPCD N = 130; AP-HP N = 62) at two large psychiatric care facilities between January 1st and the May 30th 2021. Serum levels of SARS-CoV-2 antibodies against Spike proteins (full length), spike subunit 1 (S1), spike subunit 2 (S2), spike subunit 1 receptor binding domain (S1-RBD) and Nucleocapsid proteins were quantitatively determined using an advanced capillary Western Blot technique. To assess the robustness of the between-group seroprevalence differences, we performed sensitivity analyses with stringent cut-offs for seropositivity. We also assessed peripheral concentrations of IL-6, IL-8 and TNF-a using ELLA assays. Secondary analyses included comparisons of SARS-CoV-2 seroprevalence and titers between patient diagnostic subgroups, and between newly admitted (hospitalization ≤ 7 days) and hospitalized patients (hospitalization > 7 days) and correlations between serological and cytokines.

RESULTS

Patients had a significantly higher SARS-CoV-2 seroprevalence (67.85 % [95% CI 62.20-73.02]) than hospital caregivers (27.08% [95% CI 21.29-33.77]), and had significantly higher global SARS-CoV-2 titers (F = 29.40, df = 2, p < 0.0001). Moreover, patients had a 2.51-fold (95% CI 1.95-3.20) higher SARS-CoV-2 exposure risk compared to hospital caregivers (Fisher's exact test, P < 0.0001). No difference was found in SARS-CoV-2 seroprevalence and titers between patient subgroups. Patients could be differentiated most accurately from hospital caregivers by their higher Spike protein titers (OR 136.54 [95% CI 43.08-481.98], P < 0.0001), lower S1 (OR 0.06 [95% CI 0.02-0.15], P < 0.0001) titers and higher IL-6 (OR 3.41 [95% CI 1.73-7.24], P < 0.0001) and TNF-α (OR 34.29 [95% CI 5.00-258.87], P < 0.0001) and lower titers of IL-8 (OR 0.13 [95% CI 0.05-0.30], P < 0.0001). Seropositive patients had significantly higher SARS-COV-2 antibody titers compared to seropositive hospital caregivers (F = 19.53, df = 2, P < 0.0001), while titers were not different in seronegative individuals. Pro-inflammatory cytokine concentrations were not associated with serological status.

CONCLUSION

Our work demonstrated a very high unrecognized exposure to SARS-CoV-2 among newly admitted and hospitalized psychiatric inpatients, which is cause for concern in the context of highly robust evidence of adverse outcomes following COVID-19 in psychiatric patients. Attention should be directed toward monitoring and mitigating exposure to infectious agents within psychiatric hospitals.

Deep Learning Segmentation of the Nucleus Basalis of Meynert on 3T MRI

BACKGROUND AND PURPOSE

The nucleus basalis of Meynert is a key subcortical structure that is important in arousal and cognition and has been explored as a deep brain stimulation target but is difficult to study due to its small size, variability among patients, and lack of contrast on 3T MR imaging. Thus, our goal was to establish and evaluate a deep learning network for automatic, accurate, and patient-specific segmentations with 3T MR imaging.

MATERIALS AND METHODS

Patient-specific segmentations can be produced manually; however, the nucleus basalis of Meynert is difficult to accurately segment on 3T MR imaging, with 7T being preferred. Thus, paired 3T and 7T MR imaging data sets of 21 healthy subjects were obtained. A test data set of 6 subjects was completely withheld. The nucleus was expertly segmented on 7T, providing accurate labels for the paired 3T MR imaging. An external data set of 14 patients with temporal lobe epilepsy was used to test the model on brains with neurologic disorders. A 3D-Unet convolutional neural network was constructed, and a 5-fold cross-validation was performed.

RESULTS

The novel segmentation model demonstrated significantly improved Dice coefficients over the standard probabilistic atlas for both healthy subjects (mean, 0.68 [SD, 0.10] versus 0.45 [SD, 0.11], P = .002, t test) and patients (0.64 [SD, 0.10] versus 0.37 [SD, 0.22], P < .001). Additionally, the model demonstrated significantly decreased centroid distance in patients (1.18 [SD, 0.43] mm, 3.09 [SD, 2.56] mm, P = .007).

CONCLUSIONS

We developed the first model, to our knowledge, for automatic and accurate patient-specific segmentation of the nucleus basalis of Meynert. This model may enable further study into the nucleus, impacting new treatments such as deep brain stimulation.

Pompe disease ascertained through The Lantern Project, 2018-2021: Next-generation sequencing and enzymatic testing to overcome obstacles to diagnosis

The Lantern Project is an ongoing complimentary diagnostic program for patients in the United States sponsored by Sanofi and implemented by PerkinElmer Genomics. It combines specific enzymatic, biomarker, and genetic testing to facilitate rapid, accurate laboratory diagnosis of Pompe disease and several other lysosomal storage diseases, and a multigene next-generation sequencing panel including Pompe disease, LGMD, and other neuromuscular disorders. This article reports data for Pompe disease collected from October 2018 through December 2021, including acid α-glucosidase (GAA) enzyme assay and GAA sequencing (standard or expedited for positive newborn screening [NBS] to rule out infantile-onset Pompe disease [IOPD]) and the Focused Neuromuscular Panel, which includes GAA. One hundred forty patients (12 received only GAA enzyme testing, 128 had GAA sequencing alone or in addition to enzyme assay) have been confirmed with Pompe disease in this project. Eight of the 140 had a variant of unknown significance, but GAA activity ≤2.10 μmol/L/h, thus were confirmed with Pompe disease. Three diagnosed patients 0-2 years old had cross-reactive immunologic material (CRIM)-negative GAA variants and thus IOPD. One additional infant with presumptive IOPD had a homozygous frameshift c.1846del, likely CRIM-negative; symptoms were not provided. Among the 128 patients with molecular results, the c.-32-13T>G splice variant was homozygous in 11, compound-heterozygous in 98, and absent in 19. Proximal muscle weakness (58 patients) was the most common sign reported at testing; elevated creatine kinase (29 patients) was the most common laboratory result. The most common symptom categories were muscular (73 patients), musculoskeletal (13 patients), and respiratory (23 patients). Clinical information was not available for 42 samples, and 17 infants had only "abnormal NBS" or "low GAA" reported. Cardiac symptoms in 7 included potentially age-related conditions in five c.-32-13T>G-compound-heterozygous adults (myocardial infarction, heart murmur/palpitations, congestive heart failure: 1 each; 2 with atrial fibrillation) and hypertrophic cardiomyopathy in 2 children (1 and 2 years old) with presumptive IOPD. One novel GAA variant was observed in a patient with enzyme activity 0.31 μmol/L/h: c.1853_1854ins49, a frameshift pathogenic variant. The Lantern Project demonstrates the combinatorial utility of enzyme assay, targeted single-gene testing, and a focused neuromuscular next-generation sequencing panel in diagnosing Pompe disease.

Plasma Inflammatory Biomarkers and Anorexia of Ageing among Community-Dwelling Older Adults: An Exploratory Analysis of the MAPT Study

Anorexia of aging and biological aging might share physiological underpinnings. The aim of this secondary analysis was to investigate the associations between circulating inflammation-related markers and anorexia of aging in community-dwelling older adults. C-reactive protein (CRP), tumor necrosis factor receptor-1 (TNFR-1), interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1) and growth/differentiation factor-15 (GDF-15) were measured in plasma. Anorexia of aging was defined by the response "severe/moderate decrease in food intake" to the first item of the Mini-Nutritional Assessment. We included 463 subjects (median age=74y, IQR=71-78; 63.1% women). 33 subjects (7.1%) presented with anorexia at baseline, whereas 25 out of 363 (6.9%) developed it along 1-year follow-up. We found that TNFR1 (OR=1.74, 95%CI=1.27-2.39) and GDF-15 (OR=1.38, 95%CI=1.01-1.89) were associated with a significant increase in the odds of presenting with anorexia of aging cross-sectionally. No further significant associations were found. Biological aging mechanisms might be involved in the pathogenesis of anorexia of aging.

Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Geometry and Segmentation of Cerberus Fossae, Mars: Implications for Marsquake Properties

The NASA InSight mission to Mars successfully landed on 26 November 2018 in Elysium Planitia. It aims to characterize the seismic activity and aid in the understanding of the internal structure of Mars. We focus on the Cerberus Fossae region, a giant fracture network ∼1,200 km long situated east of the InSight landing site where M ∼3 marsquakes were detected during the past 2 years. It is formed of five main fossae located on the southeast of the Elysium Mons volcanic rise. We perform a detailed mapping of the entire system based on high-resolution satellite images and Digital Elevation Models. The refined cartography reveals a range of morphologies associated with dike activity at depth. Width and throw measurements of the fossae are linearly correlated, suggesting a possible tectonic control on the shapes of the fossae. Widths and throws decrease toward the east, indicating the long-term direction of propagation of the dike-induced graben system. They also give insights into the geometry at depth and how the possible faults and fractures are rooted in the crust. The exceptional preservation of the fossae allows us to detect up to four scales of segmentation, each formed by a similar number of 3-4 segments/subsegments. This generic distribution is comparable to continental faults and fractures on Earth. We anticipate higher stress and potential marsquakes within intersegment zones and at graben tips.

The influence of angioplasty balloon sizing on acute post-procedural outcomes: a Finite Element Analysis

Atherosclerosis is one of the most common vascular pathologies in the world. Among the most commonly performed endovascular treatments, percutaneous transluminal angioplasty (PTA) has been showing significantly positive clinical outcomes. Due to the complex geometries, material properties and interactions that characterize PTA procedures, finite element analyses of acute angioplasty balloon deployment are limited. In this work, finite element method (FEM) was used to simulate the inflation and deflation of a semi-compliant balloon within the 3D model of a stenosed artery with two different plaque types (lipid and calcified). Self-defined constitutive models for the balloon and the plaque were developed based on experimental and literature data respectively. Balloon deployment was simulated at three different inflation pressures (10, 12 and 14 atm) within the two plaque types. Balloon sizing influence on the arterial elastic recoil obtained immediately after PTA was then investigated. The simulated results show that calcified plaques may lead to higher elastic recoil ratios compared to lipid stenosis, when the same balloon inflation pressures are applied. Also, elastic recoil increases for higher balloon inflation pressure independent of the plaque type. These findings open the way for a data-driven assessment of angioplasty balloon sizing selection and clinical procedures optimization.Clinical Relevance- The FE model developed in this work aims at providing quantitative evaluation of recoil after balloon angioplasty. It may be useful for both manufacturers and clinicians to improve efficiency of angioplasty balloon device design and sizing selection with respect to plaque geometry and constitution, consequently enhancing clinical outcomes.

Determination of Atrazine in Water by Magnetic Particle Immunoassay: Collaborative Study

A collaborative study was performed to determine mean recovery and precision for analysis of atrazine in drinking and surface waters by immunoassay. The study design was based on the blind duplicate test plan for collaborative studies. Three blank waters (municipal drinking water, well water, and surface water) were spiked at 3 atrazine levels. Two water samples with naturally incurred atrazine loads were also spiked with atrazine at 3 levels. In the enzyme-linked immunoassay method, the water sample is mixed with a pesticide–enzyme conjugate and added to paramagnetic particles with triazine-specific antibodies attached. After separation of antibody-bound atrazine and atrazine–enzyme conjugate from free components, the bound enzyme conjugate catalyzes a reaction producing a colored end product. The color developed is inversely proportional to the original concentration of atrazine in the water sample. Fourteen laboratories participated in the collaborative study. Data were analyzed for repeatability and reproducibility, and average recoveries at the spike levels were calculated. Over the concentration range tested, the mean recovery of atrazine spiked into blank and pesticide-contaminated waters was 104%. Overall RSDRaveraged about 40% for atrazine concentrations near the method detection limit (0.05 μg/L) and about 15% at concentrations above 5 times the detection limit (0.25 μg/L). Corresponding single-analyst RSDr values were 24 and 10%. Recovery and precision for the 3 blank water matrixes and the waters that had been naturally contaminated with atrazine showed no significant differences. The magnetic particle immunoassay

P14.93 The utility of the brain 18-FDG-PET and perfusion magnetic resonance imaging in the radionecrosis differential diagnosis

BACKGROUND

Radiation-induced necrosis (RDN) is a side effect observed in patients who underwent stereotactic radiosurgery (SRS) alone or combined with whole brain radiotherapy (WBRT) as treatment for their brain tumors. Nowadays, RDN diagnosis and differentiation from tumor progression using the standard imaging techniques represents a challenge, and histological diagnosis still is the gold standard.Our aim is to assess the positive and negative predictive values (PPV, NPV) of FDG-PET and perfusion magnetic resonance imaging (MRI) in RDN diagnosis.

MATERIAL AND METHODS

From our Pathology department database, all patients with RDN or mixed (tumor plus RDN) brain lesions diagnosis during last 5 years were reviewed. Demographic, clinical and oncologic treatment characteristics were recorded. MRI and FDG-PET images at the suspicion (clinical or radiological) of progression or RDN were registered and compared with the definite diagnosis provided by the tissue sample analysis. Sensitivity, specificity, as such as PPV and NPV for perfusion MRI sequences and FDG-PET image analysis were calculated.

RESULTS

162 patients underwent SRS+/- WBRT in a 5 year period. During follow-up, 11 patients had surgery-confirmed RDN. There are 11 patients (3 women) with 12 lesions, 3 from a breast cancer, 6 from a lung tumor, 1 from a melanoma, 1 atypical meningioma and 1 glioblastoma. 9 of them were treated with both SRS and WBRT, and the 3 others with WBRT alone. The mean age was 65.36 (range: 44–77) years. The median time between the completion of radiation therapy and the suspicion of RDN was 19.7 (range: 3–34) months. With the evolution, it was observed an evident increase in the size of surronding oedema (2–6 times) by FLAIR RMI. We estimate a PPV 0.40 and NPV 0.80 for perfusion MRI, and PPV 0.25 and NPV 0.75 for FDG-PET, respectively.

CONCLUSION

The diagnostic performance of both techniques in our series is low and similar to published data; therefore its results must be carefully interpreted in each case. It is peremptory to implement new diagnostic tools in the standard of care with better diagnostic outcomes.

Variability and trends in corticosteroid use by male United States participants with Duchenne muscular dystrophy in the Duchenne Registry

Background

Treatment options for Duchenne muscular dystrophy remain limited, although consensus treatment guidelines recommend corticosteroid use.

Methods

This retrospective analysis assessed corticosteroid use in ambulatory and nonambulatory US males with Duchenne, age 35 and under, or Becker muscular dystrophy, who enrolled in The Duchenne Registry from 2007 to 2016 (formerly DuchenneConnect).

Results

The mean (SD) age of corticosteroid use initiation was 5.9 (2.5) years, and deflazacort use (54%) was slightly more common than prednisone/prednisolone (46%). Among all responses from those with Duchenne, 63% were currently on corticosteroids, 12% were no longer on corticosteroids, and 25% had never been on corticosteroids. Among those who were nonambulatory, 49% were currently on corticosteroids, 28% had discontinued corticosteroids, and 23% had never used corticosteroids. Primary reasons for never initiating therapy were that corticosteroids were not prescribed or recommended and concerns about side effects. Corticosteroid use was maximal at age 8 (84% on corticosteroids) and gradually declined from age 10 to 19. The primary reasons for corticosteroid discontinuation were problems with side effects (65%) or not enough benefit (28%). Average doses of corticosteroids were below recommended doses. In the 159 responses with Becker muscular dystrophy, 20% were currently using corticosteroids.

Conclusions

Recognizing the self-selected nature of participation, it appears that a considerable proportion of US participants registered with The Duchenne Registry were either not on corticosteroids or not on recommended doses despite consensus recommendations. Side effects were a consideration in initiating and discontinuing treatment.

These data reinforce the need for additional treatment options for those affected by Duchenne.

Practical Considerations for Using Online Methods to Engage Patients in Guideline Development

Clinical practice guidelines (CPGs) have been widely used in healthcare policy, practice, and for suggesting future research. As patients increasingly become involved in CPG development to produce patient-centered recommendations, more research is needed on methods to engage patients, particularly methods allowing for scalable engagement of large, diverse, and geographically distributed groups of patients. In this article, we discuss practical considerations for using online methods to engage patients in CPG development. To inform this discussion, we conducted a rapid, systematic review of literature on patient involvement in CPG development and used qualitative evidence synthesis techniques to make inferences about potential advantages and challenges of using online methods to engage patients in this context. We identified 79 articles containing information about involving patients in CPG development. Potential advantages include the ability of online methods to facilitate greater openness and honesty by patients, as well as to reflect the diversity of patient views, which in turn further improve the utility of CPGs. Potential challenges of using online methods may include the extra skill, time, and certain types of resources that may be needed for patient engagement, as well as the difficulty engaging specific patient populations. However, these challenges are mitigated by growing calls for patient engagement as normative for CPG development in addition to patients' increasing familiarity with online technologies. These practical considerations should be examined empirically as guideline development groups further explore the appropriateness of using online methods to engage patients across different stages of CPG development.

DMD genotype correlations from the Duchenne Registry: Endogenous exon skipping is a factor in prolonged ambulation for individuals with a defined mutation subtype

Antisense oligonucleotide (AON)‐mediated exon skipping is an emerging therapeutic for individuals with Duchenne muscular dystrophy (DMD). Skipping of exons adjacent to common exon deletions in DMD using AONs can produce in‐frame transcripts and functional protein. Targeted skipping of DMD exons 8, 44, 45, 50, 51, 52, 53, and 55 is predicted to benefit 47% of affected individuals. We observed a correlation between mutation subgroups and age at loss of ambulation in the Duchenne Registry, a large database of phenotypic and genetic data for DMD (N = 765). Males amenable to exon 44 (N = 74) and exon 8 skipping (N = 18) showed prolonged ambulation compared to other exon skip groups and nonsense mutations (P = 0.035 and P < 0.01, respectively). In particular, exon 45 deletions were associated with prolonged age at loss of ambulation relative to the rest of the exon 44 skip amenable cohort and other DMD mutations. Exon 3–7 deletions also showed prolonged ambulation relative to all other exon 8 skippable mutations. Cultured myotubes from DMD patients with deletions of exons 3–7 or exon 45 showed higher endogenous skipping than other mutations, providing a potential biological rationale for our observations. These results highlight the utility of aggregating phenotypic and genotypic data for rare pediatric diseases to reveal progression differences, identify potentially confounding factors, and probe molecular mechanisms that may affect disease severity.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Low annual frequency of HbA1c testing in people with Type 2 diabetes in primary care practices in Germany

AIMS

To analyse the annual frequency of HbA_1c testing, as well as the factors associated with higher or lower testing frequency, in people with Type 2 diabetes mellitus in general practices and specialist diabetes practices in Germany.

METHODS

A total of 43 509 people diagnosed with Type 2 diabetes between January 2016 and December 2016 in 557 medical practices (51% of all practices) were included in this study. The primary outcome was the annual recorded frequency of HbA_1c testing in 2016. Multivariable logistic regression analyses were performed to identify variables associated with the odds of HbA_1c concentration being tested at least twice in 2016, using predefined demographic and clinical variables.

RESULTS

The mean (sd) number of reported HbA_1c tests was 2.7 (1.6) in 2016. Overall, 74% of individuals had at least two annual HbA_1c measurements. The likelihood of receiving ≥2 HbA_1c tests was inversely associated with stroke (odds ratio 0.81, 95% CI 0.74-0.89), shorter diabetes duration (≤1 year: odds ratio 0.77, 95% CI 0.70-0.84) and higher mean HbA_1c concentration (≥8.5%: odds ratio 0.85, 95% CI 0.76-0.94) and was positively associated with specialist diabetes care (odds ratio 1.24, 95% CI 1.14-1.36), hypertension (odds ratio 1.10, 95% CI 1.04-1.17), hyperlipidaemia (odds ratio 1.48, 95% CI 1.41 to 1.55), renal complications (odds ratio 1.41, 95% CI 1.32 to 1.50), neuropathy (odds ratio 1.27, CI 1.20 to 1.35) and retinopathy (odds ratio 1.38, 95% CI 1.25 to 1.52).

CONCLUSIONS

Only three out of four individuals with Type 2 diabetes underwent at least two HbA_1c tests in Germany in 2016, which means that 25% of individuals underwent fewer tests than required by German guidelines.

An Evidence-Based, Community-Engaged Approach to Develop an Interactive Deliberation Tool for Pediatric Neuromuscular Trials

Duchenne/Becker muscular dystrophy (DBMD) and spinal muscular atrophy (SMA) are rare neuromuscular disorders that present challenges to therapeutic and clinical trial decision making. We developed an interactive, evidence-based online tool designed to encourage thoughtful deliberation of the pros and cons of trial participation and to inform meaningful discussions with healthcare providers. Prior research demonstrates the importance of tool availability at the time each family is considering trial participation, which may be prior to the informed consent process. The tool is intended to be easily modified to other pediatric disease communities. Tool development was informed by prior qualitative research, literature reviews, and stakeholder input. Specific items were derived based on an online exploratory questionnaire of parents whose children participated in a trial for DBMD or SMA to understand motivations for participation. Parent participants in the exploratory survey reported strong impact of altruistic and individual benefit motivations and placed much greater emphasis on anticipated trial benefits than on harms when making participation decisions. We used this data to develop the evidence-based deliberation tool using a community-engaged approach. We initially targeted the tool for DBMD while using SMA survey data to evaluate ease of transition to that population. We conducted two iterative sets of activities to inform development and refinement of the tool: (1) community engagement of key stakeholders and (2) user experience testing. These activities suggest that the tool may increase deliberation and the weighing of benefits and harms. Ongoing evaluation will determine the acceptability and efficacy of this online intervention.

Edawu: a journey from in-patient rehabilitation to community-based treatment and rehabilitation in Nigeria

Community-based rehabilitation is the strategy endorsed by the World Health Organization and other international bodies to promote the inclusion of people with disabilities, particularly in low- and middle-income countries. In this article we trace the journey of Edawu, a mental health rehabilitation unit in a rural area of Benue State, Nigeria, from an in-patient rehabilitation unit to a community-focused service. The partnership of organisations from the UK with Edawu along the journey is also described. The authors set out learning points from the project and the principles behind sustainable overseas organisational partnerships.

Delayed onset of ambulation in boys with Duchenne muscular dystrophy: Potential use as an endpoint in clinical trials

Individuals with Duchenne muscular dystrophy (DMD) often exhibit delayed motor and cognitive development, including delayed onset of ambulation. Data on age when loss of independent ambulation occurs are well established for DMD; however, age at onset of walking has not been well described. We hypothesize that an effective medication given in early infancy would advance the age when walking is achieved so that it is closer to age-matched norms, and that this discrete event could serve as the primary outcome measure in a clinical trial. This study examined three data sets, Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet); Dutch Natural History Survey (DNHS); and Parent Project Muscular Dystrophy (PPMD). The distribution of onset of ambulation in DMD (mean ± SD) and median age, in months, at the onset of ambulation was 17.3 (±5.5) and 16.0 in MD STARnet, 21.8 (±7.1) and 20.0 in DNHS, and 16.1 (±4.4) and 15 in PPMD. Age of ambulation in these data sets were all significantly later (P <0.001) than the corresponding age for typically developing boys, 12.1 (±1.8). A hypothetical clinical trial study design and power analyses are presented based on these data.

Engaging Patients and Caregivers Managing Rare Diseases to Improve the Methods of Clinical Guideline Development: A Research Protocol

BACKGROUND

Clinical guidelines provide systematically developed recommendations for deciding on appropriate health care options for specific conditions and clinical circumstances. Up until recently, patients and caregivers have rarely been included in the process of developing care guidelines.

OBJECTIVE

This project will develop and test a new online method for including patients and their caregivers in this process using Duchenne muscular dystrophy (DMD) care guidelines as an example. The new method will mirror and complement the RAND/UCLA Appropriateness Method (RAM)-the gold standard approach for conducting clinical expert panels that uses a modified Delphi format. RAM is often used in clinical guideline development to determine care appropriateness and necessity in situations where existing clinical evidence is uncertain, weak, or unavailable.

METHODS

To develop the new method for engaging patients and their caregivers in guideline development, we will first conduct interviews with experts on RAM, guideline development, patient engagement, and patient-centeredness and engage with Duchenne patients and caregivers to identify how RAM should be modified for the purposes of patient engagement and what rating criteria should patients and caregivers use to provide their input during the process of guideline development. Once the new method is piloted, we will test it by conducting two concurrently run patient/caregiver panels that will rate patient-centeredness of a subset of DMD care management recommendations already deemed clinically appropriate and necessary. The ExpertLens™ system-a previously evaluated online modified Delphi system that combines two rounds of rating with a round of feedback and moderated online discussions-will be used to conduct these panels. In addition to developing and testing the new engagement method, we will work with the members of our project's Advisory Board to generate a list of best practices for enhancing the level of patient and caregiver involvement in the guideline development process. We will solicit input on these best practice from Duchenne patients, caregivers, and clinicians by conducting a series of round-table discussions and making a presentation at an annual conference on Duchenne.

RESULTS

The study protocol was reviewed by RAND's Human Subjects Protection Committee, which determined it to be exempt from review. Interviews with RAM experts have been completed. The projected study completion date is May 2020.

CONCLUSIONS

We expect that the new method will make it easier to engage large numbers of patients and caregivers in the process of guideline development in a rigorous and culturally appropriate manner that is consistent with the way clinicians participate in guideline development. Moreover, this project will develop best practices that could help involve patients and caregivers in the clinical guideline development process in other clinical areas, thereby facilitating the work of guideline developers.

Complex regulation of LCoR signaling in breast cancer cells

Ligand-dependent corepressor (LCoR) is a transcriptional repressor of ligand-activated estrogen receptors (ERs) and other transcription factors that acts both by recruiting histone deacetylases and C-terminal binding proteins. Here, we first studied LCOR gene expression in breast cancer cell lines and tissues. We detected two mRNAs variants, LCoR and LCoR2 (which encodes a truncated LCoR protein). Their expression was highly correlated and localized in discrete nuclear foci. LCoR and LCoR2 strongly repressed transcription, inhibited estrogen-induced target gene expression and decreased breast cancer cell proliferation. By mutagenesis analysis, we showed that the helix-turn-helix domain of LCoR is required for these effects. Using in vitro interaction, coimmunoprecipitation, proximity ligation assay and confocal microscopy experiments, we found that receptor-interacting protein of 140 kDa (RIP140) is a LCoR and LCoR2 partner and that this interaction requires the HTH domain of LCoR and RIP140 N- and C-terminal regions. By increasing or silencing LCoR and RIP140 expression in human breast cancer cells, we then showed that RIP140 is necessary for LCoR inhibition of gene expression and cell proliferation. Moreover, LCoR and RIP140 mRNA levels were strongly correlated in breast cancer cell lines and biopsies. In addition, RIP140 positively regulated LCoR expression in human breast cancer cells and in transgenic mouse models. Finally, their expression correlated with overall survival of patients with breast cancer. Taken together, our results provide new insights into the mechanism of action of LCoR and RIP140 and highlight their strong interplay for the control of gene expression and cell proliferation in breast cancer cells.

Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant

BACKGROUND

An understanding of predictors of breast milk production may enable the provision of better advice and support to mothers with preterm infants who may need to express milk for long periods.

OBJECTIVE

To investigate factors predicting the amount of milk expressed by mothers for their preterm infant (1) during the first 10 days and (2) during the infant's whole hospital stay.

METHODS

62 mothers with preterm infants <34 weeks who participated in a randomised trial comparing two breast pumps completed 10-day diaries including weight of milk expressed and questionnaires giving their opinion of the breast pump; 47 mothers provided data on milk expression up to the infant's hospital discharge.

RESULTS

Significant predictors of 10-day milk weight in multivariate models were the number of episodes of 'breast feeding' (17 g (95% CI 8 to 26, p=0.001) increase per episode), the use of double versus single pumping (109 (31-186, p=0.007) g/day more) and the number of complete daily records (17 (1-33, p=0.04) g increase/day). Significant multivariate predictors of total milk production were double versus single pumping (491 (55) mL/day vs 266 (44) mL/day), expressing 500 mL/day by day 10 (525 (53) mL/day vs 232 (43) mL/day) and a higher score for breast pump 'comfort' (best=489 (39) mL/day, middle=335 (57) mL/day, worst=311 (78) mL/day).

CONCLUSIONS

These results suggest that relatively simple, modifiable factors can favourably impact milk production in the neonatal intensive care unit setting and emphasise the importance of double pumping, early establishment of milk production and design features of the breast pump that promote comfort.

TRIAL REGISTRATION NUMBER

NCT00887991.

Knowledge of carrier status and barriers to testing among mothers of sons with Duchenne or Becker muscular dystrophy

Our study objective was to survey female carriers for Duchenne and Becker muscular dystrophy to identify barriers to carrier testing and the impact of carrier risk knowledge on cardiac and reproductive health management. We surveyed women who have or had biological sons with Duchenne or Becker muscular dystrophy and were enrolled in the US DuchenneConnect patient registry, with questions assessing knowledge of carrier status and recurrence risk, knowledge of care standards for carriers, and barriers to testing. Of the 182 eligible respondents, 25% did not know their carrier status and 14% incorrectly classified themselves as not at risk. Cost of testing was the most commonly identified barrier to testing. Women reporting unknown carrier status were 13 times as likely to express uncertainty regarding their recurrence risk compared to women reporting positive carrier status. 37% of women at an increased risk for cardiomyopathy had never had an echocardiogram. Women who were certain of their positive carrier status were twice as likely to have had an echocardiogram in the last five years compared to women with unknown carrier status. Future research on reducing barriers to counseling and carrier testing, such as cost, may improve care standard adherence.