Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Prevalence and impact of TWILIGHT criteria in all-comer patients undergoing percutaneous coronary intervention

Background

The Ticagrelor with Aspirin or Alone in High-Risk Patients after Coronary Intervention (TWILIGHT) randomized clinical trial demonstrated that in selected high risk patients who took ticagrelor and aspirin for 3 months after percutaneous coronary intervention (PCI), continuing ticagrelor alone was associated with significantly less bleeding events than ticagrelor plus aspirin and did not lead to ischemic harm over a period of 1 year (1).

The prevalence and risk of adverse events of patients fulfilling the TWILIGHT inclusion criteria in real-world setting is unclear.

Purpose

To elucidate the prevalence and prognosis of patients fulfilling the TWILIGHT inclusion criteria.

Methods

Patients that received at least one drug eluting stent in a coronary artery at a large tertiary center (Mount Sinai Hospital, New York) were considered for inclusion. As in the TWILIGHT trial, individuals on chronic oral anticoagulation treatment, with STEMI, cardiogenic shock, on dialysis, with prior stroke, or platelet count &lt;100,000 were excluded. Patients were stratified in two groups: 1) TWILIGHT-like patients, who met at least one clinical (age ≥65 years, female sex, established vascular disease, diabetes mellitus, estimated glomerular fraction rate &lt;60mL/min, acute coronary syndrome with troponin increase) and one angiographic (multivessel coronary artery disease [CAD], stent length &gt;30mm, thrombotic target lesion, bifurcation requiring 2 stents, left main or proximal left anterior descending artery lesion, atherectomy device use, SYNTAX score ≥23) TWILIGHT inclusion criterion; 2) Non-TWILIGHT-like patients, who did not fulfil at least one clinical and one angiographic TWILIGHT inclusion criterion.

The primary outcome was a composite of death, myocardial infarction (MI), stroke. Secondary outcomes included bleeding, components of the primary outcome, target vessel and target lesion revascularization, stent thrombosis. All events were assessed at 1 year after PCI.

Results

Out of 30,470 patients undergoing PCI between 2012 and 2019, 13,236 were included in the current analysis. TWILIGHT criteria were met in 11,018 (83%) patients. Established vascular disease and multivessel CAD were the most frequently fulfilled criteria. At 1 year, TWILIGHT-like patients were at higher risk for the primary outcome (3.2% vs 1.1%, HR 2.85, 95% CI 1.83–4.44), severe bleeding (3.3% vs 1.8%, HR 1.86, 95% CI 1.32–2.62), all-cause death (1.4% vs 0.4%, HR 3.63, 95% CI 1.70–7.77), myocardial infarction (1.8% vs 0.6%, HR 2.81 95% CI 1.56–5.04), TVR (7.8% vs 4.1%, HR 1.94, 95% CI 1.53–2.47), TLR (5.1% vs 1.7%, HR 2.98 95% CI 2.07–4.29). Stent thrombosis and stroke rate were generally low and did not differ between patients meeting or not the TWILIGHT inclusion criteria.

Conclusion

Among all-comer patients undergoing PCI, the fulfillment of the TWILIGHT inclusion criteria is frequent and is associated with a higher risk of death, ischemic and bleeding complications

Funding Acknowledgement

Type of funding sources: None.

Incidence, Mechanisms, and Characteristics of Injuries in Pole Dancers: A Prospective Cohort Study

OBJECTIVE

Pole dancing is a challenging physical activity. Prospective injury studies in pole dancing are lacking. The aim of this study was to describe the incidence, mechanisms, and characteristics of injuries in pole dancers.

METHODS

A total of 66 pole dancers from 41 studios across Australia were prospectively followed over 12 months. An intake questionnaire was administered including items on pole dancers' demographics and training characteristics. Exposure was assessed using a daily online training diary. Self-reported injury data were collected via an incident report form and subsequently coded using the Orchard Sports Injury Classification System. Injuries occurring during pole-specific and pole-related activities were included in the analyses.

RESULTS

The sample included 63 females and 3 males, mean age 32.3 ± 8.9 years and mean pole training experience 3.5 ± 2.8 years. 25 of 66 participants completed the full study. The 1-year incidence of all new injuries was 8.95/1,000 exposure hours (95% CI 6.94 - 10.96), 7.65/1,000 hrs (95% CI 5.79 - 9.51) for pole-specific injuries and 1.29/1,000 hrs (95% CI 0.53 - 2.06) for pole-related injuries. A total of 103 injuries occurred, 62.1% of which were sudden onset and 37.9% gradual onset. Mechanism of onset included 54.4% acute and 45.6% repetitive in nature. Shoulder (20.4%) and thigh (11.7%, majority ham¬string) were the most reported anatomic injury sites. Non-contact mechanisms accounted for the majority of injuries (57.3%). The most reported primary contributor to injury onset at the shoulder were manoeuvres characterised by loaded internal humeral rotation (33.3%), and at the hamstring were manoeuvres and postures involving front splits (100.0%).

CONCLUSION

The findings indicate that pole dancers are at high risk for injuries. Future research is needed to understand the biomechani¬cal demand of manoeuvres and training characteristics of pole dancing (e.g., workload and recovery) to guide the development of preventative interventions, particularly targeted toward the shoulder and hamstring.

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.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Interdisciplinary Team for MEDSReM-2 and Decision Support Through Pharmacology of Aging Principles

The interdisciplinary team members with distinct and complementary expertise working collaboratively to advance MEDSReM to MEDSReM-2 will be introduced. The decision support functionality in MEDSReM-2 application (app) is to guide older users on making decisions about missed doses. MEDSReM-2 medication formulary was created to include safe hypertension medications for older adults. Pharmacology of aging, including Pharmacokinetic and Pharmacodynamic principles, along with published studies and expert peer reviews, were used to create an algorithm for safe window of time to take the missed medications. We will present the processes for developing the decision support algorithm for the MEDSReM-2 App and how this guide will be communicated to the users to inform their decision making about missed doses. Interdisciplinary collaboration including pharmacy, nursing, cognitive aging, and technology development that was crucial for designing and implementing decision support within the MEDSReM-2 app for older users will be shared.

488 GRIP STRENGTH FROM MIDLIFE AS AN INDICATOR OF LATER-LIFE COGNITION AND BRAIN HEALTH: EVIDENCE FROM A BRITISH BIRTH COHORT

Introduction

Grip strength is an objective measure of physical function with potential predictive value for health in ageing populations. We aimed to assess whether levels and changes in grip strength from midlife predicted later-life brain health and cognition.

Methods

446 participants in an ongoing British birth cohort study, the MRC National Survey of Health and Development (NSHD), had their maximum grip strength measured at ages 53, 60–64, and 69, and underwent neuroimaging as part of its neuroscience sub-study, Insight 46, at 69–71. A group-based trajectory model identified latent groups of individuals in the whole NSHD cohort with below- and above-average grip strength over time, plus a reference group. Trajectory group membership, plus standardised grip strength levels and change from age 53, were each related to MRI-derived measures of whole-brain volume (WBV) and white-matter hyperintensity volume (WMHV), plus several cognitive tests. Models were adjusted for sex, body size, head size (where appropriate), sociodemographics, and behavioural and vascular risk factors.

Results

Consistently below-average grip strength from midlife was associated with lower WBV and non-verbal reasoning ability at age 69–71 (e.g. low group WBV vs. reference group β = −13.38 cm^3; 95% CI = (−24.12 cm^3, −2.64 cm^3); p = 0.015). There was some accompanying evidence that above-average maximum grip strength showed a positive association with WBV, which was more pronounced in female participants (high group female WBV vs. reference group β = 18.30 cm^3; 95% CI = (1.34 cm^3, 35.29 cm^3); p = 0.034). Steeper than average declines in grip strength between 53 and 69 were additionally weakly associated with an estimated 10% higher WMHV at age 69–71 (β = 1.10, 95% CI = (1.00, 1.22); p = 0.053).

Conclusion

This study provides preliminary evidence that tests of maximum grip strength may have value in predicting brain health. Future work should assess how these observed differences relate to later-life negative health outcomes, and whether changes in grip strength reflect concurrent changes in brain structure and connectivity.

Neural correlates of cognitive variability in childhood autism and relation to heterogeneity in decision-making dynamics

Heterogeneity in cognitive and academic abilities is a prominent feature of autism spectrum disorder (ASD), yet little is known about its underlying causes. Here we combine functional brain imaging during numerical problem-solving with hierarchical drift-diffusion models of behavior and standardized measures of numerical abilities to investigate neural mechanisms underlying cognitive variability in children with ASD, and their IQ-matched Typically Developing (TD) peers. Although the two groups showed similar levels of brain activation, the relation to individual abilities differed markedly in ventral temporal-occipital, parietal and prefrontal regions important for numerical cognition: children with ASD showed a positive correlation between functional brain activation and numerical abilities, whereas TD children showed the opposite pattern. Despite similar accuracy and response times, decision thresholds were significantly higher in the ASD group, suggesting greater evidence required for problem-solving. Critically, the relationship between individual abilities and engagement of prefrontal control systems anchored in the anterior insula was differentially moderated by decision threshold in subgroups of children with ASD. Our findings uncover novel cognitive and neural sources of variability in academically-relevant cognitive skills in ASD and suggest that multilevel measures and latent decision-making dynamics can aid in characterization of cognitive variability and heterogeneity in neurodevelopmental disorders.

Feasibility and preliminary effects of a peer-led motivationally-embellished workplace walking intervention: A pilot cluster randomized trial (the START trial)

Walking interventions can be effective in increasing physical activity amongst physically inactive employees. However, despite their promising potential regarding sustainability and scalability, peer-led workplace walking interventions have not been tested. We evaluated a peer-led workplace group walking intervention designed to engage physically inactive employees. A 16-week pilot cluster randomized controlled trial consisted of enhanced (5 worksites; n = 50 participants) and minimal treatment (3 worksites; n = 47) conditions. All participants were provided with a Fitbit Zip and information on health benefits of walking. Enhanced treatment participants had access to a mobile phone app incorporating behavior change techniques, were trained on principles of autonomous motivation, and had a peer leader trained in a motivationally supportive communication style. Feasibility assessments included recruitment and drop-out rates, assessment completion rates, training acceptability (walkers and peer leaders), and intervention acceptability (walkers only). Outcomes assessed included movement-related behaviors (assessed via activPAL devices), cardio-metabolic risk factors, motivation to walk, and well-being, and these measures were taken at baseline and post-intervention. The results supported intervention feasibility. Preliminary efficacy evidence was mixed. Markers of cardio-metabolic risk improved in the enhanced treatment only. Autonomous motivation increased in both conditions. There were no changes in step counts, standing, and sitting time, or well-being. Further fine tuning is needed before a definitive RCT. Australian and New Zealand Clinical Trials Registry: ACTRN12618000807257.

Myogenic and Central Neurogenic Factors in Fatigue in Multiple Sclerosis

Short episodes of electrical stimulation were applied to the right quadriceps muscle of patients with multiple sclerosis (MS) and healthy subjects at different times during 60 sec sustained voluntary muscle contractions at 0 to 100% levels of maximal voluntarily generated joint torque. The amplitude of electrically induced increments of torque (ΔT) has been shown to depend upon both the level of muscular contraction and time from the beginning of the contraction. The dependence of ΔT upon the time from the beginning of contraction has been assumed to reflect muscle fatigue. Patients with MS demonstrated an apparent involvement of central neurogenic mechanisms in fatigue manifested as a drop in muscle torque during sustained contractions at 75 and 100% levels when electrical stimulation was able to induce considerable increments in muscle torque. These patients also demonstrated a dependence of ΔT upon the contraction level suggesting that they did not produce maximal voluntary contraction torque in the pre-trial. Fatigue in MS is due to central, neurogenic factors and does not seem to involve any myogenic factors such as might be related to secondary muscle changes due to the long-standing disorder. The subjective feeling of tiredness (‘fatigue’) may be related to a dissociation between central motor commands (‘effort’) and their mechanical consequences.

Beyond symptom monitoring: Consumer needs for bipolar disorder self-management using smartphones

OBJECTIVES

To investigate the potential use of smartphone apps to support self-management in young adults with bipolar disorder.

METHODS

We recruited 89 young adults (18-30 years) with bipolar disorder to complete a cross-sectional online survey. The survey contained quantitative and qualitative questions regarding technology use, current use of disorder-management apps, types of apps desired for disorder management, and app features that users would consider important when selecting apps. Results were analysed using descriptive statistics and thematic analysis.

RESULTS

Almost all participants used a smartphone daily and 40% currently used apps for disorder management. Of those not currently using apps, 79% indicated they would like to try them. On average, participants rated 61% of the self-management strategies listed as desirable for app support, with sleep-management, understanding early warning signs and triggers, and stay-well plans the most frequently endorsed. App features considered important during app selection were ease-of-use, scientific quality, flexibility/customisation, and data privacy.

CONCLUSIONS

The results indicate that young adults with bipolar disorder are interested in a wide range of apps for self-management. Participants were interested in apps to support self-management strategies considered clinically important for disorder management. Many of these app needs are currently unmet. Results suggest diversifying and prioritising app capabilities to ensure evidence-based resources for a broader range of app functions are available to consumers.

Assessment of treatment patterns associated with injectable disease-modifying therapy among relapsing-remitting multiple sclerosis patients

Background

Availability of oral disease-modifying therapy (DMT) for relapsing–remitting multiple sclerosis (RRMS) may affect injectable DMT (iDMT) treatment patterns.

Objective

The objective of this paper is to evaluate iDMT persistency, reasons for persistency lapses, and outcomes among newly diagnosed RRMS patients.

Methods

Medical records of 300 RRMS patients initiated on iDMT between 2008 and 2013 were abstracted from 18 US-based neurology clinics. Eligible patients had ≥3 visits: pre-iDMT initiation, iDMT initiation (index), and ≥1 visit within 24 months post-index. MS-related symptoms, relapses, iDMT treatment patterns (i.e. persistency, discontinuation, switching, and restart), and reasons for non-persistency were tracked for 24 months.

Results

At 24 months, iDMT persistency was 61.0%; 28.0% of patients switched to another DMT, 8.0% discontinued, and 3.0% stopped and restarted the same iDMT. The most commonly identified reasons for non-persistency were perceived lack of efficacy (22.2%), adverse events (18.8%), and fear of needles/self-injecting (9.4%). At 24 months, 38.0% of patients had experienced a relapse and 11.0% had changes in MRI lesion counts. Patients without MS-related symptoms at index reported increases in the incidence of these symptoms at 24 months.

Conclusions

Non-persistency with iDMT remains an issue in the oral DMT age. Many patients still experienced relapses and disease progression, and should consider switching to more effective therapies.

Estrogen modulates 7/4 antigen distribution within eccentrically contracted injured skeletal muscle

Eccentric contractions are skeletal muscle stretches with concurrent active force production; these contractions commonly occur during dynamic sports activities and can cause acute muscle injury. Recovery from this injury depends in part on pro-inflammatory processes, such as neutrophil infiltration at the injured site, which is affected by estrogen. This estrogen effect has been examined broadly, but without distinguishing between major compartments within muscle in which neutrophil infiltration can occur. Therefore, we compared neutrophil antigen expression in two compartments of eccentrically contracted muscle of ovariectomized mice with or without estrogen. To quantify neutrophil antigen expression, serial cross sections of muscle were immunolabeled with antibodies that recognize 7/4 or Ly6C/G, then quantified using computer-assisted image analysis. At 48 h post injury, estrogen-positive (E+) mice had more 7/4-positive and Ly6C/G-positive myofibers, increased 7/4 area percentage, and more 7/4-positive cells in the connective tissue. In addition, E+ mice showed more 7/4-positive myofibers that were Ly6C/G-negative and more Ly6C/G-positive myofibers that were 7/4-negative. These data suggest that in injured muscle, estrogen increases 7/4 antigen in connective tissue and myofibers and is associated with more Ly6C/G-positive myofibers when the 7/4 antigen is absent from these myofibers.

New and Emerging Disease-Modifying Therapies for Relapsing-Remitting Multiple Sclerosis: What is New and What is to Come

The therapeutic landscape for multiple sclerosis (MS) is rapidly changing. Currently, there are eight FDA approved disease modifying therapies for MS including: IFN-β-1a (Avonex, Rebif), IFN-β-1b (Betaseron, Extavia), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), natalizumab (Tysabri), and fingolimod (Gilenya). This review will highlight the experience to date and key clinical trials of the newest FDA approved agents, natalizumab and fingolimod. It will also review available efficacy and safety data on several promising therapies under active investigation including four monoclonal antibody therapies: alemtuzumab, daclizumab, ocrelizumab and ofatumumab and three oral agents: BG12, laquinimod, and teriflunomide. To conclude, we will discuss where each of these new therapies may best fit into treatment algorithms.

Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster randomized, controlled trial

OBJECTIVE

Chronic joint pain is a major cause of pain and disability. Exercise and self-management have short-term benefits, but few studies follow participants for more than 6 months. We investigated the long-term (up to 30 months) clinical and cost effectiveness of a rehabilitation program combining self-management and exercise: Enabling Self-Management and Coping of Arthritic Knee Pain Through Exercise (ESCAPE-knee pain).

METHODS

In this pragmatic, cluster randomized, controlled trial, 418 people with chronic knee pain (recruited from 54 primary care surgeries) were randomized to usual care (pragmatic control) or the ESCAPE-knee pain program. The primary outcome was physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function), with a clinically meaningful improvement in physical function defined as a ≥15% change from baseline. Secondary outcomes included pain, psychosocial and physiologic variables, costs, and cost effectiveness.

RESULTS

Compared to usual care, ESCAPE-knee pain participants had large initial improvements in function (mean difference in WOMAC function -5.5; 95% confidence interval [95% CI] -7.8, -3.2). These improvements declined over time, but 30 months after completing the program, ESCAPE-knee pain participants still had better physical function (difference in WOMAC function -2.8; 95% CI -5.3, -0.2); lower community-based health care costs (£-47; 95% CI £-94, £-7), medication costs (£-16; 95% CI £-29, £-3), and total health and social care costs (£-1,118; 95% CI £-2,566, £-221); and a high probability (80-100%) of being cost effective.

CONCLUSION

Clinical and cost benefits of ESCAPE-knee pain were still evident 30 months after completing the program. ESCAPE-knee pain is a more effective and efficient model of care that could substantially improve the health, well-being, and independence of many people, while reducing health care costs.

Food portion weights in primary and secondary school lunches in England

BACKGROUND

National Nutritional Standards for school lunches were reintroduced in 2001, and included guidance on portion sizes for primary schools. For the first time since 1997, nationally representative data on school food portion sizes in England have been collected using direct assessment rather than reported portion sizes.

METHODS

Food portions were weighed directly in foods served in nationally representative samples of primary and secondary school meals. Results were grouped by food or food group.

RESULTS

The number of portions weighed was 7975 in primary schools and 3354 in secondary schools. Individual portion weights were grouped by food or food group to yield mean, median, SD and inter-quartile range. For a given food or food group, the number of portions weighed varied from 5 to 210 portions in primary schools and between 5 and 194 portions in secondary schools.

CONCLUSIONS

The results provide a good representation of typical portion weights for different foods and food groups in primary and secondary schools in England. Portion size is one factor that determines nutrient intake. New standards for school lunches are both nutrient and food-based. Guidance on portion weights will help to ensure that pupils consume the correct balance of foods to obtain the recommended nutrient intake. The present findings complement and extend existing guidance on portion sizes for pupils in schools in England and Scotland.

Hippocampal scrapie infection impairs operant DRL performance in mice

In differential reinforcement of low rates of responding (DRL) tasks, animals are trained to respond for rewards that become available only after some set time has elapsed since the animal's previous response. DRL performance is impaired by hippocampal lesions regardless of their precise location, and can be measured using automated operant equipment, whereas spatial tasks are selectively impaired by dorsal, but not ventral hippocampal lesions, and are typically conducted by hand. Earlier studies of prion infection following dorsal hippocampal micro-injections of scrapie have shown clear impairments of spatial alternation, but these occurred significantly later than dysfunction in hippocampus-dependent 'domestic' tasks such as nesting or burrowing. In the present experiment, mice were trained to respond on an automated DRL schedule prior to dorsal hippocampal ME7 scrapie injection. Post-operative DRL performance was monitored, along with performance on 'domestic' and other tests, which provided additional measures of disease progression. Animals with scrapie developed a clear DRL deficit at approximately the same time as their deficits on the other tests became apparent, and long before clinical signs were detectable. DRL deficits thus appeared earlier in the sequence of disease progression than previously reported for spatial alternation, suggesting that early signs of scrapie infection are caused in part by neuronal dysfunction extending beyond the dorsal hippocampal region of initial infection.

Effect of a protease inhibitor on in vitro stability of intact parathyroid hormone

BACKGROUND

We investigated whether increased protease activity explains the increased in vitro degradation of intact parathyroid hormone (iPTH) observed in serum when compared to EDTA plasma.

METHODS

Pre-dialysis blood samples for iPTH were taken from 11 patients with chronic renal failure and collected into plain glass tubes, tubes containing 200 KIU/mL aprotinin (a protease inhibitor) and EDTA tubes. All sample aliquots were separated at 20 min, 1 h, 2 h, 4 h, 8 h and 24 h post collection.

RESULTS

Over 24 h, iPTH concentrations remained unchanged in EDTA tubes. iPTH concentrations were significantly lower in both plain tubes (P < 0.01) and aprotinin tubes (P < 0.001) at 24 h when compared to the baseline sample (20 min). At 24 h, iPTH concentrations in EDTA tubes were higher than in plain tubes (P < 0.001) and aprotinin tubes (P < 0.01). The addition of aprotinin to plain tubes significantly reduced the degradation of iPTH (P < 0.05) at 24 h.

CONCLUSION

Aprotinin significantly reduces the in vitro degradation of iPTH in plain tubes at 24 h from 24.7% to 9.6%. We suggest that increased protease activity contributes to the decline in serum iPTH over time. As this is observed in serum and not plasma it suggests that the increased protease activity may be due to the clotting process.

Integrated care

The integrated care model for delivering RRT offers apparent advantages in patient choice, optimal survival, and economical use of resources. Dialysis and transplantation have always been used that way; but, by integrating all three treatments--HD, PD, and transplantation--the options for the multi-professional team and the patients are increased. The practical implications of the approach include the need for all treatments to be available, for patients and professionals to be educated in the approach, and for a change in therapy to be anticipated and accepted, not seen as a mark of treatment failure. Prospective studies are needed to quantify the benefits in a more systematic way.

Human herpesvirus 8 (HHV-8)-encoded cytokines induce expression of and autocrine signaling by vascular endothelial growth factor (VEGF) in HHV-8-infected primary-effusion lymphoma cell lines and mediate VEGF-independent antiapoptotic effects

The potential roles of human herpesvirus 8 (HHV-8) cytokines in HHV-8 pathogenesis were investigated by determining the expression of the HHV-8 chemokines viral macrophage inflammatory protein 1A (vMIP-1A) and vMIP-1B in primary effusion lymphoma (PEL)-derived cell lines and examining the signaling activities of these chemokines and HHV-8-encoded vIL-6 in these cells. Secreted vMIP-1A and vMIP-1B were detected in biologically significant concentrations following tetradecanoyl phorbol acetate treatment, which induces productive replication. vIL-6 and vMIP-1A, added exogenously to cultures of four different PEL cell lines, induced the expression of vascular endothelial growth factor type B (VEGF-B) and VEGF-A, respectively. These cells were found to express VEGF receptor 1 (Flt-1) protein, and signaling by recombinant VEGF-A(165) was demonstrated for two of the PEL cell lines, indicating the potential for autocrine, as well as paracrine, effects of viral cytokine-induced VEGF. In addition, vMIP-1A and vMIP-1B, but not VEGF-A(165), were found to inhibit chemically induced apoptosis in PEL cells. Our data suggest that vIL-6 and vMIP-1A may influence PEL through VEGF autocrine and paracrine signaling that promotes PEL cell growth and extravascular effusion and that vMIP-1A and vMIP-1B can act independently of VEGF as antiapoptotic factors.

Detection of direct binding of human herpesvirus 8-encoded interleukin-6 (vIL-6) to both gp130 and IL-6 receptor (IL-6R) and identification of amino acid residues of vIL-6 important for IL-6R-dependent and -independent signaling

Human herpesvirus 8 (HHV-8) is associated with Kaposi's sarcoma, primary effusion lymphoma, and multicentric Castleman's disease; in all of these diseases, interleukin-6 (IL-6) has been implicated as a likely mitogenic and/or angiogenic factor. HHV-8 encodes a homologue of IL-6 (viral IL-6 [vIL-6]) that has been shown to be biologically active in several assays and whose activities mirror those of its mammalian counterparts. Like these proteins, vIL-6 mediates its effects through the gp130 signal transducer, but signaling is not dependent on the structurally related IL-6 receptor (IL-6R; gp80) subunit of the receptor-signal transducer complex. However, as we have shown previously, IL-6R can enhance vIL-6 signal transduction and can enable signaling through a gp130 variant (gp130.PM5) that is itself unable to support vIL-6 activity, indicating that IL-6R can form part of the signaling complex. Also, our analysis of a panel of vIL-6 mutants in transfection experiments in Hep3B cells (that express IL-6R and gp130) showed that most were able to function normally in this system. Here, we have used in vitro vIL-6-receptor binding assays to demonstrate direct binding of vIL-6 to both gp130 and IL-6R and vIL-6-induced gp130-IL-6R complex formation, and we have extended our functional analyses of the vIL-6 variants to identify residues important for IL-6R-independent and IL-6R-dependent signaling through native gp130 and gp130.PM5, respectively. These studies have identified residues in vIL-6 that are important for IL-6R-independent and IL-6R-mediated functional complex formation between vIL-6 and gp130 and that may be involved directly in binding to gp130 and IL-6R.

Identification of envelope glycoproteins H and B homologues of human herpesvirus 7

The genes encoding the envelope glycoprotein H (gH) and gB homologues were identified by sequencing genomic clones of human herpesvirus-7 (HHV-7), strain JI. A gB cDNA clone from HHV-7 strain AL was also identified. The deduced primary translation products of the gH and gB genes are a protein of 690 amino acids, with a predicted mass of 80.4 kD, and a protein of 822 amino acids, with a predicted mass of 93.3 kD, respectively. Both the predicted proteins have the characteristics of transmembrane glycoproteins, containing signal and transmembrane sequence motifs and characterized by the presence of 10 (gH) and 11 (gB) potential motifs for N-glycosylation. Comparison of amino acid sequence of HHV-7 gH and gB with the homologous sequences of the other human herpesviruses reveals closest homology with HHV-6 (38.8% identity for gH, 56.2% identity for the gB). In addition, significant sequence similarity was also observed between the gH and gB of HHV-7 and the homologs encoded by human cytomegalovirus (21.6% identity for gH, 37.6% identity for gB). No significant differences existed between the gB sequence of the two different HHV-7 strains analyzed. The products of the HHV-7 gH and gB expressed transiently in eukaryotic cells were specifically recognized by an HHV-7-reactive human serum in immunofluorescence assays.

Perspectives of those impacted: airline pilot's perspective

The airline pilot operates within an environment that consists of circadian dysrhythmia, reduced atmospheric pressure, mild hypoxia, low humidity, and exposure to sound, vibration, cosmic-radiation, and magnetic-field exposure. These occupational exposures present physiological challenges to the long term health of the airline pilot. In particular, exposure to cosmic radiation and its carcinogenic potential have recently received considerable attention. Given the complexity of the environment and possible synergistic exposures, there is an immediate requirement for comprehensive research into both cosmic-radiation and magnetic-field exposures in airline pilots. In response, the Airline Pilots Association International in conjunction with the Medical University of South Carolina (Department of Biometry and Epidemiology) has initiated an extensive research program into these occupational exposures. These investigations include ground based calculations, flight-dose estimates, epidemiological survey and exposure assessment, and biological marker analysis.

Magnetic field exposure of commercial airline pilots

PURPOSE: Airline pilots are exposed to magnetic fields generated by the aircraft's electrical and electronic systems. The purpose of this study was to directly measure the flight deck magnetic fields to which commercial airline pilots are exposed when flying on different aircraft types over a 75-hour flight-duty month.METHODS: Magentic field measurements were taken using personal dosimeters capable of measuring magnetic fields in the 40-800 Hz frequency range. Dosimeters were carried by either the Captain or the First Officer on Boeing 737/200, Boeing 747/400, Boeing 767/300ER, and Airbus 320 aircraft. The data were analyzed by aircraft type, with statistics based on block hours. Block hours begin when the aircraft departs the gate prior to take off and end when the aircraft returns to the gate after landing.RESULTS: Approximately 1008 block hours were recorded at a sampling rate of 3 seconds. Total block time exposure to the pilots ranged from a harmonic geometric mean of 6.7 milliGauss (mG) for the Boeing 767/300ER to 12.7 mG for the Boeing 737/200.CONCLUSIONS: Measured flight deck magnetic field levels were substantially above the 0.8 to 1 mG level typically found in the home or office and suggest the need for further study to evaluate potential health effects of long-term exposure.

Evolutionary aspects of oncogenic herpesviruses

Several of the gamma-herpesviruses are known to have cellular transforming and oncogenic properties. The genomes of eight distinct gamma-herpesviruses have been sequenced, and the resulting database of information has enabled the identification of genetic similarities and differences between evolutionarily closely related and distant viruses of the subfamily and between the gamma-herpesviruses and other members of the herpesvirus family. The recognition of coincident loci of genetic divergence between individual gamma-herpesviruses and the identification of novel genes and cellular gene homologues in these genomic regions has delineated a subset of genes that are likely to contribute to the unique biological properties of these viruses. These genes, together with gamma-herpesvirus conserved genes not found in viruses outside the family, might be responsible for virus specific pathogenicity and pathogenic effects, such as viral associated neoplasia, characteristic of the subfamily. The presence of the gamma-herpesvirus major divergent genomic loci and the apparent increased mutational frequencies of homologous genes (where they occur) within these regions, indicates that these loci possess particular features that drive genetic divergence. Whatever the mechanisms underlying this phenomenon, it potentially provides the basis for the relatively rapid adaptation and evolution of gamma-herpesviruses and the diversity of biological and pathogenic properties.

Hemodialysis-induced hypoglycemia in diabetic patients

BACKGROUND

The authors have previously reported asymptomatic hypoglycemia in non-diabetic patients on hemodialysis. The present study was designed to assess the effect of hemodialysis on plasma glucose, glucagon, cortisol and catecholamines in diabetic patients.

METHODS

Eighteen diabetic patients with chronic renal failure were hemodialyzed using a glucose-free dialysis fluid. They did not take any medication prior to dialysis and were asked not to eat during the first hour on hemodialysis. Blood and dialysate were sampled at regular intervals during the first hour of dialysis for analysis.

RESULTS

Plasma glucose fell below 4.0 mmol/l (72 mg/dl) in 7 of the 18 patients, below 3.5 mmol/l (63 mg/dl) in 3 and below 3.0 mmol/l (54 mg/dl) in one. The lowest recorded value was 2.8 mmol/l (50 mg/dl). The mean glucose loss in the waste dialysate was 9.2 g/h. In none of the group of 7 patients whose plasma glucose fell below 4.0 mmol/l (72 mg/dl) did symptoms of hypoglycemia occur. When 6 patients from this group were subsequently dialyzed with a dialysis fluid containing 5.5 mmol/l (100 mg/dl) glucose, their plasma glucose became stabilized within the fasting reference range. There were no significant hormonal changes during the dialysis or between non-hypoglycemic and hypoglycemic patients.

CONCLUSIONS

Patients undergoing hemodialysis may become hypoglycemic and not be aware of it. There is no hormonal imbalance causing the hypoglycemia and the hormonal response to the hypoglycemia is blunted. Patients with an initial plasma glucose of 5.5 mmol/l (100 mg/dl) or less who are hemodialyzed and who do not eat during dialysis may be particularly at risk, especially if they are on insulin or taking glucose-lowering medication. These should be dialyzed with a dialysis fluid containing at least 5.5 mmol/l (100 mg/dl) glucose.

The effects of hippocampal and fimbria-fornix lesions on prepulse inhibition

The present experiments tested the effects of conventional (dorsal aspiration and electrolytic) and excitotoxic (N-methyl-D-aspartate [NMDA]) hippocampal lesions and fimbria-fornix (FF) transection on prepulse inhibition (PPI) of startle response and on open-field activity. Activity was increased by FF transection and by conventional but not excitotoxic hippocampal lesions; complete NMDA lesion increased amphetamine-induced activity. Whereas dorsal hippocampal aspiration lesion disrupted PPI, the phenomenon was not affected by dorsal hippocampal electrolytic lesion, partial or complete excitotoxic (NMDA) hippocampal lesions, or complete FF transection, which interrupted the cholinergic input to the hippocampus as well as the hippocampal-subicular input to the nucleus accumbens. Systemic apomorphine disrupted PPI in both FF-transected rats and their controls. It is suggested that the hippocampus is essential for PPI disruption rather than for PPI expression.