Top 10 research priorities for digital technology for adolescents and young persons with inflammatory bowel disease: Results of a James Lind Alliance Priority Setting Partnership

OBJECTIVES

Priority Setting Partnerships (PSP's) using the James Lind Alliance (JLA) methodology, bring together health professionals, patients and parents/carers to identify and prioritise unanswered questions that can be addressed by future research projects. To identify and prioritise the top 10 unanswered research priorities in digital technology for adolescents and young people (AYP) with inflammatory bowel disease (IBD).

METHODS

A steering group (SG) consisting of AYP with IBD, their parents/carers, representatives from two charities (Crohn's & Colitis UK, Crohn's in Childhood Research Association), patient information forum and paediatric and adult and primary care healthcare professionals was established in 2021. The SG agreed the protocol, and scope of the PSP and oversaw all aspects. SG meetings were chaired by a JLA advisor and followed the established JLA methodology.

RESULTS

The initial survey generated 414 in-scope questions from 156 respondents, thematically categorised into 10 themes and consolidated into 92 summary questions by the SG. A comprehensive literature review followed by SG deliberation narrowed the unanswered summary questions to 45, for the interim prioritising survey. One hundred and two respondents ranked their top 10 research questions. Outputs generated top 18 research priorities presented at a final virtual prioritisation workshop, facilitated by JLA advisors and attended by key stakeholders, ranked into top 10 research priorities.

DISCUSSION

The top 10 research priorities will encourage researchers to undertake research that addresses these areas of unmet need for AYP living with IBD, their parents/carers and their healthcare professionals, thereby facilitating improved patient care.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

OP0038 VITAMIN D AND MARINE n-3 FATTY ACID SUPPLEMENTATION FOR PREVENTION OF AUTOIMMUNE DISEASE IN THE VITAL RANDOMIZED CONTROLLED TRIAL: OUTCOMES OVER 7 YEARS

Background

Strong biologic rationale supports both vitamin D and marine omega-3 (n-3) fatty acids for prevention of autoimmune disease (AD). Within the randomized, double-blind, placebo-controlled VITamin D and OmegA-3 TriaL (VITAL), we tested the effects of these supplements on AD incidence. We previously reported results after 5.3 years of randomized follow-up showing overall protective effects for vitamin D on AD incidence (HR 0.78, 95% CI 0.61-0.99) and suggestive results for n-3 fatty acids (HR 0.85, 95%CI 0.67-1.08)1.

Objectives

We aimed to test effects of these supplements with two more years of post-intervention follow-up in VITAL.

Methods

VITAL enrolled and randomized men and women (age ≥50 and ≥55 years, respectively) in a 2-by-2 factorial design to vitamin D3 (2000 IU/d) and/or n-3 fatty acids (1000 mg/d) or placebo and followed for median 5.3 years. Here, we followed participants for another 2 years of observation to assess for sustained effects. Incident AD diagnoses were reported by participants annually and confirmed by medical record review by expert physicians using existing classification criteria. The primary endpoint was total incident AD, including rheumatoid arthritis (RA), polymyalgia rheumatica (PMR), autoimmune thyroid disease (AITD), psoriasis, and all others. Pre-specified secondary endpoints included individual common AD; and probable AD. Cox models calcuated hazard ratios (HR) for incident ADs.

Results

Of 25,871 participants randomized, 71% self-reported non-Hispanic Whites, 20% Black, 9% other racial/ethnic groups, 51% women, mean age was 67.1 years. During 7.5 years median follow-up, confirmed AD was diagnosed in 156 participants in vitamin D arm vs 198 in vitamin D placebo arm, HR 0.79 (0.64-0.97). Incident AD was confirmed in 167 participants in n-3 fatty acid arm and 187 in n-3 fatty acid placebo arm, HR 0.89 (0.72-1.10). For vitamin D, HRs trended toward reduction for RA 0.67 (0.37- 1.21), PMR 0.69 (0.46-1.03) and psoriasis 0.57 (0.33-0.99). For n-3 fatty acids, HRs trended toward reduction for RA 0.55 (0.30-1.10) and AITD 0.61 (0.33-1.12). Vitamin D’s effect on AD incidence was stronger in those with body mass index (BMI) < 25 (HR 0.65, 0.44-0.96) than ≥ 25 kg/m2 (p interaction 0.01).

Conclusion

Supplementation for 5.3 years with 2000 IU/day vitamin D (compared to placebo), followed by 2 years of observational follow-up, significantly reduced overall incident AD by 21% in older adults. HRs for RA, PMR and psoriasis trended toward reduction with vitamin D, with stronger effect in those with normal BMI. Supplementation with 1000 mg/day n-3 fatty acids did not significantly reduce total AD.

References

[1]Hahn J et al, BMJ, 2022 Jan 26;376: e066452.

Table 1.

Hazard Ratios for Primary and Secondary Endpoints, by Randomized Assignment to Vitamin D/Placebo (Left), N-3 Fatty Acids/Placebo (Right)a

EndpointVitamin D3(N=12,927)Placebo (N=12,944)Hazard Ratio (95% CI)pN-3 Fatty Acids (N=12,933)Placebo (N=12,938)Hazard Ratio (95% CI)pPrimary: Confirmed AD1561980.79 (0.64-0.97)0.031671870.89 (0.72-1.10)0.27Secondary:Confirmed + probable AD2653210.83 (0.70-0.97)0.022713150.86 (0.73-1.01)0.06Excluding subjects with any pre-randomization AD Confirmed AD1271620. 79 (0.62-0.99)0.041411480.95 (0.75-1.20)0.66 Confirmed + probable AD2112700. 78 (0.65-0.94)0.0072322490.93 (0.78-1.11)0.41Excluding first 2 years follow-up Confirmed AD861300.66 (0.50-0.87)0.0031041120.92 (0.71-1.21)0.56 Confirmed + probable AD1472050.72 (0.58-0.89)0.0021721800.95 (0.77-1.17)0.63Individual ADb RA18270.67 (0.37-1.21)0.1816290.55 (0.30-1.01)0.06 PMR39570.69 (0.46-1.03)0.0746500.92 (0.61-1.37)0.67 AITD27181.50 (0.82-2.71)0.1917280.61 (0.33-1.12)0.11 Psoriasis20350.57 (0.33-0.99)0.0534211.62 (0.94-2.79)0.08

aAnalyses from Cox regression models controlled for age, sex, race, and other (n-3 fatty acid or vitamin D) randomization group bConfirmed AD.

Figure 1.

Disclosure of Interests

Karen Costenbader Consultant of: Astra Zeneca, Glaxo Smith Kline, Neutrolis, Grant/research support from: Merck, Exagen, Gilead, Nancy Cook: None declared, I-min Lee: None declared, Jill Hahn: None declared, Joseph Walter: None declared, Vadim Bubes: None declared, Gregory Kotler: None declared, Nicole Yang: None declared, Sonia Friedman: None declared, Erik Alexander: None declared, JoAnn Manson: None declared.

Laboratory biomarkers associated with COVID-19 severity and management

The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care.

From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66.

Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.

AB0310 TROUGH CONCENTRATION AND ESTIMATED CLEARANCE CAN DETECT IMMUNOGENICITY TO ADALIMUMAB IN RA PATIENTS: A PROSPECTIVE LONGITUDINAL MULTICENTRE STUDY

Background:

Anti-Drug Antibodies (ADA) to adalimumab increase drug clearance in rheumatoid arthritis (RA).

Objectives:

To study the ability of drug concentration or estimating clearance to identify ADA to adalimumab.

Methods:

Adalimumab concentration was measured with a validated ELISA. ADA was measured using a capture ELISA (Theradiag®) and the Meso scale discovery (MSD) platform. Using a bayesian PK model, adalimumab clearance was estimated at 1, 3, 6 and 12 months. Predictions for ADA presence were calculated, and the correlation between ADA and adalimumab clearance was analysed.

Results:

We analyzed 108 samples from 53 RA patients. Serum concentrations and clearance estimates showed good prediction performance for ADA presence (Table 1). There was a correlation between adalimumab clearance and ADA (Figure 1).

Table 1.

Immunogenicity prediction of adalimumab, using trough concentration or estimated clearance

Time of visitADA methodAdalimumab trough concentrationAdalimumab estimated clearanceAUC ROCp-valueAUC ROCp-valueMonth 1THER.55.6411.52.8358MSD.65.0821.61.1872Month 3THER.89.0006.91.0003MSD.73.0096.72.0131Month 6THER.95.0035.95.0035MSD.85.0004.84.0006Month 12THER.87.0045.86.0057MSD.88.0002.88.0002Figure 1.

correlation between adalimumab estimated clearance and ADA as provided by the Meso scale discovery (MSD) plateform

Conclusion:

Adalimumab concentration and clearance should be considered as reliable predictors for ADA presence in RA patients.

Acknowledgments:

Measurement of adalimumab serum concentrations was performed within the ‘Centre pilote de suivi biologique des anticorps thérapeutiques’ (CePiBAc)– Pilot centre for therapeutic antibodies monitoring platform of Tours University Hospital, which was cofinanced by the European Regional Development Fund (ERDF). We thank Oscar Knight, Delphine Delord and Fabien Giannoni (ABIRISK lab technician), Caroline Brochon and Anne Claire Duveau (CePIBAc), Aliette Decock-Giraudaud (Centre de ressource-Biobank), Sophie Tourdot (ABRISIK Project manager), Aline Doublet (Assistance Publique Hopitaux de Paris, Agnès Hincelin-Méry (Sanofi, Chilly-Mazarin, France). This work has received support from the Innovative Medicines Initiative Joint Undertaking (IMI JU) under grant agreement no. 115303, the resources of which are composed of financial contributions from the European Union’s Seventh Framework Programme (FP7/2007-2013) and European Federation of Pharmaceutical Industries and Associations (EFPIA) companies’ in-kind contributions.

Disclosure of Interests:

David Ternant Consultant of: Sanofi and Amgen., Jamal Elhasnaoui: None declared, Natacha Szely: None declared, Salima Hacein-Bey: None declared, Aude Gleizes: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Jessica Manson: None declared, Martin SOUBRIER: None declared, Olilvier Brocq: None declared, Jérôme Avouac: None declared, Anna Fogdell-Hahn Grant/research support from: Biogen Idec and Pfizer., Consultant of: Pfizer, Biogen, Merck-Serono, and Sanofi-Genzyme., Pierre Dönnes: None declared, Gilles Paintaud Grant/research support from: Amgen, Genzyme (Sanofi), Lilly, Merck, Novartis, and Roche Pharma., Consultant of: Chugai, Novartis and Shire (Takeda), with remunerations received by his institution., Céline Desvignes: None declared, Florian Deisenhammer: None declared, Sebastian Spindeldreher Employee of: Novartis, Marc Pallardy: None declared, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Denis Mulleman Grant/research support from: Non-governmental organisation Lions Club Tours Val de France, French Society for Rheumatology., Consultant of: Pfizer, Novartis.

Abstract 14: Secular Trends in Racial and Socioeconomic Status Disparities in the Rate of Coronary Revascularization Among Post-Menopausal Women Before and After 2005 for Acute Coronary Syndrome: The Women Health Initiative

Background: We looked at a large multi-racial, geographically diverse cohort of post-menopausal women to determine whether revascularization for either acute coronary syndrome (ACS) or coronary disease (CHD) differed by race and socioeconomic status when 2002 ACC/AHA guidelines secular trends are considered.

Methods: Using data from the WHI, we evaluated the rate of revascularization among 20,262 post-menopausal women (2,181 were Black, 572 Hispanic, and 17,509 white). We chose 2005 as the cut-point for the secular trend as it usually takes 2-3 years for guidelines to be implemented. We used a Cox proportional hazards models with unadjusted, age-adjusted, and fully adjusted hazards ratios to examine revascularization disparities by race and SES.

Results: Revascularization rates increased over the two decades studied but the racial disparities did not narrow. Black women with either ACS or CHD had significantly lower rates of revascularization pre and post 2005. Hispanic women with acute coronary syndrome or CHD had significantly lower rates of revascularization pre-2005 and a trend for lower rates post-2005. Black women with STEMI had trend towards lower rates of revascularization pre and post 2005 compared to their white counterparts. Hispanic women with STEMI have similar rates of revascularization pre-2005 and a trend towards lower rates of revascularization post-2005. Black women with NSTEMI trend towards a higher rate of revascularization pre-2005 and a trend towards a lower rate of revascularization post-2005. Hispanics with NSTEMI had a trend for higher revascularization pre-2005, and similar rates of revascularization post-2005. Low SES women with acute coronary syndrome or coronary heart disease had no difference in the rate of revascularization pre-2005 and significantly lower revascularization post-2005. Low SES with STEMI and NSTEMI had comparable rates of revascularization for both time periods when compared to their high SES counterparts.

Conclusions: Black women with ACS or CHD had lower rates of revascularization, regardless of timing, compared to their white counterpart. Despite having similar rates of coronary events, low SES women had lower rates of revascularization in the post 2005 period when compared to their high SES counterpart.

Phthalate Metabolites and Postmenopausal Breast Cancer Risk

Mounting laboratory and animal model evidence supports the potentially carcinogenic effects of phthalates, chemicals used as plasticizers in a wide variety of consumer products (e.g., cosmetics, medications, vinyl flooring). Phthalate metabolites (PMs) are measurable in nearly 100% of the U.S. population, though levels vary widely, and also have been reported in human breast milk. However, prospective data on whether phthalates affect human breast cancer risk is lacking. Methods We conducted a nested case-control study within the Women's Health Initiative (WHI) prospective cohort (N = 419 invasive cases and 838 matched controls). Controls were matched 2:1 on age, enrollment date, follow-up time, and study group (WHI clinical trial or observational study). We measured a panel of thirteen PMs and creatinine in two or three urine samples per participant over 1 to 3 years. Multivariable conditional logistic regression analysis was used to estimate risk ratios and 95% confidence intervals (RR, 95% CI) for breast cancer risk associated with each PM, with incorporation of measurement error correction approaches to account for the moderate within-participant variability of PMs. Results Overall, we did not observe statistically significant associations between individual PMs and breast cancer risk in analyses adjusted for matching factors, creatinine, body mass index, smoking status, and race/ethnicity: e.g., mono-2-ethylhexyl phthalate (MEHP; p trend = 0.31; e.g., RR 0.91, 95% CI, 0.62–1.33), monoethyl phthalate (MEP; p trend = 0.16; e.g., RR 0.80, 95% CI, 0.55–1.16 for 4th quartile vs. 1st quartile), monohydroxy-isobutyl phthalate (MHiBP; p trend = 0.11; e.g., RR 0.78, 95% CI, 0.51–1.18 for 4th quartile vs. 1st quartile, and monobenzyl phthalate (MBzP; p trend = 0.11; e.g., RR 0.86, 95% CI, 0.57–1.28 for 4th quartile vs. 1st quartile). Conclusions These results indicate that urinary phthalate metabolite levels are not related to increased breast cancer risk. However, some phthalate metabolites may be associated with decreased risk, possibly through anti-estrogenic actions. Future analyses will explore grouping metabolites by parent phthalate and also will separately evaluate breast cancer risk by tumor estrogen receptor status and explore potential effect modification.

Persistent lymphopenia is an independent predictor of mortality in critically ill emergency general surgical patients

INTRODUCTION

Lymphopenia has been associated with poor outcome following sepsis, burns and trauma. This study was designed to establish whether lymphocyte count was associated with mortality in emergency general surgery (EGS) patients, and whether persistent lymphopenia was an independent predictor of mortality.

METHODS

A retrospective review of a prospectively compiled database of adult patients requiring ICU admission between 2002 and 2013 was performed. EGS patients with acute intra-abdominal pathology and organ dysfunction were included. Lymphocyte counts obtained from the day of ICU admission through to day 7 were examined. Multivariate logistic regression models were used to determine the relationship between persistent lymphopenia and outcome. The primary outcome measure was in-hospital mortality.

RESULTS

The study included 173 patients, of whom 135 (78 %) had a low lymphocyte count at admission to ICU and 91 % (158/173) developed lymphopenia on at least one occasion. Lymphocyte counts were lower among non-survivors compared with survivors on each day from day 2 (0.62 vs 0.81, p = 0.03) through to day 7 (0.87 vs 1.15, p < 0.01). Patients with a persistently low lymphocyte count during the study period had significantly higher mortality when compared to patients with other lymphocyte patterns (64 vs 29 %, p < 0.01). On multivariate regression analysis, persistent lymphopenia was independently associated with increased in-hospital mortality [odds ratio 3.5 (95 % CI 1.7-7.3), p < 0.01].

CONCLUSION

Lymphopenia is commonly observed in critically ill EGS patients. Patients with persistent lymphopenia are 3.5 times more likely to die and lymphopenia is an independent predictor of increased mortality in this patient group.

The incidence and magnitude of fibrinolytic activation in trauma patients

BACKGROUND

Trauma is a global disease, with over 2.5 million deaths annually from hemorrhage and coagulopathy. Overt hyperfibrinolysis is rare in trauma, and is associated with massive fatal injuries. Paradoxically, clinical trials suggest a much broader indication for antifibrinolytics.

OBJECTIVE

To determine the incidence and magnitude of fibrinolytic activation in trauma patients and its relationship to clot lysis as measured by thromboelastometry.

METHODS

A prospective cohort study of 303 consecutive trauma patients admitted between January 2007 and June 2009 was performed. Blood was drawn on arrival for thromboelastometry (TEM) and coagulation assays. Follow-up was until hospital discharge or death. TEM hyperfibrinolysis was defined as maximum clot lysis of > 15%. Fibrinolytic activation (FA) was determined according to plasmin-antiplasmin (PAP) complex and D-dimer levels. Data were collected on demographics, mechanism, severity of injury, and baseline vital signs. The primary outcome measure was 28-day mortality. The secondary outcome measures were 28-day ventilator-free days and 24-h transfusion requirement.

RESULTS

Only 5% of patients had severe fibrinolysis on TEM, but 57% of patients had evidence of 'moderate' fibrinolysis, with PAP complex levels elevated to over twice normal (> 1500 μg L(-1)) without lysis on TEM. TEM detected clot lysis only when PAP complex levels were increased to 30 times normal (P < 0.001) and antiplasmin levels were < 75% of normal. Patients with FA had increased 28-day mortality as compared with those with no FA (12% vs. 1%, P < 0.001), fewer ventilator-free days, and longer hospital stay.

CONCLUSIONS

FA occurs in the majority of trauma patients, and the magnitude of FA correlates with poor clinical outcome. This was not detected by conventional TEM, which is an insensitive measure of endogenous fibrinolytic activity.

Abstract PD03-09: Statins and breast cancer risk: A follow-up analysis of the Women's Health Initiative Cohort

Introduction: Statins (HMG CoA reductase inhibitors) are a class of cholesterol lowering drugs that affect many intracellular pathways and have implications for chemopreventive activity against cancer. Epidemiological data on statins and breast cancer risk are conflicting. We analyzed updated data from the Women's Health Initiative (WHI) to assess the relationship between statins and breast cancer risk.

Methods: This analysis included 154,587 post-menopausal women ages 50–79 years at baseline, in which 7,430 incident cases of invasive breast cancer were identified over an average of 10.8 (SD 3.3) years of follow-up. All cases of breast cancer were confirmed by review of medical records and pathology reports. Participants were asked to bring all current medications to their baseline visits and information on statin use was recorded. Statins were classified as lipophilic (lovastatin, simvastatin, fluvastatin) or hydrophilic (pravastatin and atorvastatin). Self and interviewer-administered questionnaires were used to collect information on other breast cancer risk factors. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Analyses investigated the association of any statin use as well as, type of statin (lipophilic vs. hydrophilic), statin potency, and duration of use with breast cancer. To evaluate the effect of change in statin use over time, statin use was examined as a time-dependent exposure using updated information on statin use gathered during follow-up visits. Separate analyses were conducted by hormone receptor and HER2neu status, other tumor characteristics and use of postmenopausal hormone therapy. All statistical tests were two-sided.

Results: Statins were used at baseline by 11,584 (7.5%) women in the cohort of whom 7,840 used lipophilic statins. The annualized rate of breast cancer was 0.42% among statin users and 0.42% among nonusers. The multivariable adjusted HR of breast cancer for statin users compared with non-users was 0.93 (95% C.I. 0.83–1.05), however for women using lipophilic statins the HR was 0.86 (95% CI, 0.74–1.00). Statin use for &lt; 1 year was associated with a reduction in risk (HR 0.79, 95% C.I. 0.63–0.99) however there was no trend for overall duration of use. In the stratified analysis by tumor size, there was a marginal reduction in risk for tumors between 10 and 30 mm but not in smaller or larger tumors. There were no effect modifications by tumor stage, hormone receptor or HER2neu status, hormone therapy use, family history of breast cancer or body mass index. In the multivariable adjusted time-dependent model, the HR for simvastatin was 0.80 (95% CI, 0.64–0.99).

Conclusion: Simvastatin was associated with a reduced risk of invasive breast cancer, and as a class, lipophilic statins were associated with a marginal benefit. This provides further evidence for possible class differences in statins with regard to chemo-preventive effects in breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD03-09.

Trauma alarmins as activators of damage-induced inflammation

BACKGROUND

A systemic inflammatory response syndrome (SIRS) is frequently observed after traumatic injury. The response is sterile and the activating stimulus is tissue damage. Endogenous molecules, called alarmins, are reputed to be released by injured tissues but the precise identity of these mediators is unclear. This review summarizes current preclinical and clinical evidence for trauma alarmins and their role in innate immune activation.

METHODS

A comprehensive literature review of putative alarmins in tissue damage after traumatic injury was conducted.

RESULTS

The presence of SIRS at admission is an independent predictor of mortality after trauma. The primary initiators of the human immune response are unclear. Several endogenous substances display alarmin characteristics in vitro. Preclinical studies demonstrate that blockade of certain endogenous substances can reduce adverse clinical sequelae after traumatic injury. Human evidence for trauma alarmins is extremely limited.

CONCLUSION

The magnitude of acute inflammation is predictive of outcome after trauma, suggesting that an early opportunity for immune modulation may exist. An understanding of the mechanisms of innate immune activation following trauma may lead to new therapeutic agents and improved patient survival.

Clinical and biomarker profile of trauma-induced secondary cardiac injury

BACKGROUND

Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma-induced secondary cardiac injury, and investigate its impact on outcomes in injured patients.

METHODS

Injured adult patients eligible for enrolment in the Activation of Coagulation and Inflammation in Trauma 2 study, and admitted to the intensive care unit between January 2008 and January 2010, were selected retrospectively for the study. Markers of cardiac injury (brain natriuretic peptide (BNP), heart-type fatty acid binding protein (H-FABP) and troponin I) were measured on admission, and after 24 and 72 h in blood samples from injured patients. Individual records were reviewed for adverse cardiac events and death.

RESULTS

During the study period, 135 patients were enrolled (106 male, 78·5 per cent) with a median age of 40 (range 16-89) years. Eighteen patients (13·3 per cent) had an adverse cardiac event during admission and these events were not associated with direct thoracic injury. The in-hospital mortality rate was higher among the adverse cardiac event cohort: 44 per cent (8 of 18) versus 17·1 per cent (20 of 117) (P = 0·008). Raised levels of H-FABP and BNP at 0, 24 and 72 h, and troponin I at 24 and 72 h, were associated with increased adverse cardiac events. BNP levels were higher in non-survivors on admission (median 550 versus 403 fmol/ml; P = 0·022), after 24 h (794 versus 567 fmol/ml; P = 0·033) and after 72 h (1043 versus 753 fmol/ml; P = 0·036), as were admission troponin I levels.

CONCLUSION

Clinical and cardiac biomarker characteristics support the existence of trauma-induced secondary cardiac injury, which is associated with death, and unrelated to direct thoracic injury.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Sex Hormones and Risk of Estrogen Receptor (ER)-Positive and ER-Negative Breast Cancer

Background: There is a need for improved breast cancer risk prediction by tumor estrogen receptor (ER) status. Endogenous sex hormone levels are associated with risk of overall breast cancer and the ER-positive subtype. However, the role of estradiol (E2) and testosterone (T) in the development of ER-negative tumors remains unclear. We investigated the associations of circulating levels of endogenous E2 and T with the risk of ER-positive as well as ER-negative breast cancer in postmenopausal women.Methods: We performed a case-cohort study within the Women's Health Initiative- Observational Study of postmenopausal women not taking exogenous hormones (age range: 50-79 years). Baseline endogenous levels of bioavailable E2 and T were measured using radioimmunoassays (University of Southern California, LA, CA) in 196 cases of invasive ER-positive breast cancer, 107 cases of invasive ER-negative cancer, and 560 randomly selected controls. The average follow-up time was 7.3 years.Results: After adjustment for putative risk factors, women with E2 levels in the upper three quartiles had an approximately 2-fold increased risk of ER-positive breast cancer, compared to those with E2 in the lowest quartile. These associations were only modestly decreased after adjustment for T. Higher T levels also indicated increased risk of ER-positive breast cancer; women in the third quartile of T had a 1.7-fold significantly higher risk, compared to those in the first quartile. However, this association was substantially diminished and not significant after controlling for E2.No association was observed between E2 levels and ER-negative cancer. However, women with T levels in the second, third, and fourth quartiles had lower risks of ER-negative cancer in the order of 54% (p= 0.018), 38% (p= 0.13), and 46% (p= 0.05), respectively, compared to women with T in the lowest quartile. These associations did not change materially after adjusting for E2.Table 1. Risk (Hazard Ratio (HR) and 95% CI) of ER-positive and ER-negative breast cancer by E2 and T quartiles ER-positive (HR (95% CI))ER-negative (HR (95% CI)) Model 1*Model 2**Model 1*Model 2*E2    Q11.001.001.001.00Q22.19 (1.25-3.84)2.12 (1.16-3.87)0.57 (0.29-1.12)0.72 (0.34-1.53)Q31.92 (1.10-3.35)1.74 (0.92-3.33)0.75 (0.40-1.42)1.09 (0.51-2.3)Q42.11 (1.21-3.68)1.86 (0.97-3.56)0.88 (0.48-1.62)1.36 (0.60-3.08)P for trend0.020.150.840.44T    Q11.001.001.001.00Q21.01 (0.57-1.78)0.82 (0.44-1.53)0.46 (0.24-0.88)0.45 (0.22-0.92)Q31.72 (1.04-2.84)1.36 (0.75-2.48)0.62 (0.34-1.15)0.56 (0.27-1.18)Q41.45 (0.85-2.46)1.16 (0.62-2.17)0.54 (0.29-1.00)0.44 (0.20-1.00)P for trend0.050.280.100.09*Model1: adjusted for age, race, age at menopause, alcohol use, physical activity, history of needle aspiration, lifetime use of estrogen+progestin, and time since quitting hormone therapy use. **Model2: adjusted for Model1 + sex hormones.Conclusion: Higher endogenous E2 levels were associated with increased risk of ER-positive breast cancer, independent of risk factors and T. In contrast, higher concentrations of endogenous T were related to lower risk of ER-negative breast cancer, independent of risk factors and E2. This is the first study to report an association of testosterone with ER-negative breast cancer. Further studies are needed to confirm this association.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 907.

280. INSL3 is a measure of human Leydig cell functionality both during fetal and adult life

Insulin like factor 3 (INSL3) and testosterone are the two major secretory products of the testis, both produced by the interstitial Leydig cells. The Leydig cells of the testis have two distinct generations, one developing before birth (fetal Leydig cells, FLC) and an adult type (adult Leydig cells, ALC) that become differentiated and functional at puberty. Although these two types of Leydig cells represent distinct populations, rodent studies show that both types produce testosterone and INSL3. Both are presumed to have evolved from a common stem cell pool. We measured INSL3 levels in human amniotic fluids collected at various times of gestation and show for the first time that the human male fetus indeed generates INSL3 at a time appropriate for the first transabdominal phase of testicular descent, which appears to be the primary physiological role for the fetal hormone. INSL3 appears to be independent of androgen production. The adult type Leydig cells (in adult men) secrete INSL3 that can be measured in the peripheral circulation at levels ranging from 0.5 to 2.5 ng/mL. We studied a large randomly recruited cohort of 1183 men from South Australia, comparing serum INSL3 concentrations with age, and a variety of endocrine, cognitive and morphological parameters. INSL3 concentration was observed to decline significantly with age. This however, had no correlation with testosterone or components of the HPG axis. INSL3 is an independent measure of Leydig cell function (quality and number), which appears to be independent of acute control via the HPG axis. Its decline with age reflects a decline in the properties of the Leydig cell population only, and emphasises a gonadal component in the age-related decrease in androgen production. Research supported by ARC Discovery grant DP0773315.

Differential expression of erythroid genes in prion disease

We previously reported reduced expression of erythroid-associated factor (ERAF) within haematopoietic tissues of rodent scrapie models, suggesting an unrecognized role for the erythroid lineage in prion disease. In the present study, we compared the expression of a panel of erythroid genes within four murine scrapie models and five virus infection models with parallels to prion disease pathogenesis. We report that differential expression of erythroid genes is not limited to ERAF, and is a common feature of murine scrapie, dependent on host expression of cellular prion protein. In contrast, erythroid gene expression was not altered following virus infection. Whilst these results further implicate cells of the erythroid lineage in the peripheral pathogenesis of prion disease, analysis of blood from BSE-infected cattle and scrapie-infected sheep reveals that the extent of differential expression of erythroid genes within peripheral blood is not sufficient to provide a discriminatory diagnostic test.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Pilot Study of Preoperative Combined Modality Treatment for Locally Advanced Operable Oesophageal Carcinoma: Toxicities and Long-term Outcome

AIMS

Paclitaxel, a radiosensitiser, has significant activity in oesophageal cancer. We aimed to conduct a feasibility study of preoperative chemoradiation using paclitaxel, cisplatin and 5-fluorouracil (5-FU).

MATERIALS AND METHODS

Sixteen eligible patients were enrolled. Infusional 5-FU, paclitaxel and cisplatin were given for 6 weeks before and concurrent with radiation. Conformal radiotherapy was delivered in two phases (45 Gy in 25 fractions).

RESULTS

A total of 62.5% of the patients experienced Grade 3-4 toxicities, 50% required admission; one patient died during the neo-adjuvant phase. Twelve (75%) patients had oesophagectomy, and two (12.5%) died after surgery. Pathological complete remission (PCR) and minimal residual disease were observed in 25% (95% CI 0.5-49.5%) and 18% (95% CI 0-38%) of patients, respectively, who underwent surgery. The median survival was 39.7 months (95% CI 15, not reached); 1-, 2-, 3-, and 4-year survivals were 75% (95% CI 56.5-99.5), 56.3% (36.5-86.7), 50% (30.6-81.6), and 50% (30.6-81.6), respectively.

CONCLUSION

Paclitaxel, cisplatin and 5-FU (TCF)-chemoradiation is an active regimen; the current dose schedule tested is associated with unacceptable toxicity, and cannot be recommended for routine clinical use.

B cell depletion therapy in systemic lupus erythematosus: Effect on autoantibody and antimicrobial antibody profiles

OBJECTIVE

Autoantibody production in patients with systemic lupus erythematosus (SLE) is associated with abnormalities of B cell function and phenotype. Clinical responses to B cell depletion therapy (BCDT), based on rituximab, are encouraging. Therefore, we undertook this study to investigate the effect of BCDT on antibody profiles.

METHODS

Serial sera from 16 patients with active, refractory SLE were assayed for antinucleosome antibodies, anti-double-stranded DNA (anti-dsDNA), anti-extractable nuclear antigen, anti-tetanus toxoid, and antibodies to pneumococcal capsular polysaccharide for at least 1 year following BCDT. Anti-dsDNA antibodies derived from the V(H)4.34 immunoglobulin germ line gene (9G4+) were also measured.

RESULTS

All patients achieved peripheral B cell depletion and improved clinically for at least 3 months. Antinucleosome and anti-dsDNA antibodies decreased to a mean +/- SD of 64 +/- 37% and 38 +/- 33% of baseline values, respectively, by 6-8 months post-BCDT. Levels of other autoantibodies and antimicrobial antibodies were generally unchanged. In the 9 of 16 patients who were still well at 1 year, anti-dsDNA antibodies fell to 42 +/- 36% of baseline values at 6-8 months and to 37 +/- 33% at 10-14 months. In patients who had disease flares within 1 year of BCDT, levels of these antibodies decreased to 60 +/- 40% and 83 +/- 93% of baseline values at 6-8 months and at 10-14 months, respectively. Circulating anti-dsDNA antibodies were positive for 9G4 expression in 4 of 6 patients tested, and flares in 2 of these patients were accompanied by rises in 9G4+ anti-dsDNA antibodies.

CONCLUSION

These observations suggest that B cell clones committed to producing antinucleosome and anti-dsDNA antibodies, including the V(H)4.34 subpopulation of anti-dsDNA antibodies, have a relatively rapid turnover compared with B cell clones producing other antibodies. There was also a trend toward a greater and more sustained decrease in anti-dsDNA antibodies in patients with clinical benefit lasting >1 year.

Glycosylation and misfolding of PrP

The TSEs (transmissible spongiform encephalopathies) are not only devastating neurological diseases but also provide a biochemical conundrum; how can a disease agent replicate in the apparent absence of genetic material? The prion hypothesis proposes that the TSE agent is a misfolded form of the host glycoprotein PrP (prion protein). However, a number of questions regarding the hypothesis remain to be addressed. We are using gene-targeted PrP transgenics models to investigate these issues. Here we discuss our recent results that examine the importance of PrP's N-glycans to the misfolding of the protein.

X-linked myotubular myopathy in a family with three adult survivors

We describe a family with an extremely mild form of X-linked myotubular myopathy. Three affected males survived to adulthood with sufficient muscle strength to enable them to carry out normal daily activities. The mildness of the myopathy in this family is highlighted by the following: no neonatal or infant mortality resulting from the myopathy; one affected male who did not have neonatal asphyxia and had normal early motor milestones - this affected male was able to increase his muscle bulk and strength to normal by weightlifting; and a 55-year-old male who still lives an independent life. DNA sequencing identified a novel missense mutation - G469A (E157K) - in exon 7 of the MTM1 gene in this family. To our knowledge, this is the third X-linked myotubular myopathy family, with multiple adult survivors, to be reported in the literature.

Embryonic activation and developmental expression of the murine prion protein gene

While it is well established that cellular prion protein (PrP(C)) expression is required for the development of transmissible spongiform encephalopathies (TSEs), the physiological function of PrP(C) has yet to be determined. A number of studies have examined PrP expression in different tissues and in the later stages of embryonic development. However, the relative levels of expression of PrP RNA and protein in tissues outside the central nervous system (CNS) is not well documented and the exact point of transcriptional activation of PrP during embryogenesis is unknown. We have studied PrP mRNA expression in murine embryos and both mRNA and protein expression in a variety of adult tissues. PrP RNA was detected at different levels in all tissues tested while PrP(C) protein was detectable in all adult tissues tested with the exception of kidney and liver. RNA and protein levels were also assessed at four points during postnatal brain development and levels of both were seen to increase with development. We also established that, during embryogenesis, induction of PrP RNA expression occurs between E8.5 and E9, during the period of transition from anaerobic to aerobic metabolism. Preliminary experiments investigating the effects of superoxide radicals on PrP expression in cultured neuroblastoma and astrocyte cells support the suggestion that PrP(C) forms part of a cellular antioxidant defense mechanism.