Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in general practices of England in the years 2018-2020

OBJECTIVES

To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England's National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage.

DESIGN

Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression.

PARTICIPANTS

Survey respondents of the GPPS 2018-2020.

PRIMARY OUTCOME MEASURES

Online appointment booking and online repeat prescription ordering.

RESULTS

1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups.

CONCLUSIONS

Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the different patients' needs could inform solutions to increase the uptake and use of the services.

A novel likely pathogenic CLCN5 variant in Dent's disease

BACKGROUND

The majority of cases of Dent's disease are caused by pathogenic variants in the CLCN5 gene, which encodes a voltage-gated chloride ion channel (ClC-5), resulting in proximal tubular dysfunction. We present three members of the same family and one unrelated paediatric patient with the same insertion-deletion CLCN5 variant. The identification of these patients and positive familial segregation led to the re-classification of this variant from one of unknown significance to one of likely pathogenicity.

CASE PRESENTATION

A 41 year old male presented with end stage kidney failure, proteinuria and haematuria. Whole genome sequencing identified an insertion-deletion variant in CLCN5, resulting in a missense change (c.1744_1745delinsAA p.(Ala582Lys)). His brother and nephew, who both exhibited renal impairment, haematuria, proteinuria, glycosuria and nephrocalcinosis, were found to have the same variant. In addition, genetic testing of an unrelated paediatric patient who presented with proteinuria and hypercalciuria, demonstrated the same variant.

CONCLUSIONS

The identification of this novel variant in four individuals with features of Dent's disease, has led to the re-classification of the variant to one of likely pathogenicity. As a result, our patients and any future patients with the same variant can be offered a likely diagnosis, without the need for kidney biopsy, and their family members can be offered genetic screening.

Targeting a free viral fraction enhances the early alert potential of wastewater surveillance for SARS-CoV-2: a methods comparison spanning the transition between delta and omicron variants in a large urban center

Introduction

Wastewater surveillance has proven to be a valuable approach to monitoring the spread of SARS-CoV-2, the virus that causes Coronavirus disease 2019 (COVID-19). Recognizing the benefits of wastewater surveillance as a tool to support public health in tracking SARS-CoV-2 and other respiratory pathogens, numerous wastewater virus sampling and concentration methods have been tested for appropriate applications as well as their significance for actionability by public health practices.

Methods

Here, we present a 34-week long wastewater surveillance study that covers nearly 4 million residents of the Detroit (MI, United States) metropolitan area. Three primary concentration methods were compared with respect to recovery of SARS-CoV-2 from wastewater: Virus Adsorption-Elution (VIRADEL), polyethylene glycol precipitation (PEG), and polysulfone (PES) filtration. Wastewater viral concentrations were normalized using various parameters (flow rate, population, total suspended solids) to account for variations in flow. Three analytical approaches were implemented to compare wastewater viral concentrations across the three primary concentration methods to COVID-19 clinical data for both normalized and non-normalized data: Pearson and Spearman correlations, Dynamic Time Warping (DTW), and Time Lagged Cross Correlation (TLCC) and peak synchrony.

Results

It was found that VIRADEL, which captures free and suspended virus from supernatant wastewater, was a leading indicator of COVID-19 cases within the region, whereas PEG and PES filtration, which target particle-associated virus, each lagged behind the early alert potential of VIRADEL. PEG and PES methods may potentially capture previously shed and accumulated SARS-CoV-2 resuspended from sediments in the interceptors.

Discussion

These results indicate that the VIRADEL method can be used to enhance the early-warning potential of wastewater surveillance applications although drawbacks include the need to process large volumes of wastewater to concentrate sufficiently free and suspended virus for detection. While lagging the VIRADEL method for early-alert potential, both PEG and PES filtration can be used for routine COVID-19 wastewater monitoring since they allow a large number of samples to be processed concurrently while being more cost-effective and with rapid turn-around yielding results same day as collection.

Diagnosing and Characterizing the Mechanisms of Biological Phosphorus Removal at the Great Lakes Water Authority (GLWA) Water Resource Recovery Facility (WRRF)

Previous research has demonstrated that biological phosphorus removal (bio-P) occurs in the Great Lakes Water Authority (GLWA) Water Resource Recovery Facility (WRRF) High Purity Oxygen Activated Sludge (HPO-AS) process, suggesting that sludge fermentation in the secondary clarifier sludge blanket is key to bio-P occurrence. This study, combining batch reactor testing, the development of a process model for the HPO-AS process using Sumo21 (Dynamita), and the analysis of eight and a half years of plant operating data, showed that bio-P consistently occurs at the GLWA WRRF. This occurrence is attributed to the unique configuration of the HPO-AS process, which has a relatively large secondary clarifier compared to the bioreactor, and the characteristics of the influent wastewater, primarily particulate matter with limited concentrations of dissolved biodegradable organic matter. The volatile fatty acids (VFAs) needed for polyphosphate accumulating organisms (PAOs) growth are produced in the secondary clarifier sludge blanket, which provides more than four times the anaerobic biomass inventory compared to the anaerobic zones in the bioreactor, thus facilitating bio-P in the current system. Opportunities exist to further optimize the phosphorus removal performance of the HPO-AS process and reduce the amount of ferric chloride used. These findings may be of interest to researchers investigating biological phosphorus removal in similar systems.

Wastewater surveillance beyond COVID-19: a ranking system for communicable disease testing in the tri-county Detroit area, Michigan, USA

Introduction

Throughout the coronavirus disease 2019 (COVID-19) pandemic, wastewater surveillance has been utilized to monitor the disease in the United States through routine national, statewide, and regional monitoring projects. A significant canon of evidence was produced showing that wastewater surveillance is a credible and effective tool for disease monitoring. Hence, the application of wastewater surveillance can extend beyond monitoring SARS-CoV-2 to encompass a diverse range of emerging diseases. This article proposed a ranking system for prioritizing reportable communicable diseases (CDs) in the Tri-County Detroit Area (TCDA), Michigan, for future wastewater surveillance applications at the Great Lakes Water Authority's Water Reclamation Plant (GLWA's WRP).

Methods

The comprehensive CD wastewater surveillance ranking system (CDWSRank) was developed based on 6 binary and 6 quantitative parameters. The final ranking scores of CDs were computed by summing the multiplication products of weighting factors for each parameter, and then were sorted based on decreasing priority. Disease incidence data from 2014 to 2021 were collected for the TCDA. Disease incidence trends in the TCDA were endowed with higher weights, prioritizing the TCDA over the state of Michigan.

Results

Disparities in incidences of CDs were identified between the TCDA and state of Michigan, indicating epidemiological differences. Among 96 ranked CDs, some top ranked CDs did not present relatively high incidences but were prioritized, suggesting that such CDs require significant attention by wastewater surveillance practitioners, despite their relatively low incidences in the geographic area of interest. Appropriate wastewater sample concentration methods are summarized for the application of wastewater surveillance as per viral, bacterial, parasitic, and fungal pathogens.

Discussion

The CDWSRank system is one of the first of its kind to provide an empirical approach to prioritize CDs for wastewater surveillance, specifically in geographies served by centralized wastewater collection in the area of interest. The CDWSRank system provides a methodological tool and critical information that can help public health officials and policymakers allocate resources. It can be used to prioritize disease surveillance efforts and ensure that public health interventions are targeted at the most potentially urgent threats. The CDWSRank system can be easily adopted to geographical locations beyond the TCDA.

Improving Multidisciplinary Team Working to Support Integrated Care for People with Frailty Amidst the COVID-19 Pandemic

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic. Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills. 115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care. 38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

Simple methods for early warnings of COVID-19 surges: Lessons learned from 21 months of wastewater and clinical data collection in Detroit, Michigan, United States

Wastewater-based epidemiology (WBE) has drawn great attention since the Coronavirus disease 2019 (COVID-19) pandemic, not only due to its capability to circumvent the limitations of traditional clinical surveillance, but also due to its potential to forewarn fluctuations of disease incidences in communities. One critical application of WBE is to provide "early warnings" for upcoming fluctuations of disease incidences in communities which traditional clinical testing is incapable to achieve. While intricate models have been developed to determine early warnings based on wastewater surveillance data, there is an exigent need for straightforward, rapid, broadly applicable methods for health departments and partner agencies to implement. Our purpose in this study is to develop and evaluate such early-warning methods and clinical-case peak-detection methods based on WBE data to mount an informed public health response. Throughout an extended wastewater surveillance period across Detroit, MI metropolitan area (the entire study period is from September 2020 to May 2022) we designed eight early-warning methods (three real-time and five post-factum). Additionally, we designed three peak-detection methods based on clinical epidemiological data. We demonstrated the utility of these methods for providing early warnings for COVID-19 incidences, with their counterpart accuracies evaluated by hit rates. "Hit rates" were defined as the number of early warning dates (using wastewater surveillance data) that captured defined peaks (using clinical epidemiological data) divided by the total number of early warning dates. Hit rates demonstrated that the accuracy of both real-time and post-factum methods could reach 100 %. Furthermore, the results indicate that the accuracy was influenced by approaches to defining peaks of disease incidence. The proposed methods herein can assist health departments capitalizing on WBE data to assess trends and implement quick public health responses to future epidemics. Besides, this study elucidated critical factors affecting early warnings based on WBE amid the COVID-19 pandemic.

Surveillance of SARS-CoV-2 in nine neighborhood sewersheds in Detroit Tri-County area, United States: Assessing per capita SARS-CoV-2 estimations and COVID-19 incidence

Wastewater-based epidemiology (WBE) has been suggested as a useful tool to predict the emergence and investigate the extent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this study, we screened appropriate population biomarkers for wastewater SARS-CoV-2 normalization and compared the normalized SARS-CoV-2 values across locations with different demographic characteristics in southeastern Michigan. Wastewater samples were collected between December 2020 and October 2021 from nine neighborhood sewersheds in the Detroit Tri-County area. Using reverse transcriptase droplet digital polymerase chain reaction (RT-ddPCR), concentrations of N1 and N2 genes in the studied sites were quantified, with N1 values ranging from 1.92 × 10² genomic copies/L to 6.87 × 10³ gc/L and N2 values ranging from 1.91 × 10² gc/L to 6.45 × 10³ gc/L. The strongest correlations were observed with between cumulative COVID-19 cases per capita (referred as COVID-19 incidences thereafter), and SARS-CoV-2 concentrations normalized by total Kjeldahl nitrogen (TKN), creatinine, 5-hydroxyindoleacetic acid (5-HIAA) and xanthine when correlating the per capita SARS-CoV-2 and COVID-19 incidences. When SARS-CoV-2 concentrations in wastewater were normalized and compared with COVID-19 incidences, the differences between neighborhoods of varying demographics were reduced as compared to differences observed when comparing non-normalized SARS-CoV-2 with COVID-19 cases. This indicates when studying the disease burden in communities of different demographics, accurate per capita estimation is of great importance. The study suggests that monitoring selected water quality parameters or biomarkers, along with RNA concentrations in wastewater, will allow adequate data normalization for spatial comparisons, especially in areas where detailed sanitary sewage flows and contributing populations in the catchment areas are not available. This opens the possibility of using WBE to assess community infections in rural areas or the developing world where the contributing population of a sample could be unknown.

Correlation of SARS-CoV2 Viral Growth on Cultures, Ct Values, SARS-CoV-2 Variant and Vaccination Status in Asymptomatic, Pre-Symptomatic and Post-Infection Asymptomatic COVID Patients

Introduction/Objective

COVID-19 large scale immunizations have helped control the infectious spread, but breakthrough infections are still observed and some of these patients remain asymptomatic. In this study, we compared the viral growth characteristics with vaccination status in asymptomatic patients.

Methods/Case Report

We searched our institutional laboratory database for asymptomatic patients infected with delta variant (November-December 2021, n=65) and omicron variant (December 2021, n=68), that were further classified as “truly asymptomatic”, “pre-symptomatic” and “post-infection asymptomatic” based on detailed chart reviews. The patients’ left-over nasopharyngeal swab samples’ cycle threshold values and the recovery of infectious virus in cell culture were compared.

Results (if a Case Study enter NA)

In the delta cohort, out of 65 asymptomatic patients, 36 were truly asymptomatic, 26 presymptomatic and 3 post infection asymptomatic patients. In the omicron cohort, out of 68 asymptomatic patients, 45 were truly asymptomatic and 23 were presymptomatic patients. The vaccination rate was 59% in truly asymptomatic (delta cohort=56%, omicron cohort=62%), 55% in presymptomatic (delta cohort=50%, omicron cohort=61%) and 67% in post-infection patients (delta cohort only). There was no significant difference in the Ct values of truly asymptomatic (mean Ct=21.08), presymptomatic (mean Ct=20.30) and post-infection asymptomatic patients (mean Ct=20.84) in the combined cohort (p=0.78) and in the delta (p=0.95) or omicron (p=0.45) subcohorts. The Ct values were not correlated with the vaccination status of the patients (vaccinated patients mean Ct=20.56, non-vaccinated patients mean Ct=20.16, p=0.68). Samples with positive viral growth on cultures had significantly lower Ct values (mean Ct= 17.16), compared to samples with negative viral culture results (mean Ct= 24.61) (p<0.0001). The viral growth on culture was not associated with the symptom status, SARS-CoV-2 variant type (delta vs omicron) and vaccination status of the patients in the delta and omicron subcohorts.

Conclusion

Our findings show that there is no significant correlation between vaccination status and viral loads and culture results in asymptomatic patients.

Ethnicity, deprivation, and the use of patient portals in England’s general practices 2018-2020

Background

Patient portals are made available and widely promoted in healthcare systems in the USA and Europe. These technologies can help patients access healthcare, receive timely treatment, and manage their health through services such as appointment booking and repeat prescription ordering. However, it is not clear if all patients who need the services are using them. This study explored patient portal use (online appointment booking and repeat prescription ordering features) and patient characteristics among NHS England GP practice patients.

Methods

The study used cross-sectional participant-level data from the GP Patient Survey (GPPS) of 2018, 2019, and 2020. Performing multilevel regression analysis, we explored the association between patient portal feature use and ethnicity and deprivation and controlled for eight other patient characteristics and one GP practice level characteristic, and modelled GP practice as a random effect in the model.

Results

In the fully adjusted model controlled for all patient characteristics and GP characteristics, participants of the Black and Other ethnic groups were less likely to have used online appointment booking (OR: 0.84, 95% CI:0.81, 0.86, and OR: 0.96, 95% CI: 0.92, 0.99, respectively) and online repeat prescription ordering (OR: 0.76, 95% CI: 0.74-0.78 and OR: 0.78, 95% CI: 0.75-0.81, respectively) compared to the White ethnic group. Association with patient portal use increased proportionally with reduced deprivation ranking.

Conclusions

In NHS England GP practices, certain ethnic minority groups and high deprivation ranking is associated with a reduced likelihood of using patient portals. If patient portals are the only route to access services, it is likely to lead to inequalities in use by some patient groups introducing unfair access to the services. Patients could continue to be provided with alternatives to patient portals to prevent potential inequities in access to services.

Key messages

• Patient portals are widely used in the healthcare system and can benefit all patients given that disparities are prevented by understanding patient groups who cannot access portals.

• Understanding patient groups less likely to use patient portals could help adapt healthcare system services and meet the needs of all patient groups.

263 INFORMING INTERVENTION DESIGN IN COGNITIVELY IMPAIRED POPULATIONS: LESSONS LEARNED FROM THE OPTIMIZE DEPRESCRIBING INTERVENTION

Background

Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions increasing their risks of adverse drug events, hospitalization, further cognitive decline and death and leading to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes. The OPTIMIZE trial examined whether educating and activating patients, family and clinicians about deprescribing reduces number of medications for older adults with cognitive impairment and multiple chronic conditions. Acceptability and challenges of intervention delivery in this vulnerable population are not well understood.

Methods

We explored mechanisms of intervention effectiveness through post hoc qualitative interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. We assessed accessibility and delivery of materials as well as the ability of the materials to facilitate conversations and influence decisions around deprescribing.

Results

Acceptance of the intervention was affected by contextual factors including cognition and prior knowledge of deprescribing. Positive effects of the intervention included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials by patients was inconsistent but highest shortly after intervention delivery. Short clinic visit times remained the largest clinician barrier to deprescribing.

Conclusion

Our work identifies key learnings in intervention roll out which can guide future scaling of our intervention and other pragmatic deprescribing intervention studies in patients with cognitive impairment. We highlight the critical roles of both timing and repetition in intervention delivery to cognitively impaired populations as well as the barrier to deprescribing posed by short clinic consultation time. Our success in activating deprescribing conversations in this population highlights the need to incentivize medical professionals and health systems to incorporate deprescribing into routine clinical practice and expand proven interventions to other vulnerable populations.

Five-week warning of COVID-19 peaks prior to the Omicron surge in Detroit, Michigan using wastewater surveillance

Wastewater-based epidemiology (WBE) is useful in predicting temporal fluctuations of COVID-19 incidence in communities and providing early warnings of pending outbreaks. To investigate the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in communities, a 12-month study between September 1, 2020, and August 31, 2021, prior to the Omicron surge, was conducted. 407 untreated wastewater samples were collected from the Great Lakes Water Authority (GLWA) in southeastern Michigan. N1 and N2 genes of SARS-CoV-2 were quantified using RT-ddPCR. Daily confirmed COVID-19 cases for the City of Detroit, and Wayne, Macomb, Oakland counties between September 1, 2020, and October 4, 2021, were collected from a public data source. The total concentrations of N1 and N2 genes ranged from 714.85 to 7145.98 gc/L and 820.47 to 6219.05 gc/L, respectively, which were strongly correlated with the 7-day moving average of total daily COVID-19 cases in the associated areas, after 5 weeks of the viral measurement. The results indicate a potential 5-week lag time of wastewater surveillance preceding COVID-19 incidence for the Detroit metropolitan area. Four statistical models were established to analyze the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in the study areas. Under a 5-week lag time scenario with both N1 and N2 genes, the autoregression model with seasonal patterns and vector autoregression model were more effective in predicting COVID-19 cases during the study period. To investigate the impact of flow parameters on the correlation, the original N1 and N2 gene concentrations were normalized by wastewater flow parameters. The statistical results indicated the optimum models were consistent for both normalized and non-normalized data. In addition, we discussed parameters that explain the observed lag time. Furthermore, we evaluated the impact of the omicron surge that followed, and the impact of different sampling methods on the estimation of lag time.

Discovery and Optimization of Pyrrolopyrimidine Derivatives as Selective Disruptors of the Perinucleolar Compartment, a Marker of Tumor Progression toward Metastasis

The perinucleolar compartment (PNC) is a dynamic subnuclear body found at the periphery of the nucleolus. The PNC is enriched with RNA transcripts and RNA-binding proteins, reflecting different states of genome organization. PNC prevalence positively correlates with cancer progression and metastatic capacity, making it a useful marker for metastatic cancer progression. A high-throughput, high-content assay was developed to identify novel small molecules that selectively reduce PNC prevalence in cancer cells. We identified and further optimized a pyrrolopyrimidine series able to reduce PNC prevalence in PC3M cancer cells at submicromolar concentrations without affecting cell viability. Structure-activity relationship exploration of the structural elements necessary for activity resulted in the discovery of several potent compounds. Analysis of in vitro drug-like properties led to the discovery of the bioavailable analogue, metarrestin, which has shown potent antimetastatic activity with improved survival in rodent models and is currently being evaluated in a first-in-human phase 1 clinical trial.

Providing pharmacy support to housebound patients: learning from the COVID-19 pandemic

Introduction

Housebound patients may face challenges to their medicines management due to reduced household mobility and potential lack of access to healthcare services. Previous literature has explored the medication-related needs of housebound patients from pharmacists’ perspectives (1-2). However little work has focussed on the patient/family perspective. In this study, we used data obtained from those staying at home as much as possible during the COVID-19 pandemic to fill this gap.

Aim

To explore home medicine practices and safety for people who were housebound during the COVID19 pandemic and to create guidance, from the patient/family perspective, for enabling pharmacists to facilitate safe medicine practices for this population.

Methods

Interviews were carried out with people who were taking at least one long term medication and met the criteria for ‘shielding’ and/or were over 70 years of age during the first wave of the COVID-19 pandemic in the UK and/or their family carers. Respondents were recruited through patient and public involvement representatives, the research team’s networks, and support groups. Potential participants were approached via personal contact and social media. Interviews were conducted by telephone or video conferencing and participants asked about their medicines management while staying at home. Inductive thematic analysis was carried out. Patient and public involvement representatives were involved in the data analysis alongside the researchers.

Results

Fifty people were interviewed (16 males, 34 females; mean age 68 years, range 26–93 years). Interview data suggested diversity of experiences of medicines management while staying at home. Some respondents reported no or little change, others an initial crisis followed by re-stabilisation, and others that the pandemic was a tipping point, exacerbating underlying challenges and having negative effects on their health and wellbeing. Medicine safety issues reported included omitted doses and less-effective formulations being used. Participants also described experiencing high levels of anxiety related to obtaining medicines, monitoring medicines and feeling at risk of contracting COVID-19 while accessing medicine-related healthcare services. Key factors identified as facilitating a smooth transition included patients’ own agency, support from family, friends and community, good communication with pharmacy staff, continuity of pharmacy services and synchronisation of medicines supply so that a maximum of one collection/delivery was required each month.

Conclusion

The study findings that we have presented relate to the UK only; this may limit the generalisability of our findings to other countries. Findings from Ireland are in the process of being analysed and will provide a basis of comparison. In addition, more females took part than males, despite efforts to address this. However, our findings suggest pharmacy staff can support medicines management for people who are housebound by synchronisation of medicines supply, delivering medicines where possible, developing/raising awareness of alternative means of communication, providing continuity of pharmacy services and signposting any community support available.

References

(1) Kayyali R, Funnell G, Harrap N, Patel A. Can community pharmacy successfully bridge the gap in care for housebound patients? Research in Social and Administrative Pharmacy 2019;15:425-439.

(2) Latif A, Mandane B, Anderson E, Barraclough C, Travis S. Optimizing medicine use for people who are homebound: an evaluation of a pilot domiciliary Medicine Use Review (dMUR) service in England. Integr Pharm Res Pract 2018;7:33-40.

Medicines management at home during the COVID-19 pandemic: a qualitative study exploring the UK patient/carer perspective

OBJECTIVES

To explore home medicine practices and safety for people shielding and/or over the age of 70 during the COVID-19 pandemic and to create guidance, from the patient/carer perspective, for enabling safe medicine practices for this population.

METHODS

Semi-structured interviews were carried out with 50 UK participants who were shielding and/or over the age of 70 and who used medicines for a long-term condition, using telephone or video conferencing. Participants were recruited through personal/professional networks and through patient/carer organisations. Participants were asked about their experiences of managing medicines during the pandemic and how this differed from previous practices. Data were analysed using inductive thematic analysis.

KEY FINDINGS

Patients' and their families' experiences of managing medicines safely during the pandemic varied greatly. Analysis suggests that this was based on the patient's own agency, the functioning of their medicines system pre-pandemic and their relationships with family, friends, community networks and pharmacy staff. Medicine safety issues reported included omitted doses and less-effective formulations being used. Participants also described experiencing high levels of anxiety related to obtaining medicines, monitoring medicines and feeling at risk of contracting COVID-19 while accessing healthcare services for medicine-related issues. Effects of the pandemic on medicines adherence were reported to be positive by some and negative by others.

CONCLUSIONS

Pharmacy staff have a key role to play by establishing good relationships with patients and their families, working with prescribers to ensure medicines systems are as joined up as possible, and signposting to community networks that can help with medicines collection.

Time-dependent cognitive and somatic symptoms of depression as predictors of new cardiac-related events in at-risk patients: the UPBEAT-UK cohort

BACKGROUND

Evidence suggests that somatic rather than cognitive depressive symptoms are risk factors for recurrent cardiac events in at-risk patients. However, this has never been explored using a time-dependent approach in a narrow time-frame, allowing a cardiac event-free time-window.

METHODS

The analysis was performed on 595 participants [70.6% male, median age 72 (27-98)] drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Depressive symptomatology was measured using the Patient Health Questionnaire-9 (PHQ-9) (four somatic, five cognitive items). New cardiac events (NCEs) including cardiac-related mortality were identified by expert examination of patient records. Analyses were performed using Cox proportional hazard models with delayed entry, with time-dependent depressive dimensions and covariates measured 12-18 months (median: 14.1, IQR: 3.5) prior to the event, with a 12-month cardiac event-free gap.

RESULTS

There were 95 NCEs during the follow-up [median time-to-event from baseline: 22.3 months (IQR: 13.4)]. Both the somatic (HR 1.12, 95% CI 1.05-1.20, p = 0.001) and cognitive dimensions (HR 1.11, 95% CI 1.03-1.18, p = 0.004) were time-dependent risk factors for an NCE in the multi-adjusted models. Specific symptoms (poor appetite/overeating for the somatic dimension, hopelessness and feeling like a failure for the cognitive dimension) were also significantly associated.

CONCLUSION

This is the first study of the association between depressive symptom dimensions and NCEs in at-risk patients using a time-to-event standardised approach. Both dimensions considered apart were independent predictors of an NCE, along with specific items, suggesting regular assessments and tailored interventions targeting specific depressive symptoms may help to prevent NCEs in at-risk populations.

Sound and Vibration as Research Variables in Terrestrial Vertebrate Models

Sound and vibration have been shown to alter animal behavior and induce physiological changes as well as to cause effects at the cellular and molecular level. For these reasons, both environmental factors have a considerable potential to alter research outcomes when the outcome of the study is dependent on the animal existing in a normal or predictable biological state. Determining the specific levels of sound or vibration that will alter research is complex, as species will respond to different frequencies and have varying frequencies where they are most sensitive. In consideration of the potential of these factors to alter research, a thorough review of the literature and the conditions that likely exist in the research facility should occur specific to each research study. This review will summarize the fundamental physical properties of sound and vibration in relation to deriving maximal level standards, consider the sources of exposure, review the effects on animals, and discuss means by which the adverse effects of these factors can be mitigated.

The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial

Background

Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI.

Methods

With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions.

Discussion

The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC.

Trial registration

NCT03984396. Registered on 13 June 2019

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience

Background

Patients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.

Methods

We used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts.

Results

We identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals.

Conclusion

Our findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a ‘one size fits all’ approach.

Pimavanserin: Potential Treatment For Dementia-Related Psychosis

Psychosis is common across dementia types with a prevalence of 20% to 70%. Currently, no pharmacologic treatment is approved for dementia-related psychosis. Atypical antipsychotics are frequently used to treat these disorders, despite significant safety concerns. Pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved in the U.S. for treating hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Patients in the pimavanserin group experienced a significant (p=0.001) improvement in Scale for the Assessment of Positive Symptoms - Parkinson's disease (SAPS-PD) scores vs. placebo. In a subgroup analysis of patients with cognitive impairment (MMSE score ≥21 but ≤24), the observed improvement on the SAPS-PD with pimavanserin (N=50) was also significant (p=0.002) and larger than in the overall study population without an adverse effect on cognition. In a Phase 2 study with pimavanserin in Alzheimer's disease psychosis, pimavanserin significantly (p=0.045) improved psychosis at Week 6 vs. placebo on the NPI-NH Psychosis Score (PS). In a prespecified subgroup of patients with a baseline NPI-NH PS ≥12, a substantively larger treatment effect (p=0.011) was observed vs. participants with NPI-NH PS <12. The results of these studies in cognitively impaired patients with PDP provided the scientific foundation for an ongoing study of pimavanserin for treating patients with dementia-related psychosis associated with the most common neurodegenerative disorders. The study uses a relapse-prevention design with the endpoint of time-to-relapse of psychosis to evaluate the long-term efficacy and safety of pimavanserin as a potential treatment for hallucinations and delusions of dementia-related psychosis.

Metarrestin, a perinucleolar compartment inhibitor, effectively suppresses metastasis

Metastasis remains a leading cause of cancer mortality due to the lack of specific inhibitors against this complex process. To identify compounds selectively targeting the metastatic state, we used the perinucleolar compartment (PNC), a complex nuclear structure associated with metastatic behaviors of cancer cells, as a phenotypic marker for a high-content screen of over 140,000 structurally diverse compounds. Metarrestin, obtained through optimization of a screening hit, disassembles PNCs in multiple cancer cell lines, inhibits invasion in vitro, suppresses metastatic development in three mouse models of human cancer, and extends survival of mice in a metastatic pancreatic cancer xenograft model with no organ toxicity or discernable adverse effects. Metarrestin disrupts the nucleolar structure and inhibits RNA polymerase (Pol) I transcription, at least in part by interacting with the translation elongation factor eEF1A2. Thus, metarrestin represents a potential therapeutic approach for the treatment of metastatic cancer.

Comments on: involving service users in the qualitative analysis of patient narratives to support healthcare quality improvement

PLAIN ENGLISH SUMMARY

Some previous researchers (Locock et al) have written about what may be the best way for public contributors to be involved in data analysis in research projects. Their experience has been that giving public contributors large amounts of text to read is not the best use of their time and experience. They have recommended that a better approach would be for a researcher to meet with a group of users at the start of analysis, to discuss what to look out for. However, as another patient group that has been involved in analysis, we think differently. The approach we used was to be more fully involved in the project over a longer time period. Analysis tasks were broken down into stages to make it easier for those taking part. We found that this allowed us to take part fully without placing too much burden on us. We found that our approach was workable and successful and see no reason why it could not be applied in other circumstances.

ABSTRACT

In this journal, Locock et al. have suggested that service users should not be overburdened with large amounts of data, and that eliciting users' reflections on their experience at the start of analysis and using this as a guide to direct researcher attention during the remainder of the process may work better. As public contributors that have been involved in analysis we suggest an alternative approach in this brief letter, based on our own experiences.

A multi-dimensional approach to the relationship between insight and aggressiveness in schizophrenia: Findings from the FACE-SZ cohort

BACKGROUND

Aggressiveness is a stigma frequently associated with schizophrenia. The role of insight as a risk factor of aggressiveness remains contradictory; mainly because single measures of these states mask their complexity and heterogeneity.

METHODS

This study was conducted on 666 patients aged 15 and above with a DSM-IV-TR diagnosis of schizophrenia spectrum disorder, drawn from the French national network of schizophrenia expert center database. Collected data comprised socio-demographics and standardized psychiatric assessments. Aggressiveness was evaluated using the Buss-Perry Aggression Questionnaire and insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and Birchwood Insight Scale (BIS).

RESULTS

Hostility was the aggressiveness dimension the most strongly associated with SUMD insight dimensions. Patients aware of their illness were nearly twice as likely to show hostility than those seriously unaware (OR = 1.95, 95% CI.: 1.08-3.5), but not when further adjusting for depression. Similarly, those aware of the consequences of their illness and of their symptoms were more hostile. Patients moderately aware of illness consequences had a higher risk of both anger and physical aggressiveness than those unaware (OR = 2.63, 95% CI.: 1.42-4.86, OR = 2.47, 95% CI.: 1.33-4.60, respectively), even when adjusting for depression for anger.

CONCLUSION

Our study confirms that a multi-dimensional approach to insight and aggressiveness is essential to understand the types of links between these clinical states. Insight may trigger the expression of an underlying hostile tendency, maybe via depression and self-stigmatisation. This should be taken into account in therapeutic approaches to improve insight.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Shooting up? Analysis of 182 gunshot injuries presenting to a London major trauma centre over a seven-year period

Introduction Metropolitan Police data, and those from the emergency department at a London major trauma centre show a resurgence in gun crime. The aim of this study was to collect data on all gunshot injuries over a seven-year period at South-East London's trauma hub. Materials and methods This was a retrospective observational study of all gunshot injuries between 1 January 2010 and 31 December 2016 at a London major trauma centre. Information regarding patient demographics, morbidity and mortality was collected. Data from the English indices of multiple deprivation were reviewed in relation to shooting locations and socioeconomic status in South-East London. Results A total of 182 patients from 939,331 emergency admissions presented with firearm injuries. Males comprised 178 (97.8%) victims and 124 (68.1%) were documented as being Black or Afro-Caribbean. The median age was 22 years. Some 124 (71.7%) victims were shot within a 4 km radius of the hospital. The mean indices of multiple deprivation decile ranking in shooting locations compared with non-shooting locations was 2.6 (± 0.1384) and 3.8 (± 0.1149), respectively. A total of 122 (67.0%) patients underwent specialist operative intervention and 111 (61.0%) suffered only superficial or musculoskeletal injuries. Six patients required emergency thoracotomies; three (50.0%) survived to discharge. The median length of stay was 4 days (interquartile range 2-9 days) and 35 (24.0%) were admitted to intensive care. Ten (5.5%) patients died. Discussion and conclusion Firearms injuries are increasing and place a significant burden on hospital resources. Care provided to gunshot victims has improved as a result of recent trauma management initiatives at South-East London's major trauma centre.

Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders

OBJECTIVE

Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs).

METHODS

2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups.

RESULTS

FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs.

CONCLUSION

Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.

Oxcarbazepine in Mood Disorders

Patients with bipolar illness or schizoaffective disorder–manic type can present with a variety of symptoms and have mixed responses to treatment. This is especially true for patients who have rapid cycling or mixed bipolar illness. The following cases describe the use of oxcarbazepine in patients with either bipolar illness or schizoaffective disorder. This agent, an analogue of carbamazepine, has fewer drug–drug interactions and side effects and thus may prove to be a better tolerated agent in the treatment of these very serious illnesses. A discussion of the properties of oxcarbazepine is also included.

Epidemiology of penetrating injuries in the United Kingdom: A systematic review

INTRODUCTION

Penetrating injuries account for a significant number of deaths in the United Kingdom (UK) annually. Numerous articles have examined the epidemiology of penetrating trauma in various areas of the UK. This article aimed to systematically review the current literature and evaluate the incidence and mortality of penetrating injury according to region in the UK.

METHODS

A systematic literature search was performed using MEDLINE^® (1946 to June 2016), EMBASE^® (1974 to June 2016), and PsycINFO^® (1806 to June 2016) databases. The following keywords were used in combination with Boolean operators: "epidemiology", "incidence", "frequency", "pattern", "distribution"; "penetrating"; "injuries", "injury", "trauma"; "United Kingdom", "UK", "England", "Scotland", "Wales", "London".

RESULTS

Eleven relevant studies were identified across five regions of the UK. Study periods ranged from 3 months to 16 years and encompassed between 343 and 127,191 patients. Relative incidence within individual studies ranged from 0.3% (Midlands) to 21.0% (London) and mortality ranged from 0.5% (London) to 15.4% (Midlands). The majority of patients were young males.

DISCUSSION

An extensive range of incidence and mortality rates were observed between studies in all regions. This was largely dependent on the study population under review. London was found to have the highest incidence of penetrating injuries, however these studies tended to focus on populations of trauma patients. The high proportion of male victims may reflect the risk of becoming involved in gangs and violence.

CONCLUSIONS

Our ambiguous results indicate the need for further work directed towards the epidemiology of penetrating injuries within regional trauma networks.

Association Between Lifetime Headache and History of Suicide Attempts in the Elderly

Background

Pain-related conditions have been reported to play a key role among risk factors for suicide. Headache in particular has been repeatedly associated with suicidal thoughts and behaviors. The aims of this study were: 1) to assess the association between lifetime headache (both non-migrainous headache and migraine) and lifetime suicide attempts (SA); 2) to differentiate, within subjects with lifetime SA, patients with and without lifetime headache in terms of socio-demographic and clinical features.

Methods

We studied 1965 subjects from a cohort of community-dwelling persons aged 65 years and over without dementia (the ESPRIT study), divided in two groups: those with (n = 75), and those without a lifetime SA (n = 1890). Logistic regression analyses were used to compare these groups according to lifetime headache status.

Results

After adjusting for gender, living alone, tobacco and alcohol consumption, and depressive, manic/hypomanic and anxiety disorders, lifetime headache frequency was significantly higher in subjects with a lifetime SA compared with controls (OR = 1.92 [1.17–3.15]). Additionally, different factors were identified as being associated with lifetime SA in participants with lifetime headache (female gender, a lower level of high-density lipoprotein cholesterol, insomnia, lifetime major depression) versus participants without headache (glycemia and lifetime major depression).

Conclusions

Lifetime headache was associated with lifetime SA. Subjects who are women and report the co-occurrence of headache and insomnia as well as lifetime major depression require higher attention and a careful screening for suicidal thoughts and behaviors.

Patterns of selective serotonin reuptake inhibitor use and risk of falls and fractures in community-dwelling elderly people: the Three-City cohort

In this population-based elderly cohort, participants using selective serotonin reuptake inhibitor (SSRI) antidepressants have an increased risk of falls and fractures notably when the treatment was continued over 4 years. Among the various SSRI types, citalopram only was at significant risk for falls and fluoxetine for fractures.

INTRODUCTION

Increased risk of falls and fractures has been reported in elderly users of SSRIs. However, biases were insufficiently addressed notably temporality between exposure and outcome and confounding by residual depression. Our objective was to examine the associations between SSRIs and fall or fracture incidence focusing on their chronic use and different types of SSRIs.

METHODS

The population-based cohort included participants aged 65 years and above, who had not fallen before inclusion (n = 6599) or were free of recent fracture (n = 6823) and were followed up twice over 4 years. New fall and fracture events were self-reported and defined as at least two falls and one fracture, respectively, during the previous 2 years. SSRI users were compared with those taking no antidepressants. Hazard ratios (HRs) were estimated using Cox models with delayed entry and adjusted for many confounders including residual depressive symptoms.

RESULTS

Incidence of falls was 19.3 % over 4 years and that of fractures 9.5 %. After multi-adjustment, SSRI intake was significantly associated with a higher risk of falls (HR, 95 % CI = 1.58, 1.23-2.03) and fractures (HR, 95 % CI = 1.61, 1.16-2.24). The risks were significantly increased by 80 % in those continuing the treatment over 4 years. Citalopram intake only was at significant risk for falls and fluoxetine for fractures.

CONCLUSIONS

In this large community-dwelling elderly sample, SSRI users were at higher risk of falls and fractures. This association was not due to reverse causality or residual depressive symptoms. Different SSRI drugs may have specific adverse effects on falls and fractures.

Are migraine and non-migrainous headache risk factors for stroke in the elderly? Findings from a 12-year cohort follow-up

BACKGROUND AND PURPOSE

There is evidence that migraine is a risk factor for stroke but little is known about this association in elderly people. Furthermore, non-migrainous headache (NMH) has received little attention despite being the most frequently reported type of headache. Late-life migraine and NMH were examined as candidate risk factors for stroke in a community-dwelling elderly sample over a 12-year follow-up.

METHODS

One thousand nine hundred and nineteen non-institutionalized subjects aged 65+, without dementia (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV criteria) and with no stroke history at baseline, were drawn from the Three-City Montpellier cohort (recruitment 1999-2001) for longitudinal analysis. Ischaemic and haemorrhagic stroke was reported at baseline and at each of the five follow-ups, with cases validated by a panel of experts, according to ICD-10 criteria (International Classification of Diseases, 10th revision). Migraine and NMH were determined at baseline during a neurological interview and examination using 1988 International Headache Society criteria.

RESULTS

A total of 110 (5.4%) cases of migraine and 179 (8.9%) cases of NMH were identified at baseline. During the median 8.8-year follow-up, incident stroke was observed in 1.9% of baseline migrainers, 6.2% of NMH and 3.6% of those with no lifetime history of headache. Cox proportional hazard models indicated that migraine was not a risk factor for stroke; however, NMH sufferers were twice as likely to have a stroke (hazard ratio 2.00, 95% confidence interval 1.00-3.93, P = 0.049).

CONCLUSIONS

This study is one of the first to suggest that late-life NMH rather than migraine could be an independent risk factor for stroke and a warning sign. The incidence of stroke in elderly migrainers, seldom reported, is particularly low.

Late-onset agoraphobia: General population incidence and evidence for a clinical subtype

The general population prevalence and incidence of late-life agoraphobia was estimated and its clinical characteristics and risk factors described using data from the French ESPRIT study. One thousand nine hundred and sixty-eight persons aged 65 and above were randomly recruited from the electoral rolls of the district of Montpellier. Prevalent and incident agoraphobia diagnosed by a standardized psychiatric examination and validated by a clinical panel was assessed at base-line and over 4-year follow-up. The one-month prevalence of agoraphobia was estimated at 10.4% of whom 10.9% reported having the first-episode at age 65 or over. During the 4-year follow-up 11.2% of participants without agoraphobia at base line were classified as cases giving an incident rate of 32 per 1000 person-years. These 132 incident late-onset cases were associated with higher incident rates of anxiety disorders and suicidal ideation. Only two incident cases had past or concurrent panic attacks, which was not significantly different from non-cases. The principal base-line risk factors for incident cases derived from a multivariate model incorporating all significant risk factors were younger age of onset (OR = 0.94; 95% CI 0.90–0.99, P = 0.02), poorer visuospatial memory performance (OR = 1.60; 95% CI 1.02–2.49, P = 0.04), severe depression (OR = 2.62; 95% CI 1.34–5.10, P = 0.005) and trait anxiety (OR = 1.73; 95% CI 1.03–2.90, P = 0.04). No significant association was found with cardiac pathologies. We conclude that agoraphobia has high prevalence in the elderly and unlike younger cases, late-onset cases are not more common in women, and are not associated with panic attacks, suggesting a late-life subtype. Severe depression, trait anxiety and poor visuospatial memory are the principal risk factors for late-onset agoraphobia.

Elevated presence of myeloid dendritic cells in nasal polyps of patients with chronic rhinosinusitis

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2 inflammation, the mechanism underlying the onset and amplification of this inflammation has not been fully elucidated. Dendritic cells (DCs) are major antigen-presenting cells, central inducers of adaptive immunity and critical regulators of many inflammatory diseases. However, the presence of DCs in CRS, especially in nasal polyps (NPs), has not been extensively studied.

OBJECTIVE

The objective of this study was to characterize DC subsets in CRS.

METHODS

We used real-time PCR to assess the expression of mRNA for markers of myeloid DCs (mDCs; CD1c), plasmacytoid DCs (pDCs; CD303) and Langerhans cells (LCs; CD1a, CD207) in uncinate tissue (UT) from controls and patients with CRS as well as in NP. We assayed the presence of DCs by immunohistochemistry and flow cytometry.

RESULTS

Compared to UT from control subjects (n = 15) and patients with CRS without NP (CRSsNP) (n = 16) and CRSwNP (n = 17), mRNAs for CD1a and CD1c were significantly elevated in NPs (n = 29). In contrast, CD207 mRNA was not elevated in NPs. Immunohistochemistry showed that CD1c(+) cells but not CD303(+) cells were significantly elevated in NPs compared to control subjects or patients with CRSsNP. Flow cytometric analysis showed that CD1a(+) cells in NPs might be a subset of mDC1s and that CD45(+) CD19(-) CD1c(+) CD11c(+) CD141(-) CD303(-) HLA-DR(+) mDC1s and CD45(+) CD19(-) CD11c(+) CD1c(-) CD141(high) HLA-DR(+) mDC2s were significantly elevated in NPs compared to UT from controls and CRSsNP, but CD45(+) CD11c(-) CD303(+) HLA-DR(+) pDCs were only elevated in NPs compared to control UT.

CONCLUSION AND CLINICAL RELEVANCE

Myeloid DCs are elevated in CRSwNP, especially in NPs. Myeloid DCs thus may indirectly contribute to the inflammation observed in CRSwNP.

Abstract 2639: Preclinical evaluation and biomarker identification for the anti-LGR5 mAb BNC101 in K-Ras mutant CRC and other solid tumor indications

BNC101 is a monoclonal antibody (mAb) targeting LGR5 that has successfully completed IND-enabling studies in preparation for Phase I clinical studies in 2015. LGR5 is a validated cancer stem cell (CSC) receptor overexpressed in colorectal cancer (CRC), pancreatic cancer and most other solid tumors. Loss and gain-of-function studies indicate that LGR5 is a functional cancer receptor involved in tumor growth and survival. Sorted LGR5+ primary CRC are highly tumorigenic compared to LGR5- cells in limiting dilution in vivo xenograft studies. BNC101 was selected as the lead LGR5 candidate for clinical development using Bionomics’ CSC Rx Discovery™ platform. Key lead selection criteria for BNC101 were anti-tumor and anti-CSC activity in vitro and in vivo, in patient-derived xenograft (PDX) tumor models from multiple tumor types. CSC activity was evaluated by functional in vivo limiting dilution assays (LDA) using tumor cells treated with BNC101 +/- standard-of-care chemotherapy (SOC) combinations. In LDA studies with the K-Ras mutant CRC PDX tumors CT1 and CT3, 5/8 (63%) and 6/8 (75%) mice implanted with serially diluted cells from BNC101 treated tumors remained tumor free, compared to 1/8 (13%) and 2/8 (25%) in the control groups. Combination with SOC further improved BNC101 activity against CT3 tumors, where 8/8 mice re-implanted for LDA had 6 months progression-free-survival (vs 3/8 in chemo group). In the pancreatic PDX model JH109, BNC101 combined with SOC flat-lined established tumors in 3/7 mice, compared to 0/7 tumors eradicated with control SOC alone. BNC101 is also active in multiple pancreatic, triple-negative breast (TNBC) and small-cell lung (SCLC) cancer xenograft models. Ongoing translational studies have identified a panel of Wnt genes modulated by BNC101 treatment that could potentially be used to identify BNC101 responsive versus resistant patients in the clinic. Furthermore, BNC101 treatment significantly reduced LGR5+ HLA+ circulating-tumor-cells (CTCs) in the peripheral blood of tumor-bearing mice, providing a pharmacodynamic (PD) biomarker of target engagement to further evaluate in clinical studies. Altogether, the preclinical data package supports our therapeutic hypothesis that BNC101 targeting of LGR5+ CSCs will significantly improve PFS and OS in solid tumor indications. Additional translational biomarker data to support the clinical development of BNC101 will also be presented.

Citation Format: Peter Chu, Kristen Smith, Farbod Shojaei, Colin Walsh, John Norton, Jose Iglesias, Christopher Reyes. Preclinical evaluation and biomarker identification for the anti-LGR5 mAb BNC101 in K-Ras mutant CRC and other solid tumor indications. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2639. doi:10.1158/1538-7445.AM2015-2639

Abstract 5368: Metarrestin effectively disassembles PNCs and inhibits metastasis

The perinucleolar compartment (PNC) is a nuclear body that forms specifically in highly malignant cancer cells. PNC prevalence is shown to reflect metastatic potential of cancer cells from solid tissue origins. A high-content screen was performed to identify small molecules that reduce PNC prevalence. Medicinal chemistry optimizations of confirmed hits yield metarrestin, having 95% of oral bioavailability and a PNC disassembly IC50 between 100 to 400 nM across multiple cancer cell lines. Metarrestin inhibits soft agar growth and the invasive capabilities of cancer cells in vitro. In vivo mouse xenograft metastatic studies showed that metarrestin effectively inhibits lung and/or liver metastasis of prostate cancer (PC3M), pancreatic cancer (organotypic spheroids of PANC1), and a breast cancer patient xenograft (PDX) model derived from metastatic cells isolated from a pleural effusion. Treated animals tolerate metarrestin well with no discernable impact on animal well-being including weight compared with control animals. These data supports the idea that the pharmacological disassembly of PNC produces the inhibition of malignant behavior of cancer cells both in vitro and in vivo. Cellular and molecular analyses of the mechanisms of action of metarrestin show that this compound induces significant and reversible changes in the nucleolar structure, accompanied by a selective reduction of pol I transcription. These studies suggest that PNC structural integrity directly associates with pol I function and nucleolar structure. Experiments are currently underway to identify the cellular factors and pathways by which metarrestin reduces PNCs, disrupts nucleolar structure, regulates transcriptions, and blocks malignant behaviors.

Citation Format: Chen Wang, Kevin Frankowski, Teper Yaroslav, Samarjit Patnaik, Frank Schoenen, Noel Southall, Wei Sun, Steve Titus, Lesley Griner, Christopher Dextras, Jamey Sultan, Irawati Kandela, Marzena Lewandowska, Yi-Ping Wen, John Norton, Jin Sol Kang, Andrew Mazar, Wei Zhang, Jeffrey Aubé, Marc Ferrer, Udo Rudloff, Juan Jose Marugan, Sui Huang. Metarrestin effectively disassembles PNCs and inhibits metastasis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5368. doi:10.1158/1538-7445.AM2015-5368

Abstract 1752: 6-Methoxyethylamino-numonafide (MEAN) inhibits hepatocellular carcinoma as a single agent or in combination with sorafenib

Hepatocellular carcinoma (HCC) is the third leading form of cancer worldwide and the incidence is increasing rapidly in the United States, tripling over the past 3 decades. Unfortunately, chemotherapeutic treatment strategies against localized and metastatic HCC are very ineffective, leading to a high mortality from the disease. Sorafenib is the sole FDA approved chemotherapeutic currently used clinically for the disease and it shows limited efficacy and substantial toxicity. We have developed a small molecule, 6-methoxyethylamino-numonafide (MEAN), which is highly effective in two murine xenograph models of human HCC. MEAN is more effective in tumor growth inhibition and less toxic than sorafenib at the same concentration. MEAN, at efficacious doses, does not significantly affect animal body weight and does not significantly induce liver damage as determined by the serum levels of liver enzymes at the experimental endpoint. NCI60 cell assay analyses using the COMPARE algorithm indicate that, at IC50 concentration, MEAN does not significantly correlate with any of the small molecules in the 60 cell assay database (correlation&lt;0.5), suggesting novel modes of action in tumor inhibition. MEAN suppresses some of the well-known oncogene expression and enhances the expression of a subset of tumor suppressors. MEAN remains effective against cancer cells that are drug resistant due to expression of P-glycoprotein drug efflux pumps and has a favorable single dose pharmacokinetic profile. In summary, MEAN is effective against HCC tumor growth and is an excellent candidate for future development as therapeutic agent for management of HCC.

Citation Format: Yanning Liu, Guohua Lou, John Norton, Chen Wang, Irawati Kandela, Shuai Tang, Min Huang, Michael Avram, Richard Green, Andrew Mazar, Daniel Appella, Zhi Chen, Sui Huang. 6-Methoxyethylamino-numonafide (MEAN) inhibits hepatocellular carcinoma as a single agent or in combination with sorafenib. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1752. doi:10.1158/1538-7445.AM2015-1752

Abstract 2315: The LGR5 monoclonal antibody BNC101 has anti-tumor and anti-cancer stem cell activity in pancreatic cancer

BNC101 is a humanized monoclonal antibody (mAb) targeting LGR5 that has successfully completed IND-enabling studies for upcoming human clinical trials. LGR5 was originally identified as a cancer stem cell (CSC) specific receptor associated with the Wnt signaling pathway in colorectal cancer (CRC). BNC101 has significant anti-tumor and anti-CSC activity in multiple CRC patient-derived xenografts (PDX), consistent with the hypothesis that LGR5 is a functional CSC target in CRC. Because LGR5 has also been reported to be expressed on regenerating pancreatic stem cells and upregulated in pancreatic cancer, we investigated pancreatic cancer as an additional indication for BNC101 therapy. LGR5 expression was screened in a panel of pancreatic PDX samples by qPCR and RNAscope, and found to be highly expressed in a number of pancreatic samples including JH109. In vivo debulking of JH109 tumors with standard of care (SOC) Gemcitabine and Abraxane combination followed by treatment with BNC101 caused complete tumor regression in 43% (3/7) of mice (compared to 0% (0/7) in control SOC only group). We also screened LGR5 expression in a series of pancreatic cancer cell lines and identified both high-LGR5 expressing lines ASPC1 and PANC1, and an LGR5-negative line, BxPc3. BNC101 monotherapy partially inhibited tumor growth in ASPC1 and PANC1 models. In combination with Gemzar, however, BNC101 significantly inhibited tumor growth in both models. In contrast, BNC101 single agent or in combination with chemotherapy had no anti-tumor activity in the LGR5 negative BxPc3 xenograft tumors. Post-study analysis of BNC101-treated tumors revealed several interesting findings related to mechanism of action and biomarker identification. LGR5 expression was upregulated in chemo-treated tumors, suggesting that BNC101 chemo combination activity was successful due to greater LGR5 target availability. IHC analysis showed an increase in CA19 and Alcian blue expression, consistent with the hypothesis that BNC101 targets CSCs and induces terminal differentiation. BNC101 treatment also significantly reduced LGR5+ HLA+ circulating-tumor-cells (CTCs) in the peripheral blood of tumor-bearing mice, providing a pharmacodynamic (PD) biomarker of target engagement to further evaluate in clinical studies. Altogether, the data support further evaluation of BNC101 in the clinic for the treatment of pancreatic cancer. Additional translational data for future clinical development of BNC101 in pancreatic cancer will also be presented.

Citation Format: Farbod Shojaei, Colin Walsh, Kristen Smith, Camino Menendez, Pedro Lopez, John Norton, Jose Iglesias, Manuel Hidalgo, Christopher Reyes, Peter Chu. The LGR5 monoclonal antibody BNC101 has anti-tumor and anti-cancer stem cell activity in pancreatic cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2315. doi:10.1158/1538-7445.AM2015-2315

Risk factors for late-onset generalized anxiety disorder: results from a 12-year prospective cohort (the ESPRIT study)

Generalized anxiety disorder (GAD) is a chronic and highly prevalent disorder associated with increased disability and mortality in the elderly. Treatment is difficult with low rate of full remission, thus highlighting the need to identify early predictors for prevention in elderly people. The aim of this study is to identify and characterize incident GAD predictors in elderly people. A total of 1711 individuals aged 65 years and above and free of GAD at baseline were randomly recruited from electoral rolls between 1999 and 2001 (the prospective ESPRIT study). The participants were examined at baseline and five times over 12 years. GAD and psychiatric comorbidity were diagnosed with a standardized psychiatric examination, the Mini-International Neuropsychiatry Interview on the basis of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria and validated by a clinical panel. During the follow-up, 8.4% (95% confidence interval=7.1-9.7%) of the participants experienced incident GAD, 80% being first episodes; the incident rate being 10 per 1000 person-years. The principal predictors of late-onset incident GAD over 12 years derived from a multivariate Cox model were being female, recent adverse life events, having chronic physical (respiratory disorders, arrhythmia and heart failure, dyslipidemia, cognitive impairment) and mental (depression, phobia and past GAD) health disorders. Poverty, parental loss or separation and low affective support during childhood, as well as history of mental problems in parents were also significantly and independently associated with incident GAD. GAD appears as a multifactorial stress-related affective disorder resulting from both proximal and distal risk factors, some of them being potentially modifiable by health care intervention.

Abstract 3894: Targeting colorectal and pancreatic cancer stem cells with the LGR5 monoclonal antibody BNC101

BNC101 is a monoclonal antibody (mAb) targeting LGR5 currently undergoing IND-enabling studies in preparation for Phase I clinical studies in 2014. LGR5 is a validated cancer stem cell (CSC) receptor overexpressed in colorectal cancer (CRC), pancreatic cancer and most other solid tumors. Loss and gain-of-function studies indicate that LGR5 is a functional cancer receptor involved in the growth and survival of colon cancer cells in vitro and in vivo. Sorted LGR5+ primary CRC are highly tumorigenic compared to LGR5- cells in limiting dilution in vivo xenograft studies. Using Bionomics' CSC Rx Discovery™ platform, a panel of high affinity LGR5 mAbs were generated and screened for in vitro and in vivo activity against CSCs from patient-derived CRC tumors. LGR5 mAb therapeutic drug candidates were first screened and identified based on their ability to inhibit the formation of CRC CSC colonies in vitro. Top LGR5 mAb candidates were then tested as single agents and in combination with standard of care (SOC) chemotherapy in primary xenograft efficacy studies. Tumors from these studies were also harvested and re-implanted in limiting dilution assays (LDA) to assess in vivo anti-CSC activity of anti-LGR5 mAbs. A number of functional LGR5 mAbs with significant anti-tumor and anti-CSC activity were identified through this process. A lead BNC101 mAb clone was selected for clinical development based on its ability to inhibit CSC growth and key signaling pathways from multiple patient tumors both in vitro and in vivo. In LDA studies using two different CRC patient tumors, 5/8 (63%) and 6/8 (75%) mice implanted with serially diluted cells from BNC101 treated tumors remained tumor free, compared to 1/8 (13%) and 2/8 (25%) in the control groups. Combination with SOC chemotherapy was shown to further improve BNC101 activity in one CRC model, where 8/8 mice re-implanted for LDA remained tumor-free in a 6 month follow-up. BNC101 was also found to be highly active as a single agent and in combination with SOC in multiple pancreatic models and the MDA-MB-231 triple-negative breast cancer (TNBC) xenograft model. In one primary pancreatic model, BNC101 combined with SOC completely eradicated 3/7 established tumors, compared to 0/7 tumors eradicated with control SOC alone. Additional translational data in CRC, pancreatic and TNBC supporting our hypothesis that BNC101 targeting of CSCs will significantly improve survival and increase duration of response in cancer patients will be presented.

Citation Format: Peter Chu, Kristen Smith, John Norton, Colin Walsh, Farbod Shojaei, Jose Iglesias, Christopher Reyes. Targeting colorectal and pancreatic cancer stem cells with the LGR5 monoclonal antibody BNC101. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3894. doi:10.1158/1538-7445.AM2014-3894

Existe-t-il une association entre Motivation et Apathie dans la Schizophrénie ?

Les symptômes négatifs dans la schizophrénie, le plus souvent chroniques et prédictifs du fonctionnement actuel et futur des patients, restent actuellement difficiles à traiter tant sur le plan médicamenteux que psychothérapique. Or, il s’agit d’un groupe de symptômes vaste et hétérogène qu’il est difficile d’étudier dans son ensemble. C’est pourquoi, nous avons choisi de nous intéresser à l’un d’entre eux : l’apathie à la fois symptôme cardinal dans les descriptions précoces de la schizophrénie et symptôme transnosographique. Dans la schizophrénie, il est également admis qu’il existe des troubles de la motivation qui entrent dans la description des symptômes négatifs. Les données de la littérature suggèrent qu’il existerait uniquement sur un plan conceptuel un lien entre motivation et apathie. L’objectif principal de cette étude transversale est de rechercher s’il existe une association entre motivation et apathie chez des patients souffrant de schizophrénie. Soixante-quinze patients hospitalisés ayant un diagnostic de schizophrénie selon les critères du DSM IV, âgés de 18 à 60 ans ont été inclus. Les critères de jugement principaux sont :

– l’Apathie évaluée par deux échelles dont la « Lille Apathy Rating Scale » (LARS) ;

– la Motivation explorée par la BIRT Motivation Questionnaire (BMQ), par une échelle de sensibilité à la punition et à la récompense et par une tâche d’apprentissage par renforcement.

Les résultats montrent que les patients apathiques sont significativement moins motivés et plus sensibles à la punition que les patients non apathiques, et présentent une corrélation positive significative entre les scores obtenus à la LARS et à la BIRT (p < 0,001). Il existe donc une association entre motivation et apathie chez des patients souffrant de schizophrénie montrant que plus les patients sont apathiques, moins ils sont motivés. Une meilleure compréhension de cette symptomatologie négative doit permettre le développement de stratégies thérapeutiques spécifiques.

Abstract A48: Therapeutic targeting of colorectal cancer stem cells with BNC101, a functional anti-LGR5 monoclonal antibody

BNC101 is a monoclonal antibody that targets LGR5, a validated cancer stem cell (CSC) receptor overexpressed in colorectal cancer (CRC) and most other solid tumors. Loss and gain-of-function studies found that LGR5 is a functional cancer receptor involved in the growth and survival of colon cancer cells in vitro and in vivo. Sorted LGR5+ primary CRC cells were highly tumorigenic compared to LGR5- cells in limiting dilution in vivo xenograft studies. Using Bionomics’ CSC Rx Discovery™ platform, a panel of high affinity LGR5 mAbs was generated and screened for in vitro and in vivo activity against CSCs from patient-derived CRC tumors. In vitro assays initially identified top LGR5 mAb drug candidates based on their ability to inhibit the formation of CSC colonies. In vivo assays tested candidate LGR5 mAbs as single agents and in combination with standard of care (SOC) chemotherapy in primary xenograft efficacy studies. Tumors from these studies were then harvested and re-implanted in limiting dilution assays (LDA) to assess anti-CSC activity. A number of functional LGR5 mAbs with significant anti-tumor and anti-CSC activity were identified through this process. The lead BNC101 mAb clone was selected for clinical development based on its ability to inhibit CSC growth and key signaling pathways from multiple patient tumors both in vitro and in vivo. In LDA studies using two different CRC patient tumors, 5/8 (63%) and 6/8 (75%) mice implanted with serially transplanted cells from BNC101 treated tumors remained tumor free, compared to 1/8 (13%) and 2/8 (25%) in the control groups. Combination with SOC chemotherapy was shown to further improve BNC101 activity in one CRC model, where 8/8 mice re-implanted for LDA remained tumor-free in a 6 month follow-up. BNC101 was also found to be active against tumors from additional cancer indications outside of CRC. Current research is focused on advancing BNC101 translational studies to support clinical development. Significant progress and new results in these studies will be presented, in particular the identification of optimal BNC101 chemo combination strategies, biomarkers and mechanism of action. Altogether, the data support our therapeutic hypothesis that anti-LGR5 mAb BNC101 treatment will be part of an effective strategy in combination with SOC therapy to significantly improve survival and increase duration of response for patients with colorectal cancer and other solid tumors. BNC101 is currently undergoing IND-enabling manufacturing and safety studies in preparation for Phase I clinical studies scheduled for 2014.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):A48.

Citation Format: Peter Chu, Kristen Smith, Farbod Shojaei, Colin Walsh, John Norton, Jose Iglesias, Christopher Reyes. Therapeutic targeting of colorectal cancer stem cells with BNC101, a functional anti-LGR5 monoclonal antibody. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr A48.

Extraction protocol and mass spectrometry method for quantification of doxorubicin released locally from prodrugs in tumor tissue

The localized conversion of inactive doxorubicin prodrug chemotherapeutics to pharmacalogically active forms is difficult to quantify in mouse tumor models because it occurs only in small regions of tissue. The tumor tissue extraction protocol and LC-MS/MS analysis method described here were optimized to obtain a detection limit of 7.8 pg for the activated doxorubicin and 0.36 ng for the doxorubicin prodrug. This method can be useful for determining the biodistribution and activation efficiency for many different doxorubicin prodrugs. It can also be used for quantification of doxorubicin from tumor models that have poor vascularization resulting in low tissue accumulation.