Inhaled corticosteroids and adverse outcomes among chronic obstructive pulmonary disease patients with community-acquired pneumonia: a population-based cohort study

INTRODUCTION

While inhaled corticosteroids (ICS) may increase pneumonia risk in patients with chronic obstructive pulmonary disease (COPD), the impact of ICS on pneumonia outcomes is debated. We examined whether ICS use is associated with adverse outcomes among COPD patients with community-acquired pneumonia (CAP).

MATERIALS AND METHODS

Population-based cohort study of all COPD patients with an incident hospitalization for CAP between 1997 and 2013 in Northern Denmark. Information on medications, COPD severity, comorbidities, complications, and death was obtained from medical databases. Adjusted risk ratios (aRRs) for pleuropulmonary complications, intensive care unit (ICU) admissions, and 30-day mortality in current and former ICS users were compared with those in non-users, using regression analyzes to handle confounding.

RESULTS

Of 11,368 COPD patients with CAP, 6,073 (53.4%) were current ICS users and 1,733 (15.2%) were former users. Current users had a non-significantly decreased risk of pleuropulmonary complications [2.6%; aRR = 0.82 (0.59-1.12)] compared to non-users (3.2%). This was also observed among former users [2.5%; aRR = 0.77 (0.53-1.12)]. Similarly, decreased risks of ICU admission were observed among current users [aRR = 0.77 (0.57-1.04)] and among former users [aRR = 0.81 (0.58-1.13)]. Current ICS users had significantly decreased 30-day mortality [9.1%; aRR = 0.72 (0.62-0.85)] compared to non-users (12.6%), with a stronger association observed among patients with frequent exacerbations [0.58 (0.39-0.86)]. No significant association was observed among former ICS users [0.89 (0.75-1.05)].

CONCLUSION

Our results suggest a decreased risk of death with ICS use among COPD patients admitted for CAP.

Caregiver survey in glioblastoma focused on cognitive dysfunction: development and results from a multicenter study

Aim: This study aimed to develop a cognitive dysfunction (CD) focused questionnaire to evaluate caregiver burden in glioblastoma. Materials & methods: The survey was developed from stakeholder consultations and a pilot study, and disseminated at eight US academic cancer centers. Caregivers self-reported caring for an adult with glioblastoma and CD. Results: The 89-item survey covered demographics, CD symptoms and caregiver burden domains. Among 185 caregivers, most were white, educated females and reported memory problems as the most common CD symptom. An exposure-effect was observed, with increase in number of CD symptoms significantly associated with greater caregiver burden. Conclusion: This questionnaire could guide caregiver interventions and be adapted for use longitudinally, in community cancer settings, and in patients with brain metastases.

Real-world survival analysis by tumor mutational burden in non-small cell lung cancer: a multisite U.S. study

BACKGROUND

Tumor mutational burden (TMB) is a potential biomarker to predict tumor response to immuno-oncology agents in patients with metastatic non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

A multi-site cohort study evaluated patients diagnosed with stage IV NSCLC between 2012 and 2019 who had received comprehensive genomic profiling (CGP) and any NSCLC-related treatment at 9 U.S. cancer centers. Baseline characteristics and clinical outcomes were compared between patients with TMB <10 and TMB ≥10.

RESULTS

Among the 667 patients with CGP results, most patients received CGP from Foundation Medicine (64%) or Caris (20%). Patients with TMB ≥10 (vs. TMB <10) were associated with a positive smoking history. TMB was associated with ALK (p = 0.01), EGFR (p < 0.01), and TP53 (p < 0.05) alterations. TMB >10 showed a significant association towards longer overall survival (OS) (HR: 0.43, 95% CI: 0.21-0.88, p = 0.02) and progression-free survival (PFS) (HR: 0.43, 95% CI: 0.21-0.85, p = 0.02) in patients treated with first-line immunotherapy and tested by Foundation Medicine or Caris at treatment initiation.

CONCLUSIONS

TMB levels greater than or equal to 10 mut/Mb, when tested by Foundation Medicine or Caris at treatment initiation, were significantly associated with improved OS and PFS among patients treated with first-line immunotherapy-containing regimens. Additional prospective research is warranted to validate this biomarker along with PD-L1 expression.

Caregiver burden by treatment and clinical characteristics of patients with glioblastoma

BACKGROUND

Glioblastoma is an incurable disease with a poor prognosis. For caregivers of people with glioblastoma, the burden of care can be high. Patients often present with different clinical characteristics, which may impact caregiver burden in different ways. This study aimed to evaluate associations between patient clinical characteristics and caregiver burden/quality of life (QoL).

METHODS

Caregiver-patient dyads were enrolled at 7 academic cancer centers in the United States. Eligible caregiver participants were self-reported as the primary caregiver of an adult living with glioblastoma and completed a caregiver burden survey. Eligible patients were age ≥ 18 years at glioblastoma diagnosis and alive when their respective caregiver entered the study, with the presence of cognitive dysfunction confirmed by the caregiver. Data were analyzed with descriptive statistics and multivariable analyses.

RESULTS

The final cohort included 167 dyads. Poor patient performance status resulted in patient difficulty with mental tasks, more caregiving tasks, and increased caregiving time. Language problems were reported in patients with left-sided lesions. Patient confusion was negatively associated with all caregiver domains: emotional health, social health, general health, ability to work, confidence in finances, and overall QoL. Better caregiver QoL was observed in patients with frontal lobe lesions versus non-frontal lobe lesions.

CONCLUSION

This study reinforced that patient performance status is a critical clinical factor that significantly affects caregiver burden, caregiving tasks, and caregiver time. Additionally, patient confusion affects multiple facets of caregiver burden/QoL. These results could be used to support guided intervention for caregiver support, customized to the patient experience.

Assessment of Educational Attainment and Employment Among Individuals With Autism Spectrum Disorder in Denmark

IMPORTANCE

Population-based data on educational and employment outcomes in adulthood among individuals diagnosed with autism spectrum disorder (ASD) in childhood are currently limited.

OBJECTIVE

To evaluate educational attainment and employment among individuals with and without a diagnosis of ASD before age 12 years in Denmark.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cross-sectional prevalence study was conducted using data from Danish registers. Individuals with a diagnosis of ASD recorded before age 12 years were identified among all individuals born in Denmark between January 1, 1989, and December 31, 1991, who were alive at age 25 years. Individuals with ASD were then matched on a 10:1 ratio by age, sex, and region of residence with a comparison population of individuals without a diagnosis of ASD at age 12 years. Data were analyzed from March 2019 to December 2020.

EXPOSURES

Autism spectrum disorder diagnosis and diagnostic subtype recorded before age 12 years.

MAIN OUTCOMES AND MEASURES

Adjusted prevalence ratios (aPRs) with 95% CIs for the completion of compulsory primary and lower secondary school (grade 9), upper secondary school (grades 10-12 or vocational), and tertiary school (university) and for employment by age 25 years were estimated using log-binomial regression analysis.

RESULTS

A total of 810 individuals with a diagnosis of ASD before age 12 years were matched with a comparison population of 8100 individuals without ASD. The prevalence of ninth-grade completion was similar among those with and without ASD (785 individuals [96.9%] and 7982 individuals [98.5%], respectively; aPR, 0.98; 95% CI, 0.97-1.00). Compared with those without ASD, persons with ASD had a lower prevalence of completing upper secondary school (6338 individuals [78.2%] vs 286 individuals [35.3%], respectively; aPR, 0.46; 95% CI, 0.42-0.50) and tertiary school (2185 individuals [27.0%] vs 70 individuals [8.6%]; aPR, 0.33; 95% CI, 0.26-0.41) and obtaining employment (4284 individuals [77.7%] vs 177 individuals [27.2%]; aPR, 0.35; 95% CI, 0.31-0.40) at age 25 years. A ninth-grade final examination score was available for 394 individuals (48.6%) with ASD and 7417 individuals (91.6%) without ASD. In an analysis stratified by ASD subtype, individuals diagnosed with childhood autism had lower educational attainment and employment than those diagnosed with Asperger syndrome or pervasive developmental disorder not otherwise specified. A total of 461 individuals (56.9%) with ASD were receiving public assistance or a pension (ie, disability benefits) at age 25 years compared with 1094 individuals (13.5%) without ASD in the comparison population.

CONCLUSIONS AND RELEVANCE

In this population-based cross-sectional study, a diagnosis of ASD in childhood was not associated with the completion of compulsory primary and lower secondary education (ninth grade). An ASD diagnosis before age 12 years was associated with a lower prevalence of attaining education beyond ninth grade and obtaining employment by age 25 years, indicating a substantially higher risk of reliance on public assistance in young adulthood.

Indium-111 labelling of liposomal HEGF for radionuclide delivery via ultrasound-induced cavitation

The purpose of this exploratory study was to investigate the combination of a radiopharmaceutical, nanoparticles and ultrasound (US) enhanced delivery to develop a clinically viable therapeutic strategy for tumours overexpressing the epidermal growth factor receptor (EGFR). Molecularly targeted radionuclides have great potential for cancer therapy but are sometimes associated with insufficient delivery resulting in sub-cytotoxic amounts of radioactivity being delivered to the tumour. Liposome formulations are currently used in the clinic to reduce the side effects and improve the pharmacokinetic profile of chemotherapeutic drugs. However, in contrast to non-radioactive agents, loading and release of radiotherapeutics from liposomes can be challenging in the clinical setting. US-activated cavitation agents such as microbubbles (MBs) have been used to release therapeutics from liposomes to enhance the distribution/delivery in a target area. In an effort to harness the benefits of these techniques, the development of a liposome loaded radiopharmaceutical construct for enhanced delivery via acoustic cavitation was studied. The liposomal formulation was loaded with peptide, human epidermal growth factor (HEGF), coupled to a chelator for subsequent radiolabelling with ¹¹¹Indium ([¹¹¹In]In³⁺), in a manner designed to be compatible with preparation in a radiopharmacy. Liposomes were efficiently radiolabelled (57%) within 1 h, with release of ~12% of the radiopeptide following a 20 s exposure to US-mediated cavitation in vitro. In clonogenic studies this level of release resulted in cytotoxicity specifically in cells over-expressing the epidermal growth factor receptor (EGFR), with over 99% reduction in colony survival compared to controls. The formulation extended the circulation time and changed the biodistribution compared to the non-liposomal radiopeptide in vivo, although interestingly the biodistribution did not resemble that of liposome constructs currently used in the clinic. Cavitation of MBs co-injected with liposomes into tumours expressing high levels of EGFR resulted in a 2-fold enhancement in tumour uptake within 20 min. However, owing to the poor vascularisation of the tumour model used the same level of uptake was achieved without US after 24 h. By combining acoustic-cavitation-sensitive liposomes with radiopharmaceuticals this research represents a new concept in achieving targeted delivery of radiopharmaceuticals.

Clinical and economic analysis of patients with acute myeloid leukemia by FLT3 status and midostaurin use at a Comprehensive Cancer Center

INTRODUCTION

Identification of cytogenetic and molecular abnormalities has become vital for the appropriate treatment of acute myeloid leukemia (AML). One of the most common molecular alterations in AML is the constitutive activation by internal tandem duplication of FMS-like tyrosine kinase 3 (FLT3).

METHODS

This observational, retrospective, cohort study at the Huntsman Cancer Institute (HCI) had two time periods: 1) a historical pre-midostaurin time period which consisted of the FLT3 mutated (FLT3m) and FLT3 wild type (FLT3wt) cohorts from January 1, 2007, to December 31, 2016, and 2) a post-midostaurin cohort which consisted of the FLT3 mutated midostaurin-user cohort (early mido) from May 01, 2017 to December 31, 2018.

RESULTS

In total, 39 patients were included in the FLT3m cohort, 61 in the FLT3wt cohort, and seven in the early mido cohort. FLT3m patients spent fewer days in the hospital during the first consolidation regimen and received fewer consolidation cycles compared to FLT3wt patients. Overall survival (OS) was similar between FLT3m and FLT3wt patients. For patients without hematopoietic stem cell transplant, OS was significantly shorter for FLT3m patients compared to FLT3wt patients. Mean AML related inpatient charges and physician charges for FLT3m patients were significantly higher than FLT3wt patients.

CONCLUSION

The FLT3 mutation is historically associated with a shorter time to transplant and increased total health care charges. More information is needed to evaluate the real-world treatment strategies for FLT3-mutated patients in the presence of FLT3 inhibitors and the impact of these treatment strategies on clinical and economic outcomes.

QOLP-09. IMPACT OF GLIOBLASTOMA (GBM) PATIENTS’ CLINICAL AND TREATMENT CHARACTERISTICS ON CAREGIVER BURDEN AND QUALITY OF LIFE (QOL)

BACKGROUND

GBM is an aggressive cancer with poor prognosis. We explored impact of disease on caregivers by characterizing caregiver burden and QOL associated with patient characteristics.

METHODS

Primary caregivers of living adult GBM patients with cognitive dysfunction completed a GBM-specific caregiver burden survey and the validated Caregiver Quality of Life Index–Cancer Scale (CQOLC). Patient data were abstracted from medical records (7/2018-4/2019). Patient characteristics were compared between highest and lowest tertile of CQOLC scores (range 0–140); higher scores suggest better QOL.

RESULTS

There were 140 patient-caregiver dyads enrolled in the study. Mean patient age was 57 years (range 24–63); majority white males (62.9%), unifocal lesion (90%) and normal activity level at diagnosis. Forty-percent had methylated MGMT promoter status. Caregivers were mostly white (61.4%), college-educated female spouses of similar age; 87.8% were caregiving for >6 months. Median CQOLC score was 82 (tertiles: < 76 and >92). More caregivers in the lowest vs highest CQOLC tertile reported ‘not employed due to caregiving’ (52.4% vs 12%, P< 0.01), ‘changes in patients’ personality’ (73.3% vs 42.6%, P< 0.01), ‘patient memory problems’ (93.5% vs 77.1%, P=0.02), and caring for patient with recurrence treated with ‘chemotherapy other than temozolomide’ ([TMZ], 27.7% vs 8.3%, P=0.01). There was > 10% difference in proportion of caregivers in the lowest vs highest CQOLC tertile for the following patient characteristics: largest lesion in right temporal lobe at baseline and partial resection at initial treatment. Conversely, there was > 10% difference in the highest vs lowest CQOLC tertile for Karnofsky score (> 80), largest lesion in right frontal lobe at baseline, surgical clean margins, TMZ for initial treatment, and surgery for recurrence.

CONCLUSION

Unemployment, patient personality/memory changes, and chemotherapy other than TMZ use had significant impact on caregiver burden/QoL. This may help identify caregivers to receive support and intervention.

Erythropoietin inhalation enhances adult canine alveolar-capillary formation following pneumonectomy

Paracrine erythropoietin (EPO) signaling in the lung recruits endothelial progenitor cells, promotes cell maturation and angiogenesis, and is upregulated during canine postpneumonectomy (PNX) compensatory lung growth. To determine whether inhalational delivery of exogenous EPO augments endogenous post-PNX lung growth, adult canines underwent right PNX and received, via a permanent tracheal stoma, weekly nebulization of recombinant human EPO-containing nanoparticles or empty nanoparticles (control) for 16 wk. Lung function was assessed under anesthesia pre- and post-PNX. The remaining lobes were fixed for detailed morphometric analysis. Compared with control treatment, EPO delivery significantly increased serum EPO concentration without altering systemic hematocrit or hemoglobin concentration and abrogated post-PNX lipid oxidative stress damage. EPO delivery modestly increased post-PNX volume densities of the alveolar septum per unit of lung volume and type II epithelium and endothelium per unit of septal tissue volume in selected lobes. EPO delivery also augmented the post-PNX increase in alveolar double-capillary profiles, a marker of intussusceptive capillary formation, in all remaining lobes. EPO treatment did not significantly alter absolute resting lung volumes, lung and membrane diffusing capacities, alveolar-capillary blood volume, pulmonary blood flow, lung compliance, or extravascular alveolar tissue volumes or surface areas. Results established the feasibility of chronic inhalational delivery of growth-modifying biologics in a large animal model. Exogenous EPO selectively enhanced cytoprotection and alveolar angiogenesis in remaining lobes but not whole-lung extravascular tissue growth or resting function; the nonuniform response contributes to structure-function discrepancy, a major challenge for interventions aimed at amplifying the innate potential for compensatory lung growth.

Cost-Effectiveness of Treatment Options for Neuropathic Pain: a Systematic Review

BACKGROUND

Neuropathic pain significantly reduces an individual's quality of life and places a significant economic burden on society. As such, many cost-effectiveness analyses (CEAs) have been published for treatments available for neuropathic pain.

OBJECTIVES

The primary objective of this systematic review was to provide a detailed summary of the estimates of cost-effectiveness from published CEAs comparing available treatments for neuropathic pain. The secondary objectives were to identify the key drivers of cost-effectiveness and to assess the quality of published CEAs in neuropathic pain.

METHODS

We searched Embase, MEDLINE, Cochrane CENTRAL and seven other databases to identify CEAs reporting the costs, health benefits (e.g., quality-adjusted life-years or disability-adjusted life-years) and summary statistics, such as incremental cost-effectiveness ratios, of treatments for neuropathic pain. We excluded studies reporting diseases other than neuropathic pain, those for which the full text was not available (e.g., conference abstracts), studies not written in English or not published in peer-reviewed journals, and narrative reviews, editorials and opinion papers. Titles and abstract reviews, full-text reviews, and data extraction were all performed by two independent reviewers, with disagreement resolved by a third reviewer. Mean costs, health benefits, and summary statistics were reported and qualitatively compared across studies, stratified by time horizon. Drivers of cost-effectiveness were assessed using reported one-way sensitivity analyses. The quality of all included studies was evaluated using the Tufts CEA Registry Quality Score and study reporting using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklist.

RESULTS

A total of 22 studies were identified and included in this systematic review. Included studies were heterogeneous in the treatments compared, methodology and design, perspectives, and time horizons considered, making cross-study comparisons difficult. No single treatment was consistently the most cost-effective across all studies, but tricyclic antidepressants were the preferred treatment at a willingness-to-pay threshold of $US50,000 per quality-adjusted life-year in several studies with a short time horizon and a US payer perspective. Among the 14 studies reporting one-way sensitivity analyses, drivers of cost-effectiveness included utility values for health states and the likelihood of pain relief with treatment. The quality of the identified CEAs was moderate to high, and overall reporting largely met CHEERS recommendations.

LIMITATIONS

To assess drivers of cost-effectiveness and quality, we only included studies with the full text available and thus excluded some CEAs that reported cost-effectiveness results. The heterogeneity of the included studies meant that the study results could not be synthesized and comparison across studies was limited.

CONCLUSIONS

Though many pulished studies have evaluated the cost-effectiveness of treatments for neuropathic pain, significant heterogeneity between CEAs prevented synthesis of the results. Standardized methodology and improved reporting would allow for more reliable comparisons across studies.

Impact of glioblastoma (GBM)-related cognitive dysfunction (CD) on caregiver burden: Preliminary results from multi-site study in the U.S

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Background: GBM is a largely incurable, highly aggressive cancer with high incidence of CD. Caregivers face heightened stress with loved one’s limited life expectancy and additional duties. To better understand this unique group, a survey tool was developed to examine effect of CD on caregiver burden. Methods: Four of 10 planned academic centers are enrolling towards achieving 200+ completed surveys. The survey was developed step-wise: 1) literature review of primary brain tumors, Alzheimer’s disease, and dementia to identify domains; 2) focus groups with neurooncologists and American Brain Tumor Association advocates to narrow domains; 3) caregiver interviews to verify selected domains; 4) single-site pilot study to confirm content (n=20). Dyads with caregiver survey and respective patient’s clinical data are created as possible. Results: Complete data from 31 caregivers and 28 dyads enrolled at Huntsman Cancer Institute, University of Utah and University of California, Los Angeles are currently available. Response rate was 88% for caregivers and 90% for patients. Among caregivers, 87% were patient spouse/partner, 84% female, average age 56 years, 42% currently employed, 32% have no additional help, and 26% are primary caregivers for others. Patients were male (74%), average age 59 years, not working (84%), and being treated for initial diagnosis (67%). Proportion of caregivers performing ≥ 1 caregiving task, i.e. meal preparation, doubled from before to after diagnosis (48% vs. 97%). The majority of caregivers (90%) perceived memory problems in a loved one over last 14 days. Trouble remembering recent events or things interfered with 71% of caregivers’ daily life "somewhat", "quite a bit", or "very much". When ranking effect of CD on caregiver’s general quality of life on a scale of 0 (none) to 10 (significant), 60% and 23% of caregivers indicated ≥ 5 and ≥ 8, respectively. Caregivers’ responses to survey satisfaction questions showed only 23% feel enough is being done to understand caregiving in GBM and 76% were satisfied overall with the survey. Conclusions: Caregivers are affected daily and significantly by GBM-related CD. Results will be updated at time of presentation.

Health care resource use, health care expenditures and absenteeism costs associated with osteoarthritis in US healthcare system

OBJECTIVES

We determined incremental health care resource utilization, incremental health care expenditures, incremental absenteeism, and incremental absenteeism costs associated with osteoarthritis.

DESIGN

Medical Expenditure Panel Survey (MEPS) for 2011 was used as data source. Individuals 18 years or older and employed during 2011 were eligible for inclusion in the sample for analyses. Individuals with osteoarthritis were identified based on ICD-9-CM codes. Incremental health care resource utilization included annual hospitalization, hospital days, emergency room visits and outpatient visits. Incremental health expenditures included annual inpatient, outpatient, emergency room, medications, miscellaneous and annual total expenditures.

RESULTS

Of the total sample, 1354 were diagnosed with osteoarthritis, and compared to non osteoarthritis individuals. Incremental resource utilization, expenditures, absenteeism and absenteeism costs were estimated using regression models, adjusting for age, gender, sex, region, marital status, insurance coverage, comorbidities, anxiety, asthma, hypertension and hyperlipidemia. Regression models revealed incremental mean annual resource use associated with osteoarthritis of 0.07 hospitalizations, equal to 70 additional hospitalizations per 100 osteoarthritic patients annually, and 3.63 outpatient visits, equal to 363 additional visits per 100 osteoarthritic patients annually. Mean annual incremental total expenditures associated with osteoarthritis were $2046. Annually, mean incremental expenditures were largest for inpatient expenditures at $826, followed by mean incremental outpatient expenditures of $659, and mean incremental medication expenditures of $325. Mean annual incremental absenteeism was 2.2 days and mean annual incremental absenteeism costs were $715.74. Total direct expenditures were estimated at $41.7 billion.

CONCLUSION

Osteoarthritis was associated with significant incremental health care resource utilization, expenditures, absenteeism and absenteeism costs.

Avulsion Fracture of Brachioradialis Muscle Origin: An Exceedingly Rare Entity: A Case Report

Avulsion fracture of the brachioradialis origin at its proximal attachment on the lateral supracondylar ridge of the distal humerus is exceedingly rare, and only two cases have been reported in the literature so far. In this article, we present a 38 years old patient who sustained a closed avulsion fracture of the lateral supracondylar ridge of left humerus at the proximal attachment of brachioradialis following a fall backwards on outstretched hand after being struck by a lorry from behind while riding on a two-wheeler (motorcycle). He was managed with above elbow plaster for four weeks followed by elbow and wrist mobilization. At final followup, the patient had painless full range elbow motion with good elbow flexion strength. The unique mechanism by which this avulasion fracture occurred is explained on the basis of the mode of injury, position of the limb and structure and function of the brachioradialis muscle.

Taeniasis and neurocysticercosis among Malaysians

Taeniasis, endemic in Southeast Asia, is caused by Taenia saginata (for beef) or Taenia solium and Taenia asiatica (for pork). T. solium also causes cysticercosis which can affect various organs. Taeniasis and cysticercosis cases are rarely reported in Malaysia. We report here two separate cases of beef taeniasis, and an interesting case of neurocysticercosis in a Malay Muslim. The taeniasis cases involved a Malaysian Chinese and a native Sabahan. Proglottids were recovered from them, and identification of the tapeworm done either from the microscopic examination of the egg or using PCR-based molecular diagnosis. Upon confirmation of taeniasis, both cases were given praziquantel and had been asymptomatic since. The neurocysticercosis case involving a Muslim who presented with seizure, was confirmed by histopathological examination of tissue sections taken from craniotomy excision of the brain lesion. He was given one month course of albendazole 400 mg bid and dexamethasone, and had been well and seizure free since. The two cases of taeniasis documented here had acquired the disease through eating raw or undercooked contaminated beef. For the neurocyticercosis case, it is suspected that he might have acquired the infection in one of his travels through human to human transmission via contaminated food or water consumption, given that Malaysia is not T. solium endemic area. Lastly praziquantel is an effective drug for beef taeniasis, while a combination of albendazole and dexamethasone work well for neurocysticercosis.

Solitary Osteochondroma of the Tibial Tuberosity Mimicking Osgood-Schlatter Lesion: A Rare Cause of Anterior Knee Pain in Adolescents: A Case Report

Osteochondroma arising from the tibial tuberosity is very rare. We report such a case which mimicked OsgoodSchlatter's disease in an adolescent. A 12 years-old boy presented with swelling over his right proximal tibia of one year duration associated with pain in the last three months. Examination revealed a 4 x 2cm bony mass arising from the proximal tibia. Radiographs revealed an osteochondroma of the tibial tuberosity. Computer tomography and magnetic resonance imaging confirmed the continuity of the medulla of the bony mass to that of the parent bone. Excision biopsy was done. At the final follow up, he was asymptomatic and returned back to his daily activities. We present this case for its rarity, challenges involved in diagnosis and the difficulties encountered in planning the surgery because of involvement of the apophysis and extensor mechanism attachment in a skeletally immature boy.

Interval laparoscopic abdominal cerclage for recurrent pregnancy loss

Abdominal cerclages are necessary when the standard trans-vaginal cerclages fail or anatomical abnormalities preclude the vaginal placement. In 1965, Benson and Durfee described an abdominal approach to cerclage, a procedure that was applied to congenitally short or surgically amputated cervices. Thirty-eight women with history of either recurrent mid-trimester pregnancy losses, short cervix or failed vaginal cerclage had trans-abdominal cerclage, of which 30 were done laparoscopically. A 5-mm non-absorbable needled polyester fibre tape (Mersilene) suture was placed laparoscopically at the level of the internal os as an interval procedure. All the procedures were successful. All women were discharged on post-operative day 2 and none of them required blood transfusions. There were no intraoperative or post-operative complications. Subsequently, 15 patients conceived and the foetal survival rate recorded was as high as 85.71%. Some patients manifest severe cervical injures, and others have apparent congenital absence of the cervix, rendering Shirodkar or McDonald cerclage technically difficult or impossible. The main interest of this technique is to avoid a laparotomy; thus, reducing the morbidities of a laparotomy and also the recovery time post-surgery.

Anti N-Methyl-D-Aspartate receptor encephalitis: An under-recognised cause of encephalitis

Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is an immune mediated condition with characteristic clinical presentation. We report the first case from Borneo, Sabah and the use of electroconvulsive therapy (ECT) in treating recalcitrant psychiatrist symptoms associated with this condition.

A study protocol for a randomised open-label clinical trial of artesunate-mefloquine versus chloroquine in patients with non-severe Plasmodium knowlesi malaria in Sabah, Malaysia (ACT KNOW trial)

INTRODUCTION

Malaria due to Plasmodium knowlesi is reported throughout South-East Asia, and is the commonest cause of it in Malaysia. P. knowlesi replicates every 24 h and can cause severe disease and death. Current 2010 WHO Malaria Treatment Guidelines have no recommendations for the optimal treatment of non-severe knowlesi malaria. Artemisinin-combination therapies (ACT) and chloroquine have each been successfully used to treat knowlesi malaria; however, the rapidity of parasite clearance has not been prospectively compared. Malaysia's national policy for malaria pre-elimination involves mandatory hospital admission for confirmed malaria cases with discharge only after two negative blood films; use of a more rapidly acting antimalarial agent would have health cost benefits. P. knowlesi is commonly microscopically misreported as P. malariae, P. falciparum or P. vivax, with a high proportion of the latter two species being chloroquine-resistant in Malaysia. A unified ACT-treatment protocol would provide effective blood stage malaria treatment for all Plasmodium species.

METHODS AND ANALYSIS

ACT KNOW, the first randomised controlled trial ever performed in knowlesi malaria, is a two-arm open-label trial with enrolments over a 2-year period at three district sites in Sabah, powered to show a difference in proportion of patients negative for malaria by microscopy at 24 h between treatment arms (clinicaltrials.gov #NCT01708876). Enrolments started in December 2012, with completion expected by September 2014. A total sample size of 228 is required to give 90% power (α 0.05) to determine the primary end point using intention-to-treat analysis. Secondary end points include parasite clearance time, rates of recurrent infection/treatment failure to day 42, gametocyte carriage throughout follow-up and rates of anaemia at day 28, as determined by survival analysis.

ETHICS AND DISSEMINATION

This study has been approved by relevant institutional ethics committees in Malaysia and Australia. Results will be disseminated to inform knowlesi malaria treatment policy in this region through peer-reviewed publications and academic presentations.

TRIAL REGISTRATION NUMBER

NCT01708876.

A review of malaria research in malaysia

One hundred and thirteen articles related to Malaria were found in a search through a database dedicated to indexing all original data relevant to medicine published in Malaysia between the years 2000-2013. Thirty eight articles were selected and reviewed on the basis of clinical relevance and future research implications. The epidemiology of malaria has undergone a significant change over the last decade with P. knowlesi, formerly a relatively unknown simian parasite rapidly becoming the most predominant malaria species to infect humans in Malaysia. The epidemiology, clinical features, diagnostic methods and treatment for P. knowlesi infection are described in these studies. In Malaysia, imported malaria from foreigners also poses a challenge. In view of these changes, new strategies on malaria control need to be devised and implemented, and treatment regimens need to be redefined to help Malaysia achieve the goal of malaria elimination by the year 2020.

Abstract 292: Magnetic-based Multi-layer Microparticles for Stem Cell Isolation, Enrichment, and Detachment

Due to the extensive therapeutic potential of endothelial progenitor cells (EPCs) in regenerative medicine, various techniques have been developed to isolate and expand them ex vivo . Yet these methods are limited by the use of harmful chemicals and difficulty in ex vivo stem cell expansion. The aim of this research was to develop multi-layer microparticles (MLMPs) that can magnetically isolate EPCs without using Ficoll and harsh shear forces, provide sequential proliferating and differentiating growth factor release for stem cell enrichment, and detach cells in response to temperature changes without the use of chemicals such as Trypsin. MLMPs consisted of a poly(lactic-co-glycolic acid) (PLGA) core embedded with magnetic nanoparticles and the temperature-sensitive polymer (poly( N -isopropyl acrylamide-allylamine): PNIPAAm-AH) shell. MLMPs were formulated and characterized for their physicochemical properties. Studies to investigate growth factor release, optimization concentrations of MLMPs and antibodies as well as the time required for maximal cell isolation were also carried out. Finally, effects of MLMPs on the growth of isolated cells were studied. MLMPs had core-shell structure with spherical morphology of 50-75 μm, and their growth factors were released in a sequential manner required for cell proliferation and differentiation. EPCs successfully attached to the polymer surface, while maintaining their morphology as verified from staining and SEM. Moreover, 64% EPCs were isolated over a period of 2 hours with 1 mg/ml MLMPs conjugated with 3 μg/ml CD34 antibodies. Cells were successfully detached from the particle surface by lowering the surrounding temperature to room temperature for a short time. MLMPs loaded with growth factors show an enhanced cell growth compared to those of commercial beads. These results indicate that MLMPs might have a significant impact on cell isolation and expansion technologies.

Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting?

PURPOSE

The purpose of the study was to assess the validity of surgical interference with elastic nailing in treating pediatric femur fractures in comparison with the traditional treatment method-hip spica casting.

METHODS

Sixteen consecutive femur fractures in children 5-15 years of age were recruited prospectively over 13 months. An equal number of age-matched children treated by spica casting were recruited retrospectively. Subtrochanteric, supracondylar femur fractures were excluded.

RESULTS

Fracture union occurred earlier in the surgical group (6 weeks) than in the spica group (8 weeks) (P = 0.001). Spica casting caused higher coronal plane angulation (P = 0.001), higher rotational malalignment (P < 0.001), higher limb length discrepancy at 1-year follow-up (P < 0.001), longer duration of immobilization (P < 0.001), later full weight-bearing (P < 0.001), and greater absence from school (P < 0.001). Flynn outcome scores were better with titanium elastic nailing than with hip spica casting.

CONCLUSION

Titanium elastic nailing led to better outcomes compared to hip spica casting in terms of earlier union, lower rates of malunion, shorter rehabilitation milestones, and better functional outcome scores.

Genome-wide scan identifies novel modifier loci of acromegalic phenotypes for isolated familial somatotropinoma

Isolated familial somatotropinoma (IFS) accounts for 18% of familial isolated pituitary adenoma (FIPA) cases. Recently, germline mutations of the aryl hydrocarbon receptor-interacting protein gene (AIP) have been found in families with pituitary adenoma predisposition, FIPA, and IFS. In this study, we investigate the AIP mutation status and perform a genome-wide scan to search for the modifier regions of acromegalic phenotypes in an IFS family of 31 aborigines from Borneo. Complete endocrine diagnosis and data could not be collected due to logistical and cultural reasons. AIP mutation screening was carried out by direct sequencing and the genome-wide scan was performed using 400 microsatellites. Non-parametric linkage analysis was performed to obtain the logarithm of odds (LOD) scores. A novel AIP frameshift mutation in exon 4 (c.500delC) (p.P167HfsX3) was identified in all members with acromegalic features, as well as in 15 members without acromegalic features, revealing incomplete penetrance of AIP. The data showed that patients with the same mutation may express acromegalic features of differing severity, suggesting the existence of modifier genes. The highest LOD score of 2.2 was obtained near D19S571 (19q13.41). We also found weak linkages on chromosomes 3q28, 8q12.1, and 21q22.13, with LOD scores of 1.1, 1.8, and 1.4 respectively. Our results show the first genome-wide scan that identifies novel modifier loci for acromegalic phenotypes in an IFS family. Identification of modifier loci may provide further insight into the disease mechanism and explain the clinical variability observed in its patients.

Effect of Notch inhibition on radiation in an explant model of glioblastoma multiforme

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Background: Glioblastoma Multiforme (GBM) is highly radioresistant, possibly due to a subpopulation of Brain Tumor “Stem-like‘ Cells (BTSC) capable of repopulating the tumor. The Notch signaling pathway is essential for maintaining normal neural stem cells. We asked whether Notch inhibition can overcome radioresistance by allowing BTSCs to exit their stem cell state. Methods: To maintain the BTSCs in their original niche we used an organotypic culture method (explants). GBM explants are cultured on a semiporous membrane in an air-medium interface. They are treated with the Notch inhibitor DAPT, radiation or a combination thereof. Proliferation and neurosphere forming capacity are assessed. Results: The explant model faithfully maintained the cytoarchitecture of the tumor (preservation of blood vessels and pericytes) and its high proliferation rate (%ki67+ cells: 14.3% -17.1%). The effect of DAPT or radiation treatment alone differed among tumors (from no change to a two-fold and nine-fold decrease post DAPT or radiation respectively). However, in all tumors tested the combination of DAPT and radiation dramatically decreased the proliferation rate compared to either treatment alone (%ki67 + cells: 0.19%-2.24%). Interestingly the rate of neurosphere formation was highest following radiation alone (threefold increase). Neurosphere formation after DAPT treatment differed amongst the tumors from a decrease (fourfold) to an increase (twofold). The combination treatment resulted in a modest increase over control (twofold). Conclusions: Our data demonstrates that inhibition of proliferation does not correlate with the status of neurosphere forming ability, arguably a surrogate for cancer stem cell function. Combining radiation with notch inhibition has a profound effect on GBM proliferation, most likely due to selectively inhibiting the BTSC repopulating ability. Ongoing studies will determine the impact of this approach on tumor growth and progression in in vivo tumor models.

No significant financial relationships to disclose.

Demography and clinical course of ulcerative colitis in a multiracial Asian population: a nationwide study from Malaysia

OBJECTIVE

To establish the clinical course of ulcerative colitis (UC) in the Malaysian population, comparing the three major ethnic groups: Malay, Chinese and Indian.

METHODS

Patients who were diagnosed with UC from seven major medical referral centers in Malaysia were recruited. Their baseline characteristics, and the extent of the disease, its clinical course and complications were recorded.

RESULTS

A total of 118 patients was included. The extent of disease was as follows: proctitis alone in 22 (18.6%), sigmoid colon in 23 (19.5%), descending colon in 16 (13.6%), transverse colon in 11 (9.3%), ascending colon and pancolitis 46 (39%). Most patients had chronic intermittent disease. Extra-intestinal complications were seen in 27 (22.9%) patients and fulminant colitis was seen in four (3.4%). None developed colorectal cancer. The overall cumulative colectomy rates at 1, 5 and 10 years were 3.4% (CI: 0.9-8.5), 5.9% (CI: 1.9-13.2) and 15.6% (CI: 6.5-29.4), respectively. There was a higher prevalence of extra-intestinal manifestations and a trend towards more extensive disease among Indian patients. However, no significant differences were seen in the age of onset, the severity of disease (fulminant colitis, refractory disease) and the colectomy rate.

CONCLUSION

As in developed countries, most of our patients have a remitting and relapsing pattern of disease but the clinical course appears to be milder, with lower rates of colectomies. There are differences in clinical presentation among the three major ethnic groups, with Indians having a higher prevalence of extra-intestinal manifestations and a trend towards more extensive disease.

Treating leukemia in a resource poor setting

Acute lymphatic leukemia (ALL) is the commonest childhood malignancy in India; most patients have no access to specialized health care. Our experience in treating such children who are unable to avail of facilities at specialized centers is described here. The case records of 79 patients with acute lymphatic leukemia, treated at a Government Medical College in Kerala over 15 years were analyzed. Of the 73 patients who completed treatment, 23 survived (36%) 20 had event-free survival more than 5 years after remission. The utilization of available resources is described. We suggest twinning between specialized centers in India and peripheral hospitals as a means to reach more children.

Microalbuminuria prevalence study in hypertensive type 2 diabetic patients in Malaysia

Microalbuminuria is the earliest indicator of diabetic kidney disease and generalised vascular endothelial dysfunction. The Microalbuminuria Prevalence (MAP) Study was carried out to assess the prevalence of macroalbuminuria, microalbuminuria and normoalbuminuria in Asian hypertensive patients with type 2 diabetes on usual care. This paper presents a subanalysis of data from patients in Malaysia. In 733 analysed patients, the prevalence of macroalbuminuria and microalbuminuria was 15.7% and 39.7%, respectively. The high prevalence of diabetic nephropathy in these high-risk patients is a cause for concern, and the Malaysian Health Care system should be prepared for a pandemic of end-stage renal disease due to diabetic nephropathy.

Microbial growth in vials of Botulinum toxin following use in clinic

PURPOSE

Botulinum toxin has various applications in ophthalmology and is used in the outpatient department, where it is often exposed to room temperatures for 3-4 h. The manufacturer's recommendations are that the reconstituted toxin be stored in a refrigerator when not in use and discarded 4 h after reconstitution. The aim of our study was to examine such used bottles of Botulinum toxin for microbial growth after 4 h at room temperature.

METHODS AND RESULTS

Eleven consecutive bottles of Botulinum toxin used with aseptic precautions in the Ophthalmology outpatient clinics were exposed to room temperatures for 4 h. These were subsequently analysed for microbial growth. No growth was directly obtained from any of the Botulinum toxin bottles during our study.

CONCLUSIONS

This pilot study suggests that if aseptic precautions are followed during the use of Botulinum toxin, the contents of the bottle remain sterile despite being exposed to room temperatures for up to 4 h. This has implications on the use of the reconstituted toxin after the recommended 4 h.

Fasciolopsiasis: a first case report from Malaysia

Fasciolopsiasis is a disease caused by the largest intestinal fluke, Fasciolopsis buski. The disease is endemic in the Far East and Southeast Asia. Human acquires the infection after eating raw freshwater plants contaminated with the infective metacercariae. There has been no report of fasciolopsiasis either in man or in animal in Malaysia. We are reporting the first case of fasciolopsiasis in Malaysia in a 39-year-old female farmer, a native of Sabah (East Malaysia). This patient complained of cough and fever for a duration of two weeks, associated with loss of appetite and loss of weight. She had no history of traveling overseas. Physical examination showed pallor, multiple cervical and inguinal lymph nodes and hepatosplenomegaly. Laboratory investigations showed that she had iron deficiency anemia. There was leukocytosis and a raised ESR. Lymph node biopsy revealed a caseating granuloma. Stool examination was positive for the eggs of Fasciolopsis buski. The eggs measure 140 x 72.5 microm and are operculated. In this case, the patient did not present with symptoms suggestive of any intestinal parasitic infections. Detection of Fasciolopsis buski eggs in the stool was an incidental finding. She was diagnosed as a case of disseminated tuberculosis with fasciolopsiasis and was treated with antituberculosis drugs and praziquantel, respectively.

A case for a neonatal, low-dose BCG vaccination trial

The rational design of a successful vaccination strategy against tuberculosis requires certain kinds of information and must take account of several considerations: (i) the nature of the immune response that protects the large majority of individuals infected by Mycobacterium tuberculosis, designated as healthy contacts, must be defined and distinguished from that in tuberculosis patients, whose immune system must have failed; (ii) the vaccination strategy must incorporate a way of priming the immune system to guarantee in all individuals this protective response, normally generated in healthy contacts, upon natural infection by M. tuberculosis; (iii) the strategy must incorporate a mechanism for ensuring that the effectiveness of this priming is not abrogated by exposure to environmental mycobacteria; and (iv) the strategy must take account of the fact that the vaccinated population is genetically heterogeneous, and that individuals will therefore respond variably to most standard vaccination protocols. We describe a tentative proposal for how these interrelated problems might be solved and discuss predictions of this tentative vaccination strategy. Critical testing of the neonatal, low-dose BCG vaccination strategy can only be achieved by a field trial and we outline the considerations underlying this proposal.

Ultrastructural observations on effects of different concentrations of calcium and thyroxine in vitro on larval epidermal cells of Rana catesbeiana tadpoles

During anuran metamorphosis dramatic changes in morphogenesis and differentiation of epidermis occur under the influence of thyroid hormones. Modification of ionic calcium concentration also markedly alters the pattern of proliferation and differentiation in amphibian epidermal cells in vitro. The present study was designed to determine the direct effect of low (0.05 mM) and high (0.5 mM) calcium (Ca2+) in the absence or presence of thyroxine (10(-7) M) on epidermal cells of the body and tail tissue in vitro. When tail fin and body skin explants were maintained in low (0.05 mM) calcium for 48 h, normal ultrastructural morphology and integrity of the cells was observed in both the tissue types. When tissues were exposed to high levels of calcium (0.5 mM) in culture medium, tail epidermis showed stratification, and skein cells exhibited apoptosis, both in the presence or absence of thyroid hormones. Under high calcium conditions, the body epidermis showed keratinization of apical cells, apoptosis of skein cells, and increased desmosome formation. These results suggest that (1) optimal Ca2+ concentration for larval epidermal cells is quite low (0.05 mM), (2) high Ca2+ leads to keratinization only in body epidermis, and (3) apoptosis occurred in skein cells of both the tissues at high Ca2+ concentrations (0.5 mM). The present study therefore suggests that the extracellular calcium concentration regulates the process of cell death and differentiation in Rana catesbeiana larval epidermis, and this effect may be similar to the effect of calcium on mammalian epidermal cells.

Developmental implications of differential effects of calcium in tail and body skin of Anuran tadpoles

The effects of external Ca(++) on metamorphosis of Rana catesbeiana tadpoles were assessed. Treatment of tadpoles with Ca(++) (0.05 mM) during early prometamorphic stages induced precocious metamorphic events such as tail regression, shortening of the intestine, forelimb emergence, and keratinization of body epidermis within 23 days of treatment compared to control tadpoles still in mid-prometamorphic stages. These effects of Ca(++) are probably mediated by the thyroid gland, as indicated by histological features of the gland at the light and electron microscopic levels. Calcium levels of tail and body skin were measured at various stages of development by atomic absorption spectrophotometry. In control and experimental groups, body skin had significantly higher Ca(++) concentrations than tail skin. There were no statistically significant effects of developmental stage on Ca(++) levels of tail or body skin. Experimental Ca(++) treatment significantly increased Ca(++) concentration in tail but not body skin. Ultrastructure studies and gel electrophoresis indicated that calcium induced keratinization of body skin, but not tail epidermis. Ca(++)-treated tail epidermis showed various autolysing figures in apoptotic cells. In summary, calcium treatment accelerated metamorphosis and induced the following region-dependent cellular events: keratinization of body skin-a characteristic of adult epidermis-and programmed cell death in the tail. Whatever signal elicited by calcium in this experimentally induced accelerated metamorphosis is probably mediated via the thyroid gland.