Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease

BACKGROUND

Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs.

METHODS

Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula.

RESULTS

One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used.

CONCLUSIONS

The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.

Genetic sensitivity to stress modifies the relationship between socioeconomic status and major adverse cardiovascular events

Background

Lower socioeconomic status (SES) associates with major adverse cardiovascular events (MACE), in part through stress-related neural pathways that elicit inflammation. However, it is unknown whether genes that heighten stress sensitivity modify the association between lower SES and MACE.

Purpose

To assess whether genetic predisposition to stress sensitivity would modify the link between low SES and MACE

Methods

13,154 participants (median age 60 yrs, 41% male) from the Mass General Brigham Biobank were studied. A polygenic risk score for neuroticism (nPRS) was used as a measure of genetic predisposition to stress sensitivity (GSS). Using home addresses, SES was evaluated as median income and area deprivation index (ADI). Stress-related neural activity (SNA) was assessed (N=978) using validated FDG PET/CT imaging methods. MACE, and cardiovascular disease (CVD) risk factors were evaluated. Mediation analyses were employed.

Results

Over median (IQR) 4.9 (4.1–5.9) years of follow-up, 1,030 (7.8%) individuals had MACE. Lower SES (as low income, or alternatively as high ADI) associated with incident MACE among individuals with higher GSS (nPRS ≥ median) but not lower GSS (Fig. 1A and 1B). Similarly, lower SES associated with SNA among individuals with higher but not lower GSS (Fig. 1C). SNA mediated the relationship between income and MACE (P<0.05**) among those with higher GSS.

Conclusions

Genetic predisposition to stress sensitivity appears to heighten CVD risk associated with lower SES. This relationship may result from differential activation of stress-related neural pathways.

Funding Acknowledgement

Type of funding sources: None.

Does getting away with it count? An application of stafford and warr's reconceptualised model of deterrence to drink driving

Drink drivers continue to be disproportionately represented in road mortalities and morbidities. Given these costs, countermeasures that effectively reduce the behaviour (and its consequences) are imperative. Research has produced inconsistent findings regarding the deterrent effects of some countermeasures on drink driving behaviour, namely legal sanctions, suggesting other factors may be more influential. This study aimed to determine which deterrence measures based on Classical Deterrence Theory and Stafford and Warr's (1993) reconceptualised model of deterrence influence the propensity to drink and drive over the legal blood alcohol content limit of 0.05. In total, 1257 Australian drivers aged from 16 to 85 years completed a questionnaire assessing their self-reported drink driving behaviour and perceptions of legal sanctions. Consistent with previous research, past experiences of direct punishment avoidance was the most significant predictor of drink driving. Additionally, perceptions of personal certainty of apprehension were a significant (albeit weak) negative predictor of drink driving. Counterintuitively, experiences of indirect punishment were predictive of self-reported drink driving. Similarly, penalty severity produced mixed results as those who considered a penalty would be severe were less likely to drink and drive. However those that considered the penalty would cause a considerable impact on their lives, were more likely to drink and drive. Taken together, these findings suggest that while the threat of apprehension and punishment may influence self-reported drink driving behaviours, committing and offence while avoiding detection is a significant influence upon ongoing offending. This paper will further elaborate on the findings in regards to developing salient and effective deterrents that produce a lasting effect.

Safety of Recombinant Human Factor XIII in a Cynomolgus Monkey Model of Extracorporeal Blood Circulation

Factor XIII (FXIII) is a thrombin-activated plasma coagulation factor critical for blood clot stabilization and longevity. Administration of exogenous FXIII to replenish depleted stores after major surgery, including cardiopulmonary bypass, may reduce bleeding complications and transfusion requirements. Thus, a model of extracorporeal circulation (ECC) was developed in adult male cynomolgus monkeys ( Macaca fascicularis) to evaluate the nonclinical safety of recombinant human FXIII (rFXIII). The hematological and coagulation profile in study animals during and after 2 h of ECC was similar to that reported for humans during and after cardiopulmonary bypass, including observations of anemia, thrombocytopenia, and activation of coagulation and platelets. Intravenous slow bolus injection of 300 U/kg (2.1 mg/kg) or 1000 U/kg (7 mg/kg) rFXIII after 2 h of ECC was well tolerated in study animals, and was associated with a dose-dependent increase in FXIII activity. No clinically significant effects in respiration, ECG, heart rate, blood pressure, body temperature, clinical chemistry, hematology (including platelet counts), or indicators of thrombosis (thrombin:antithrombin complex and D-Dimer) or platelet activation (platelet factor 4 and beta-thromboglobulin) were related to rFXIII administration. Specific examination of brain, heart, lung, liver, and kidney from rFXIII-treated animals provided no evidence of histopathological alterations suggestive of subclinical hemorrhage or thrombosis. Taken as a whole, the results demonstrate the ECC model suitably replicated the clinical presentation reported for humans during and after cardiopulmonary bypass surgery, and do not suggest significant concerns regarding use of rFXIII in replacement therapy after extracorporeal circulation.

Characterization of a library from a single microdissected oat (Avena sativa L.) chromosome

A plasmid library of oat chromosome No21, the smallest chromosome of the complement, was constructed by microdissection and microcloning. The chromosome was deproteinized with proteinase K and digested with Sau3A and linker adaptors were ligated to the DNA fragments. From the single chromosome (less than 0.4 pg), 10 μg of DNA was obtained after 2 rounds of PCR amplification. Cloning experiments with the amplified DNA produced as many as 500 000 recombinant clones from the single chromosome. The 500 clones evaluated ranged in size from 150 to 1700 base pairs (bp) with an average size of 650 bp. These were approximately 41% high-copy and 59% low/unique copy clones. Tandem repeats were absent in the library and may have been selected against by a combination of the Sau3A digestion, which is sensitive to C-methylation, and the PCR amplification. Many low-copy dispersed repetitive sequences were present in the library. These were present primarily on A- and D-genome chromosomes. Southern blot analysis revealed that the unique-copy clones were suitable for restriction fragment length polymorphism analysis and that they mapped to the pertinent oat nullisomic lines.

Genomic in situ hybridization in Avena sativa

Genomic fluorescent in situ hybridization was employed in the study of the genome organization and evolution of hexaploid oat (Avena sativa L. cv. Sun II, AACCDD, 2n = 6x = 42). Genomic DNAs from two diploid oat species, Avena strigosa (genomic constitution AsAs, 2n = 14) and Avena pilosa (genomic constitution CpCp, 2n = 14), were used as probes in the study. The DNA from A. strigosa labelled 28 of the 42 (2/3) chromosomes of the hexaploid oat, while 14 of the 42 (1/3) chromosomes were labelled with A. pilosa DNA, indicating a close relationship between the A and D genomes. Results also suggested that at least 18 chromosomes (9 pairs) were involved in intergenomic interchanges between the A and C genomes.

Perineural Entrapment of an Interscalene Stimulating Catheter

A patient undergoing elective total shoulder arthroplasty had an Arrow Stimucath™ (Arrow International Reading, PA, USA) stimulating catheter inserted in the region of the interscalene brachial plexus using an ultrasound-guided in-plane approach. There was subsequent difficulty in removing the catheter and traction was associated with painful paraesthesia in the patient's thumb. Plain X-ray revealed a hook-shaped deformity of the tip and surgical exploration was required to remove the catheter, the tip of which appeared to be trapped within the sheath of the brachial plexus. We speculate that the mechanism for entrapment in this case was deformation of the catheter tip into a hook-like shape. The subsequent catheter-neural interaction prevented asymptomatic removal. We recommend that removal of peripheral nerve catheters be attempted only after resolution of sensory block so as to enable patients to report pain or paraesthesia. Imaging with ultrasound or X-rays may help ascertain catheter tip location and confirm whether deformity is present. We also recommend a low threshold for proceeding to surgical extraction, particularly if neurological symptoms are present.

Cardiac biomarkers in neonatal hypoxic ischaemia

Following a perinatal hypoxic-ischaemic insult, term infants commonly develop cardiovascular dysfunction. Troponin-T, troponin-I and brain natriuretic peptide are sensitive indicators of myocardial compromise. The long-term effects of cardiovascular dysfunction on neurodevelopmental outcome following perinatal hypoxic ischaemia remain controversial. Follow-up studies are warranted to ensure optimal cardiac function in adulthood.

CONCLUSION

Cardiac biomarkers may improve the diagnosis of myocardial injury, help guide management, estimate mortality risk and may also aid in longterm neurodevelopmental outcome prediction following neonatal hypoxic-ischaemia.

The impact of risk information exposure on women's beliefs about direct-to-consumer genetic testing for BRCA mutations

Despite an increase in direct-to-consumer (DTC) genetic testing, little is known about how variations in website content might alter consumer behavior. We evaluated the impact of risk information provision on women's attitudes about DTC BRCA testing. We conducted a randomized experiment; women viewed a 'mock' BRCA testing website without [control group (CG)] or with information on the potential risks of DTC testing [RG; framed two ways: unattributed risk (UR) information and risk information presented by experts (ER)]. Seven hundred and sixty-seven women participated; mean age was 37 years, mean education was 15 years, and 79% of subjects were white. Women in the RG had less positive beliefs about DTC testing (mean RG = 23.8, CG = 25.2; p = 0.001), lower intentions to get tested (RG = 2.8, CG = 3.1; p = 0.03), were more likely to prefer clinic-based testing (RG = 5.1, CG = 4.8; p = 0.03) and to report that they had seen enough risk information (RG = 5.3, CG = 4.7; p < 0.001). UR and ER exposure produced similar effects. Effects did not differ for women with or without a personal/family history of breast/ovarian cancer. Exposing women to the potential risks of DTC BRCA testing altered their beliefs, preferences, and intentions. Risk messages appear to be salient to women irrespective of their chance of having a BRCA mutation.

Noninvasive molecular methods to identify live scarab larvae: an example of sympatric pest and nonpest species in New Zealand

Despite the negative impact that many scarab larvae have on agro-ecosystems, very little attention has been paid to their taxonomy. Their often extremely similar morphological characteristics have probably contributed to this impediment, which has also meant that they are very difficult to identify in the field. Molecular methods can overcome this challenge and are particularly useful for the identification of larvae to enable management of pest species occurring sympatrically with nonpest species. However, the invasive collection of DNA samples for such molecular methods is not compatible with subsequent behavioural, developmental or fitness studies. Two noninvasive DNA sampling and DNA analysis methods suitable for the identification of larvae from closely related scarab species were developed here. Using the frass and larval exuviae as sources of DNA, field-collected larvae of Costelytra zealandica (White) and Costelytra brunneum (Broun) (Scarabaeidae: Melolonthinae) were identified by multiplex PCR based on the difference in size of the resulting PCR products. This study also showed that small quantities of frass can be used reliably even 7 days after excretion. This stability of the DNA is of major importance in ecological studies where timeframes rarely allow daily monitoring. The approach developed here is readily transferable to the study of any holometabolous insect species for which morphological identification of larval stages is difficult.

Upregulated FGFR1 expression is associated with the transition of hormone-naive to castrate-resistant prostate cancer

BACKGROUND

Prostate cancer (PC) represents a global health issue. Treatment for locally advanced and metastatic PC remains unsatisfactory. The androgen receptor (AR) has been validated in having a key role in both naïve and castrate-resistant PC (CRPC). However, the significance of other signalling pathways in CRPC is less well validated.

METHODS

To gain a better insight into the molecular signalling cascades involved in clinical CRPC, we performed gene expression profiling using the Illumina DASL assay and studied matched hormone-naive (HN) and CR prostate tumours (n=10 pairs). Ingenuity Pathways Analysis (IPA) was used to identify potential networks involved, and further validation was performed in in vitro cell models and clinical tumours.

RESULTS

Expression of 50 genes was significantly different between HN and CRPC. IPA revealed two networks of particular interest, including AR and FGFR1, respectively. FGFR1 expression was confirmed to be significantly upregulated in CRPC (P ≤ 0.005), and abnormal FGFR1 expression was associated with shorter time to biochemical relapse in HNPC (P=0.006) and less favourable disease-specific survival in CRPC (P=0.018).

CONCLUSION

For the first time, our gene expression profiling experiment on archival tumour materials has identified upregulated FGFR1 expression to be associated with PC progression to the CR state.

Life and death decisions for incompetent patients: determining best interests--the Irish perspective

AIMS

To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions.

METHODS

An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate.

RESULTS

The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category.

CONCLUSION

These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life.

Benchmarking care for very low birthweight infants in Ireland and Northern Ireland

BACKGROUND

Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON.

METHODS

A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland.

RESULTS

Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%).

DISCUSSION

This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.

Correlation of education, age, and health insurance status with attitudes about and preferences for direct-to-consumer BRCA testing

e22116

Background: Direct-to-consumer (DTC) cancer genetic testing is increasingly common. However, little is know about peoples' attitudes about or preferences for DTC testing as compared to clinic-based genetic testing. Methods: We surveyed a convenience sample of 257 women without prior BRCA testing/counseling experience about their attitudes about and intentions to get online BRCA testing (90% participation rate). Subjects completed baseline interviews, viewed a modified commercial DTC website and completed an online survey. Results: Sample characteristics: mean age 37 (range 19–71), 80% white, mean education 3 years college, 45% with a household income <$50,000, 3% with a history of breast/ovarian cancer and mean Frank risk 4.7%. 64% of women expressed interest in BRCA testing at baseline and 24% intended to get tested in the next year. After viewing the website, 22% of women said that they would prefer DTC testing, 60% said that they would prefer clinic-based testing and 18% were indifferent. Overall, women believed that DTC testing would be more convenient (p <0.001), offer greater privacy (p <0.01), and be less likely to lead to discrimination (p <0.001) while clinic testing would provide more information (p <0.001) and counseling (p <0.001). After adjusting for confounders, older and less highly educated women had more positive attitudes about DTC BRCA testing (adjusted odds ratio (OR) 4.20, p= 0.02 and OR 10.3, p=0.03 high school (HS) vs. college and OR 16.1, p=0.02 HS vs. graduate school). Women with no health insurance and more positive attitudes about DTC genetic testing were more likely to prefer DTC genetic testing over clinic testing (adjusted OR 3.1, p=0.03 and OR 3.7, p<0.01). There were no associations between race and outcomes. Conclusions: A substantial minority of women expressed a preference for DTC BRCA testing after viewing a modified commercial website. Preferential interest in DTC testing by less educated and uninsured populations makes it especially critical that these sites provide high quality services. Without high quality service, the availability of DTC testing may only exacerbate disparities in genetic services and prevention.

No significant financial relationships to disclose.

Beware of the isolated intermediate quality measure: A lesson in choosing an ovarian cancer surgeon

6546

Background: Measuring surgical quality has recently focused on isolated processes (such as P4P measures) and intermediate outcomes (such as infection rates). Some have argued that such isolated measures are inherently flawed since they may have only minor influence on more important primary outcomes such as survival. Hence, referral decisions based on such isolated processes or intermediate outcomes may lead to less than optimal care. We asked whether surgeon type influenced isolated process measures (longer operative time, thought to be a function of increased node sampling), intermediate outcomes (deep wound infection, often found to be a function of operative time) and the primary outcome of survival. Methods: We obtained SEER-Medicare claims for the years 1991–2001 for ovarian cancer. We identified the first definitive cancer surgery and the surgical provider type for that procedure: General Surgeon (GS) N=545 and GYN Oncologist (GO) N=1,554. We determined operative time from the anesthesia claims, number of nodes sampled from the SEER record, deep wound infection from the ICD9CM secondary diagnoses and survival from Medicare vital status files. Models were adjusted for 30 patient characteristics and comorbidities. To account for potential reclassification bias due to variations in the pattern of node dissection across GO and GS surgical types, which can potentially influence stage identification, we report survival results both with and without stage adjustments. Results: Definitive surgery by GOs was associated with more extensive node dissection and longer operative time. GO patients also displayed a trend for increased deep wound infection as compared to cases operated on by GS. However, 5-year survival was significantly longer in the GO group, with or without stage adjustment. Conclusions: GO cases took longer, tended to have higher infection rates, yet had better overall 5-year survival. Isolated intermediate outcome measures, such as deep wound infection, may not be good quality indicators.

No significant financial relationships to disclose.

[Table: see text]

Androgen deprivation therapy (ADT) for node postive prostate cancer

5061

Background: The role of ADT for men with node positive prostate cancer following radical prostatectomy (RP) is unclear. One randomized trial has shown a survival advantage for men treated with immediate adjuvant (adj) ADT compared treatment at onset of clinical metastases. However, benefit of immediate therapy is less clear in the PSA era when ADT can initiated at the time of biochemical relapse. Methods: We used linked Surveillance, Epidemiology and End Results-Medicare Data to identify a cohort of men who underwent RP between 1991–1999 and were found to have positive regional lymph nodes. We searched Medicare claims to identify men with claims for ADT (hormonal therapy or orchiectomy) within 3 years of diagnosis. We excluded men who received ADT prior to RP. We classified men as receiving adj ADT if they received treatment within 120 days of RP and compared them to men who had not received adj ADT. We used propensity scores to balance potential confounders of receiving adj ADT (age, tumor characteristics, extent of nodal disease, demographics). We used Cox proportional hazard methods to estimate the impact of adj ADT on overall survival (OS) adjusting for propensity score. We conducted a sensitivity analysis using 90, 150, 180 and 365 days as the time limit for adj ADT. Results: 719 men were identified, of whom 190 received adjuvant ADT within 120 days of RP. There was no statistically significant difference in overall survival between the men who did or did not receive adj ADT (HR 0.96 95% CI 0.70–1.32) The results were similar for men who received ADT within 90 and 150 days. However, when the definition of adj ADT was moved to 180 days (HR 1.08 (0.80–1.47)) and 365 days (HR 1.24 (0.92–1.65)) the men receiving adj ADT had a slightly higher risk of death, suggesting some in the adj ADT groups using these later definitions may have received therapy as salvage therapy for progressive disease. Conclusions: This observational study suggests that in the PSA era when men can be started on ADT at the time of biochemical recurrence, overall survival may not be significantly compromised by deferring immediate ADT in men with positive lymph nodes following RP. Further clinical research is needed to better understand which patients are likely to benefit from immediate ADT, and which men can be spared the long term toxicities.

[Table: see text]

Physician initiated cancer screening discussions and patient intention to engage in screening behavior

1528

Background: Cancer screening for colon, breast, and prostate cancer remains underutilized. Physician (MD)-patient discussions of screening are common but the impact of these discussions is unknown. Methods: 2489 40–70 year old subjects completed a national survey of cancer prevention information acquisition and decision making (median age 53, 49% male, 77% white, 59% married, 61% some college). Subjects reported whether their MD initiated discussions (MDID) about colonoscopy, mammography, & PSA within the past year. Age eligible subjects were “non-routine screeners” (NRS: never screened or colonoscopy >10 yrs, mammography >2 yrs or PSA>2 yrs prior) or “routine screeners” (RS).The endpoint was intention to screen when next eligible. Results: 46%, 75% and 60% of subjects reported intentions to obtain colonoscopy, mammography and/or PSA. Logistic regression was used to determine the association between MDID and intentions to screen controlling for sociodemographics and recency of screening. For colonoscopy and mammography, MDID was significantly associated with intention to screen for NRS but not RS groups; the opposite was true for PSA. For the NRS group: comparing those saying no versus yes to MDID, intentions were 15% vs. 43% for colonoscopy, 29% to 61% for mammography (RS: 85% vs. 91% and 82% vs. 85%). For PSA, NRS: 46% vs.52% but RS group 65% vs. 85%. All interactions (screening by MDID) were significant, p<.001. Conclusions: Given high intentions to undergo colon and breast cancer screening among patients who have been screened routinely, physician discussion preferentially increases intentions for colon and breast cancer screening among patients who are not routinely undergoing the screening test. Conversely, physician discussion preferentially influences prostate cancer screening intentions among patients who have been screened in the past two years- perhaps because men who have not undergone screening are more resolved in their decision not to screen. These results define subgroups of patients where physician attention may have the greatest impact on screening adherence.

No significant financial relationships to disclose.