Application of the D3 -creatine muscle mass assessment tool to a geriatric weight loss trial: A pilot study

BACKGROUND

Traditionally, weight loss (WL) trials utilize dual energy X-ray absorptiometry (DXA) to measure lean mass. This method assumes lean mass, as the sum of all non-bone and non-fat tissue, is a reasonable proxy for muscle mass. In contrast, the D3 -creatine (D3 Cr) dilution method directly measures whole body skeletal muscle mass, although this method has yet to be applied in the context of a geriatric WL trial. The purpose of this project was to (1) describe estimates of change and variability in D3 Cr muscle mass in older adults participating in an intentional WL intervention and (2) relate its change to other measures of body composition as well as muscle function and strength.

METHODS

The INVEST in Bone Health trial (NCT04076618), used as a scaffold for this ancillary pilot project, is a three-armed, 12-month randomized, controlled trial designed to determine the effects of resistance training or weighted vest use during intentional WL on a battery of musculoskeletal health outcomes among 150 older adults living with obesity. A convenience sample of 24 participants (n = 8/arm) are included in this analysis. At baseline and 6 months, participants were weighed, ingested a 30 mg D3 Cr tracer dose, provided a fasted urine sample 3-6 days post-dosage, underwent DXA (total body fat and lean masses, appendicular lean mass) and computed tomography (mid-thigh and trunk muscle/intermuscular fat areas) scans, and performed 400-m walk, stair climb, knee extensor strength, and grip strength tests.

RESULTS

Participants were older (68.0 ± 4.4 years), mostly White (75.0%), predominantly female (66.7%), and living with obesity (body mass index: 33.8 ± 2.7 kg/m2 ). Six month total body WL was -10.3 (95% confidence interval, CI: -12.7, -7.9) kg. All DXA and computed tomography-derived body composition measures were significantly decreased from baseline, yet D3 Cr muscle mass did not change [+0.5 (95% CI: -2.0, 3.0) kg]. Of muscle function and strength measures, only grip strength significantly changed [+2.5 (95% CI: 1.0, 4.0) kg] from baseline.

CONCLUSIONS

Among 24 older adults, significant WL with or without weighted vest use or resistance training over a 6-month period was associated with significant declines in all bioimaging metrics, while D3 Cr muscle mass and muscle function and strength were preserved. Treatment assignment for the trial remains blinded; therefore, full interpretation of these findings is limited. Future work in this area will assess change in D3 Cr muscle mass by parent trial treatment group assignment in all study participants.

Benralizumab: A novel treatment for the cutaneous features of paediatric eosinophilic granulomatosis with polyangiitis (pEGPA)

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis presenting primarily with pulmonary and cutaneous features. The disease is typically seen in the fifth or sixth decade of life (1, 2). We report a case of EGPA in an adolescent who was successfully treated with the interleukin-5 (IL-5) receptor inhibitor, benralizumab.

Psychological resilience in older adults with type 2 diabetes from the Look AHEAD Trial

BACKGROUND

There is growing interest in identifying factors associated with healthy aging. This cross-sectional study evaluated associations of psychological resilience with factors associated with aging in older adults with type 2 diabetes mellitus (T2DM).

METHODS

Participants were 3199 adults (72.2 ± 6.2 years of age, 61% female, 61% White, body mass index [BMI] = 34.2 ± 8.2 kg/m2 ) with T2DM enrolled in Look AHEAD (a multi-site randomized clinical trial comparing an intensive lifestyle intervention for weight loss to diabetes education and support). Participants were followed observationally after the 10-year intervention was discontinued. The following items were assessed approximately 14.4 years post-randomization in a cross-sectional analysis: Brief Resilience Scale; overnight hospitalizations in past year; physical functioning measured objectively (gait speed, grip strength) and via self-report (Pepper Assessment Tool for Disability; physical quality of life [QOL; SF-36]); a measure of phenotypic frailty based on having ≥3 of unintentional weight loss, low energy, slow gait, reduced grip strength, and physical inactivity. Depressive symptoms (PHQ-9) and mental QOL (SF-36) were also measured. Logistic/linear/multinomial regression was used to evaluate the association of variables with resilience adjusted for age, race/ethnicity, and gender.

RESULTS

Greater psychological resilience was associated with lower BMI, fewer hospitalizations, better physical functioning (i.e., lower self-reported disability, better physical QOL, faster gait speed, greater grip strength, lower likelihood of frailty), fewer depressive symptoms, and greater mental QOL (all p < 0.05). Psychological resilience moderated the relationship of number of hospitalizations in the past year with self-reported disability and grip strength.

CONCLUSIONS

Psychological resilience is associated with better physical function and QOL among older adults. Results should be interpreted cautiously given cross-sectional nature of analyses. Exploring the clinical benefits of resilience is consistent with efforts to shift the narrative on aging beyond "loss and decline" to highlight opportunities to facilitate healthy aging.

COMPARTMENTAL FEMUR CORTICAL THICKNESS IN OLDER ADULTS DIFFERS BY DEMOGRAPHICS AND PHYSICAL FUNCTION

Previous studies have examined the relationship between cortical bone properties and fracture risk in older populations, but they have yet to examine how these properties change within the femur. Most hip fractures are classified by their location: femoral neck, intertrochanteric, or subtrochanteric fractures. Since cortical thickness can vary throughout the femur, a quantitative method of examining thickness by region was developed using a cortical mapping approach applied to computed tomography (CT) scans. Subject-specific finite element (FE) models of proximal femurs were created from baseline CT scans of 107 older adults (ages 60 – 85; 70% White; 72% Female) with obesity as classified by BMI (33.8 ± 4 kg/m2). An existing FE model was morphed to the segmented geometry of each subject’s proximal femur. A nearest neighbor search assigned cortical thickness values to the nearest finite element model node. Cortical thickness was grouped into four femoral compartments: femoral head, femoral neck, intertrochanteric and subtrochanteric regions. Pairwise paired t-tests indicated that cortical thickness differed between femoral compartments (p &lt; 0.05). Multivariate regression models showed greater cortical thicknesses in femoral head, neck, and intertrochanteric regions in African Americans compared to Whites (p &lt; 0.05). Additionally, these models suggest an association between cortical thickness and physical function assessments, such as the timed up-and-go test and leg muscle strength test. Since cortical thickness is not constant throughout the femur, future studies can use the framework developed here to assess each compartment individually and investigate the relationships between cortical thickness, demographics, and functional assessments.

Associations between cognitive function and endogenous levels of estradiol and testosterone in adults with type 2 diabetes

AIMS

To assess associations that endogenous estradiol and testosterone levels have with cognitive function in older adults with Type 2 diabetes mellitus (T2DM).

METHODS

We use data from the Look AHEAD clinical trial of behavioral weight loss. Endogenous estradiol and total testosterone levels were determined using stored serum from 996 individuals, mean age 69 years, at two times (averaging 4 years apart) during years 8-18 of follow-up. One to four standardized assessments of attention, executive function, memory, and verbal fluency were collected during this follow-up. Mixed effects models and multiple imputation were used to assess associations that estradiol and total testosterone levels had with body mass index and cognitive function.

RESULTS

Estradiol levels were not associated with cognitive function in either sex. Total testosterone levels were not associated with cognitive function in women, but greater total testosterone levels were associated with better verbal fluency in men (p < 0.001), most strongly among those carrying the APOE-e4 allele (interaction p = 0.02). The weight loss intervention left a legacy of relatively lower cognitive functioning among women, which was not mediated by current levels of sex hormones.

CONCLUSIONS

Behavioral weight loss intervention does not affect cognitive functioning through mechanisms related to estradiol or testosterone.

CLINICALTRIALS

gov Identifier: NCT00017953.

67 Does a National Lockdown Affect the Characteristics of Deep Vein Thromboses in Patients in the Community?

Aim

Has lockdown and COVID-19 led to a change into the characteristics of DVT's and patients who have them alongside a review of the DVT service.

Method

Data was collected retrospectively from electronic patient records system for the following periods: 1st April until 30th June 2019 and 1st April until 30th June 2020. These were the key months during the first United Kingdom national lockdown. Data was analysed for patient demographics, risk factors, characteristics of the DVT, management and DVT reoccurrence. Statistical analyses were preformed using GraphPad Prism 8.

Results

227 patients sustained community DVT's in 2019 and 211 patients in 2020 during the study period. 13 of these patients in 2020 were COVID-19 positive. There was a difference in gender distribution (p= 0.0128) with 128 males and 99 females in 2019, 93 males and 118 females in 2020. No significant difference was noted for the incidence of thrombophilia with 9 in 2019 and 3 in 2020 (p=0.1437). Fewer long-haul journeys were made (p=0.012) with 16 in 2019 and only 2 in 2020. Fewer patients had immobility as a risk factor with 79 in 2019 and 55 in 2020 (p=0.0494). However, there were more patients using the contraceptive pill (p=0.0086) with 1 in 2019 and 9 in 2020.

Conclusion

There is no significant difference in the characteristics, extent, and management of DVT's prior to and during Lockdown during COVID-19. National Lockdowns do not affect community DVT's however it is important to highlight the surrounding inpatient numbers.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease

BACKGROUND

A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time.

OBJECTIVE

We sought to investigate whether coagulation markers can predict severity and how they change over the disease course.

METHODS

Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups.

RESULTS

Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients.

CONCLUSION

Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

Chaos Unleashed: The impact of recreational drugs and COVID on young adults

Introduction

This case series reveals a number of young adults, whom after chronic use of recreational drugs, suffer the life-long consequence of severe chronic mental illness.

Objectives

• Review the illicit drugs that are commonly associated with psychotic symptoms. • Highlight exposures theorized to impact genetics associated with DSM 5 diseases. • Compare trends in illicit drug use during the worldwide COVID pandemic.

Methods

A literature review is used to examine the impact of COVID pandemic on illicit drug use in metropolitan cities in European countries and compare the trends with what is seen by the consult liaison psychiatry service at a metropolitan community hospital in the USA.

Results

In European Countries with data available, there were measurable differences in which illicit drugs were used most during the COVID 19 pandemic. In the US this data is not readily available at the time of submission for proper comparisson.

Conclusions

Although definitive comparrison is pending, the results of extensive illicit drug use demostrate a high comorbidity with psychotic spectrum disorders in the DSM 5.

Disclosure

No significant relationships.

The Importance of Cognitive Appraisal and Social Support in Pregnancy During COVID-19 from an Interdisciplinary View

Aim: To describe how a US-based psychiatric Mother-Baby Unit adopted a virtual platform during the pandemic. Objectives: When the Covid-19 pandemic descended, mental health clinicians world-wide were faced with maintaining access and care delivery. Pregnant and newly postpartum women experienced the pandemic and lockdown through the lens of impending parenthood and new parenthood--amplifying distress, isolation, and lack of social and family support. The lockdown prevented those with most acute illness from accessing daily treatment in our structured, supportive intensive treatment setting. We acknowledged the urgency of developing a method to continue to treat our patients in a group environment that offered psychotherapy, psychopharmacology, dyadic and family intervention, and social support. Methods: The hospital purchased “Zoom for Health” platform to ensure compliance with regulatory guidelines. Cameras for individual computers were purchased with philanthropy funds, obtaining them quickly, compared to waiting for hospital funding. The clinical team designed a schedule of groups and individual sessions, each with their own zoom link. Each morning, a team member, sent the daily schedule through the patient portal of the EMR. Conclusion: Before the pandemic, the census was 12 pts per day. The full-day program paused for 7-10 days although individual sessions and medication management were conducted by phone as the virtual platform was constructed. Once established, census resumed normal levels. Challenges to running the Day Hospital virtually included: technology glitches, family demands and distractions, and privacy concerns. Overall, the program was a success wherein women requiring intensive treatment were able to receive treatment and social support.

Resilience among older adults with Type 2 Diabetes from the Look AHEAD trial

There is growing interest in identifying factors protecting against aging-related decline. This cross-sectional study evaluated associations of self-reported resilience (ability to bounce back) with factors linked to aging-related decline among older adults with Type 2 diabetes (T2DM). Participants were 3,199 adults (72.2±6.2 years, 61% female, 61% white, BMI 34.2±8.2 kg/m2) enrolled in Look AHEAD (a multi-site RCT comparing weight loss to diabetes education among individuals with T2DM), who were followed observationally after the 10-year intervention was discontinued. The following items were assessed approximately 14.4yrs post-randomization: Brief Resilience Scale; overnight hospitalizations in past year; physical functioning measured objectively (gait speed, grip strength) and via self-report (Pepper Assessment Tool for Disability; Physical quality of life (QOL; SF-36)); a composite measure of phenotypic frailty based on having ≥3 of unintentional weight loss, low energy, slow gait, reduced grip strength, physical activity. Depressive symptoms (PHQ-9) and mental QOL (SF-36) were also measured. Logistic/linear regression was used to evaluate the association of these variables with resilience adjusted for age, race, and gender. Greater resilience was associated with lower BMI (p=.01), fewer hospitalizations (p=.02), better physical functioning (i.e., lower self-reported disability, better self-reported physical QOL, faster gait speed, greater grip strength and lower likelihood of meeting criteria for frailty; all p<.001), fewer depressive symptoms and greater mental QOL. Resilience is associated with better performance on indicators of overall functioning and risk for decline among older adults. Findings correspond with efforts to shift narrative on aging beyond ‘loss and decline’ to highlight opportunities to facilitate healthy aging.

147 ‘CHAMPIONING CONTINENCE’—ESTABLISHMENT OF A MULTIDISCIPLINARY CONTINENCE PROMOTION WORKING GROUP IN AN ACUTE TEACHING HOSPITAL

Background

In line with the National Frailty Programme1, patients over the age of 75 admitted to hospital should have a comprehensive geriatric assessment including the assessment of current continence status and any history of incontinence. Up to 39% of adults are reported to develop new onset urinary incontinence during admission to hospital2,3, however studies show that is it a problem not always identified by staff members,4. In response to these observations within an acute teaching hospital, a continence working party was formed involving members of nursing, physiotherapy and occupational therapy colleagues to explore the current practice and culture relating to continence management.

Methods

The group established key objectives which were broken into four strands;

1. Audit of documentation of baseline continence on admission (therapy and nursing).

2. Obtaining access to additional types of continence wear.

3. Staff education.

4. Pre and post education survey.

Results

1. Audit of documentation demonstrated poor standards of documentation of baseline continence. This led to an amendment to questioning prompts on therapy initial assessment forms and a plan to further evaluate the nursing documentation.

2. A wider array of continence wear has been made available on the wards providing greater options for patients.

3. Staff education session was compiled by a specialist physiotherapist and is widely available for staff to access on the hospitals online training portal.

4. Pre-education surveys have been completed with a view to re-administering following education roll-out.

Conclusion

The aim of this multidisciplinary working group is to equip staff with the correct resources, knowledge, and confidence to ensure best practice promotion of continence on the targeted wards. This project is the first strand of a wider culture changed that is needed around continence promotion for older adults in the acute setting.

146 INTRODUCTION OF A STANDARDISED SCREENING TOOL FOR REFERRAL TO OCCUPATIONAL THERAPY AND PHYSIOTHERAPY ON SPECIALIST GERIATRIC WARDS

Background

The Occupational Therapists (OTs) and Physiotherapists (PTs) on the Specialist Geriatric Wards provide assessment, rehabilitation, and discharge planning for frail older adults. All patients are screened on admission by OT or PT to determine the need for therapy input. This rapid response eliminates delay in accessing therapy input and allows for proactive commencement of intervention and discharge planning without the delay of awaiting a referral.

It was identified that the existing process for screening patients lacked structure and clarity, leading to inefficient use of time and resources with the risk of duplication.

The aim of this local Quality Improvement (QI) initiative was to standardise the process for screening using a triage sticker containing set criteria for referral to OT/PT.

Methods

Following team consultation and review of frailty screening tools, a triage sticker was adapted and modified from the ‘Think Frailty’ tool1. QI methodology and PDSA cycles identified 6 blanket triggers for OT/PT assessment on the ward.

F—Functional impairment.

R—Resident in a care home.

A—Acute/chronic confusion.

I—Immobility/Instability.

L—Living at home with support.

S—Specialist seating or skin integrity issues.

Retrospective review of traditional triage vs the new sicker was performed to evaluate accuracy.

Results

Retrospective analysis found 83% accuracy between the new triage sticker and the traditional triage method. Of the patients who did not meet the criteria for referral, to date none have been subsequently referred during their admission, demonstrating its comprehensiveness as a tool.

Conclusion

Pro-active and early intervention from OT and PT is beneficial for ensuring optimum patient care and efficient discharge planning for frail older adults admitted to hospital. This local QI project demonstrated that standardising the screening process for referral to OT/PT could improve clarity and enable more efficient use of time and resources.

Uncovering Survivorship Bias in Longitudinal Mental Health Surveys During the COVID-19 Pandemic

Aims

Markedly elevated adverse mental health symptoms were widely observed early in the coronavirus disease 2019 (COVID-19) pandemic. Unlike the U.S., where cross-sectional data indicate anxiety and depression symptoms have remained elevated, such symptoms reportedly declined in the U.K., according to analysis of repeated measures from a largescale longitudinal study. However, nearly 40% of U.K. respondents (those who did not complete multiple follow-up surveys) were excluded from analysis, suggesting that survivorship bias might partially explain this discrepancy. We therefore sought to assess survivorship bias among participants in our longitudinal survey study as part of The COVID-19 Outbreak Public Evaluation (COPE) Initiative.

Methods

Survivorship bias was assessed 4,039 U.S. respondents who completed surveys including the assessment of mental health as part of The COPE Initiative in April 2020 and were invited to complete follow-up surveys. Participants completed validated screening instruments for symptoms of anxiety, depression, and insomnia. Survivorship bias was assessed for (1) demographic differences in follow-up survey participation, (2) differences in initial adverse mental health symptom prevalences adjusted for demographic factors, and (3) differences in follow-up survey participation based on mental health experiences adjusted for demographic factors.

Results

Adjusting for demographics, individuals who completed only one or two out of four surveys had higher prevalences of anxiety and depression symptoms in April 2020 (e.g., one-survey versus four-survey, anxiety symptoms, adjusted prevalence ratio [aPR]: 1.30, 95% confidence interval [CI]: 1.08–1.55, P=0.0045; depression symptoms, aPR: 1.43, 95% CI: 1.17–1.75, P=0.00052). Moreover, individuals who experienced incident anxiety or depression symptoms had higher odds of not completing follow-up surveys (adjusted odds ratio [aOR]: 1.68, 95% CI: 1.22–2.31, P=0.0015, aOR: 1.56, 95% CI: 1.15–2.12, P=0.0046, respectively).

Conclusions

Our findings revealed significant survivorship bias among longitudinal survey respondents, indicating that restricting analytic samples to only respondents who provide repeated assessments in longitudinal survey studies could lead to overly optimistic interpretations of mental health trends over time. Cross-sectional or planned missing data designs may provide more accurate estimates of population-level adverse mental health symptom prevalences than longitudinal surveys.

A data resource from concurrent intracranial stimulation and functional MRI of the human brain

Mapping the causal effects of one brain region on another is a challenging problem in neuroscience that we approached through invasive direct manipulation of brain function together with concurrent whole-brain measurement of the effects produced. Here we establish a unique resource and present data from 26 human patients who underwent electrical stimulation during functional magnetic resonance imaging (es-fMRI). The patients had medically refractory epilepsy requiring surgically implanted intracranial electrodes in cortical and subcortical locations. One or multiple contacts on these electrodes were stimulated while simultaneously recording BOLD-fMRI activity in a block design. Multiple runs exist for patients with different stimulation sites. We describe the resource, data collection process, preprocessing using the fMRIPrep analysis pipeline and management of artifacts, and provide end-user analyses to visualize distal brain activation produced by site-specific electrical stimulation. The data are organized according to the brain imaging data structure (BIDS) specification, and are available for analysis or future dataset contributions on openneuro.org including both raw and preprocessed data.

THU0217 UPADACITINIB MONOTHERAPY IN METHOTREXATE-NAÏVE PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS AT 72 WEEKS FROM SELECT-EARLY

Background:

Upadacitinib (UPA), an oral JAK inhibitor, demonstrated significant improvements in signs, symptoms, and structural inhibition as monotherapy vs methotrexate (MTX) in a randomized, controlled trial (RCT) of MTX-naive RA patients (pts) through 48 weeks (wks).1

Objectives:

To present the safety and effectiveness of UPA through 72 wks in an ongoing long-term extension (LTE) of the SELECT-EARLY RCT.

Methods:

SELECT-EARLY included 2 study periods: (1) a 48-wk double-blind, active comparator-controlled, with pts randomized to UPA monotherapy 15 or 30 mg once daily or MTX (titrated to 20 mg/wk by Wk8); (2) an LTE, up to 4 years. Pts received open-label treatment once the last pt reached Wk48. Rescue therapy was added (MTX, for UPA groups; UPA, for MTX group) to pts not achieving CDAI remission (≤2.8) at Wk26. Non-responder imputation (NRI) was used for missing data as well as for pts receiving rescue therapy. Treatment-emergent adverse events (TEAEs) are summarized per 100 pt yrs (PY) through the cut-off date of 21 Feb 2019, when all pts had reached Wk72. Data are censored at the time of MTX or UPA addition among rescued patients.

Results:

Of 945 pts randomized and treated, 781 (83%) completed Period 1. Of these, 775 entered the LTE, including 57 rescued pts (MTX, 33; UPA 15 mg, 17; UPA 30 mg, 7). A total of 52 (7%) pts discontinued during the LTE through the cut-off date (primary reasons: AEs [n=16, 2.1%]; consent withdrawal [n=12, 1.5%]; lost to follow-up [n=10, 1.3%]). Cumulative exposures to monotherapy with MTX, UPA 15 mg, and UPA 30 mg were 350.6, 389.5, and 383.9 PYs, respectively. Both UPA 15 mg and 30 mg as monotherapy was associated with continued statistically significant improvements in disease activity measures vs MTX monotherapy through 72 wks (Table). The safety profiles of the UPA 15 and 30 mg groups were comparable for total TEAEs and numerically higher than MTX. Serious TEAEs and TEAEs leading to discontinuation of study drug were comparable across all groups (Figure). Most AEs of special interest were comparable across MTX and UPA groups, with the exception of higher rates of herpes zoster, opportunistic infections, and elevated creatine phosphokinase among the UPA groups. Two pts receiving MTX monotherapy experienced a venous thromboembolic event, with one event reported on UPA 30 mg and none on UPA 15 mg. There were 12 deaths (including 3 non-treatment-emergent) due to varied causes.

Table.

Proportion of Patients at Week 72 (NRI)

Parameter (%)MTXMonotherapyUPA 15 mg QDMonotherapyUPA 30 mg QDMonotherapyACR20/50/7050/39/2671***/62***/47***72***/67***/54***DAS28(CRP) ≤3.2/<2.638/2863***/52***69***/61***CDAI ≤10/≤2.842/1960***/35***69***/44***Boolean Remission1329***33***

***,P<0.001 for differences between MTX and UPA 15 and UPA 30 mg groups.

MTX, methotrexate; UPA, upadacitinib; QD, once daily; ACR, American College of Rheumatology; DAS28(CRP), 28-joint disease activity index based on C-reactive protein; CDAI, clinical disease activity index.

Figure.

Treatment-emergent Adverse Events Through ≥72 Weeks (E/100 PYs, 95% CI).

Conclusion:

Long-term UPA monotherapy was associated with continued improvements in RA signs and symptoms vs MTX monotherapy through 72 wks, and only a small proportion of pts required MTX addition at Wk26. Through 72 wks of treatment, the safety profile of UPA monotherapy remained consistent with data reported through 48 wks.1

References:

[1]van Vollenhoven R,et al.Ann Rheum Dis2019;78(S):376.

Disclosure of Interests: :

Ronald van Vollenhoven Grant/research support from: AbbVie, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline, Lilly, Pfizer, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, and UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Maureen Rischmueller Consultant of: Abbvie, Bristol-Meyer-Squibb, Celgene, Glaxo Smith Kline, Hospira, Janssen Cilag, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Mark Howard Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Alan Friedman Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB

0420 Fibre-Specific White Matter Neurodegeneration is Associated with Long Sleep Duration After Stroke

Introduction

Long sleep duration in aging populations has recently been proposed as a key modifiable risk factor and sequela of stroke. It is unclear whether the pathogenesis of post-stroke sleep-wake dysfunction is due to focal infarction to regional sleep-wake hubs in the brain, or to accelerated whole-brain neurodegeneration. We utilise a novel technique known as whole-brain fixel-based analyses (FBA) to characterize the first fibre-specific white-matter markers of long sleep duration after stroke.

Methods

We included 98 radiologically-confirmed ischemic stroke participants (67 male; mean age = 68) and 40 age-matched controls with no history of neurodegenerative disease imaged 3-months post-stroke. Sleep-wake was measured for one week using BodyMedia’s SenseWear armband. Diffusion-weighted MRI (DWI) were acquired using echoplanar imaging and preprocessed using MRtrix3. FBA were employed to identify tracts with altered white-matter fibre-density and fibre-bundle cross-section (FDC) in the long sleep duration (&gt;8 hr, n=20) and normal sleep duration groups (between &gt;6 hr and &lt;8 hr, n=59) compared to controls. Statistical comparisons of FDC between groups were performed at each FDC fixel by a general linear model controlling for age, sex, and intracranial volume.

Results

Stroke participants with long sleep duration exhibited significant FDC reductions of up to 40% within the cortico-ponto-cerebellar tract when compared to healthy controls (family-wise-error-corrected p=&lt;0.05). Bilateral pontine degeneration was observed at the decussation of the superior cerebellar peduncles. Stroke participants with normal sleep duration exhibited diffuse whole-brain degeneration most apparent along the corpus collosum and cingulum; however, the distribution was less extensive relative to long sleepers (i.e., no cortico-cerebellar projections) and percentage effect reductions did not exceed 20%.

Conclusion

Long sleep duration after stroke is associated with cortico-ponto-cerebellar degeneration when compared to controls or stroke-participants with normal sleep duration. Excessively long sleep may contribute to post-stroke neurodegeneration beyond the effects of direct infarction and may be a modifiable pharmacological target for abating brain volume loss after stroke.

Support

This work was supported by the National Health and Medical Research Council project grant (APP1020526), the Brain Foundation, Wicking Trust, Collie-Trust, and Sidney and Fiona Myer Family Foundation. NE was supported by the Australian Research Council DECRA award DE180100893.

Effects of route of administration on oxytocin-induced changes in regional cerebral blood flow in humans

Could nose-to-brain pathways mediate the effects of peptides such as oxytocin (OT) on brain physiology when delivered intranasally? We address this question by contrasting two methods of intranasal administration (a standard nasal spray, and a nebulizer expected to improve OT deposition in nasal areas putatively involved in direct nose-to-brain transport) to intravenous administration in terms of effects on regional cerebral blood flow during two hours post-dosing. We demonstrate that OT-induced decreases in amygdala perfusion, a key hub of the OT central circuitry, are explained entirely by OT increases in systemic circulation following both intranasal and intravenous OT administration. Yet we also provide robust evidence confirming the validity of the intranasal route to target specific brain regions. Our work has important translational implications and demonstrates the need to carefully consider the method of administration in our efforts to engage specific central oxytocinergic targets for the treatment of neuropsychiatric disorders.

Obstructive Lung Disease and Obstructive Sleep Apnea (OLDOSA) cohort study: 10-year assessment

STUDY OBJECTIVES

Asthma, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA) are very prevalent disorders. Their coexistence in the same individual has an unclear effect on natural history and long-term outcomes.

METHODS

The OLDOSA (Obstructive Lung Disease and Obstructive Sleep Apnea) cohort enrolled 4,980 veterans with an acute hospitalization and in whom asthma, COPD, OSA, overlapping conditions, or none of these disorders at baseline had been diagnosed. Pulmonary function, polysomnography, positive airway pressure (PAP) recommendations and adherence, and vital status were collected and analyzed. Various proportional hazards models were built for patients with OSA to test the effect of PAP therapy on survival.

RESULTS

Ten-year all-cause cumulative mortality rate was 52.8%; median time to death was 2.7 years. In nonoverlapping asthma, OSA and COPD, mortality rates were 54.2%, 60.4%, and 63.0%, respectively. The overlap syndromes had the following mortality: COPD-OSA 53.2%, asthma-COPD 62.1%, asthma-OSA 63.5%, and triple overlap asthma-COPD-OSA 67.8%. In patients with OSA not on PAP therapy, after adjustment for age, comorbidities, and lung function, risk of death was 1.34 (1.05-1.71) times higher than those undergoing treatment. Similarly, in patients with OSA nonadherent to PAP therapy the adjusted risk of death was 1.78 (1.13-2.82) times higher versus those using it at least 70% of nights and more than 4 hours nightly.

CONCLUSIONS

In this large longitudinal cohort of hospitalized veterans with high comorbid burden, asthma, COPD, OSA and their overlap syndromes had very high long-term mortality. In patients with OSA, PAP initiation and superior therapeutic adherence were associated with significantly better survival.

Validating data analysis of broadband laser ranging

Broadband laser ranging combines spectral interferometry and a dispersive Fourier transform to achieve high-repetition-rate measurements of the position of a moving surface. Telecommunications fiber is a convenient tool for generating the large linear dispersions required for a dispersive Fourier transform, but standard fiber also has higher-order dispersion that distorts the Fourier transform. Imperfections in the dispersive Fourier transform significantly complicate the ranging signal and must be dealt with to make high-precision measurements. We describe in detail an analysis process for interpreting ranging data when standard telecommunications fiber is used to perform an imperfect dispersive Fourier transform. This analysis process is experimentally validated over a 27-cm scan of static positions, showing an accuracy of 50 μm and a root-mean-square precision of 4.7 μm.

Distinguishing between nociceptive and neuropathic components in chronic low back pain using behavioural evaluation and sensory examination

BACKGROUND

Diagnosis of chronic low back pain (CLBP) is traditionally predicated on identifying underlying pathological or anatomical causes, with treatment outcomes modest at best. Alternately, it is suggested that identification of underlying pain mechanisms with treatments targeted towards specific pain phenotypes may yield more success. Differentiation between nociceptive and neuropathic components of CLBP is problematic; evidence suggests that clinicians fail to identify a significant neuropathic component in many CLBP patients. The painDETECT questionnaire (PDQ) was specifically developed to identify occult but significant neuropathic components in individuals thought to have predominantly nociceptive pain.

METHODS

Using the PDQ, we classified 50 CLBP patients into two distinct groups; those with predominantly nociceptive pain (Group 1) and those with a significant neuropathic component (Group 2). We characterised these two distinct CLBP sub-groups using a) questionnaire-based behavioural evaluation measuring pain-related function and quality of life, pain intensity and psychological well-being and b) sensory examination, using two-point and tactile threshold discrimination.

OBJECTIVE

We sought to determine if differences in the pain phenotype of each CLBP sub-group would be reflected in sensory and behavioural group profiles.

RESULTS

We report that Group 1 and Group 2 sub-groups demonstrate unique clinical profiles with significant differences in sensory tactile discrimination thresholds and in a wide range of behavioural domains measuring pain intensity, disability and psychological well-being.

CONCLUSION

We have demonstrated distinct clinical profiles for CLBP patient sub-groups classified by PDQ. Our results give diagnostic confidence in using the PDQ to characterise two distinct pain phenotypes in a heterogeneous CLBP population.

Preferred and actual place of death in haematological malignancy

Objectives

Home is considered the preferred place of death for many, but patients with haematological malignancies (leukaemias, lymphomas and myeloma) die in hospital more often than those with other cancers and the reasons for this are not wholly understood. We examined preferred and actual place of death among people with these diseases.

Methods

The study is embedded within an established population-based cohort of patients with haematological malignancies. All patients diagnosed at two of the largest hospitals in the study area between May 2005 and April 2008 with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma, who died before May 2010 were included. Data were obtained from medical records and routine linkage to national death records.

Results

323 deceased patients were included. A total of 142 (44%) had discussed their preferred place of death; 45.8% wanted to die at home, 28.2% in hospital, 16.9% in a hospice, 5.6% in a nursing home and 3.5% were undecided; 63.4% of these died in their preferred place. Compared to patients with evidence of a discussion, those without were twice as likely to have died within a month of diagnosis (14.8% vs 29.8%). Overall, 240 patients died in hospital; those without a discussion were significantly more likely to die in hospital than those who had (p≤0.0001). Of those dying in hospital, 90% and 75.8% received haematology clinical input in the 30 and 7 days before death, respectively, and 40.8% died in haematology areas.

Conclusions

Many patients discussed their preferred place of death, but a substantial proportion did not and hospital deaths were common in this latter group. There is scope to improve practice, particularly among those dying soon after diagnosis. We found evidence that some people opted to die in hospital; the extent to which this compares with other cancers is of interest.

High-titre circulating tissue transglutaminase-2 antibodies predict small bowel villous atrophy, but decision cut-off limits must be locally validated

Numerous studies suggest that high levels of circulating immunoglobulin (Ig)A tissue transglutaminase (TTG2) antibodies predict coeliac disease with high specificity. Accordingly, it has been suggested that duodenal biopsy may not be required routinely for diagnostic confirmation where quantitative serology identifies the presence of high antibody titres. However, defining a cut-off TTG2 threshold is problematic, as the multiple available assay methods are not harmonized and most studies have been focused on the paediatric population. Recent paediatric guidelines proposed a TTG2 antibody diagnostic cut-off at 10 × the upper limit of normal (ULN) for the method; however, concerns remain about errors of generalization, between both methods and laboratories. In this study, we used retrospective laboratory data to investigate the relationship between TTG2 antibody levels and Marsh 3 histology in the seropositive population of adults and children at a single centre. Among 202 seropositive patients with corresponding biopsies, it was possible to define a TTG2 antibody cut-off with 100% specificity for Marsh 3 histology, at just over 10 × ULN for the method. However, UK National External Quality Assurance Scheme returns during the study period showed a wide dispersion of results and poor consensus, both between methods and between laboratories using the same method. Our results support the view that high-titre TTG2 antibody levels have strong predictive value for villous atrophy in adults and children, but suggest that decision cut-offs to guide biopsy requirement will require local validation. TTG2 antibody assay harmonization is a priority, in order to meet the evolving requirements of laboratory users in this field.

Quantification of hepatic FOXP3+ T-lymphocytes in HIV/hepatitis C coinfection

Coinfection with HIV adversely impacts every stage of hepatitis C (HCV) infection. Liver damage in HCV infection results from host antiviral responses rather than direct viral pathogenesis. Despite depressed cellular immunity, coinfected patients show accelerated hepatic fibrosis compared with HCV monoinfected patients. This paradox is poorly understood. T-regulatory (Treg) cells (CD4+ and FOXP3+) are hypothesized to limit hepatic damage in HCV. Our hypothesis was that reduced frequency of hepatic Treg in HIV/HCV coinfection compared with HCV monoinfection may explain poorer outcomes. We quantified FOXP3+, CD4+, CD8+ and CD20+ cells in liver biopsies of 35 male subjects matched by age and ISHAK fibrosis score, 12 HIV monoinfected, 11 HCV monoinfected and 12 HIV/HCV coinfected. Cell counts were performed using indirect immunohistochemical staining and light microscopy. HIV/HCV coinfected subjects had fewer hepatic FOXP3+ (P = 0.031) and CD4+ cells (P = 0.001) than HCV monoinfected subjects. Coinfected subjects had more hepatic CD8+ cells compared with HCV monoinfected (P = 0.023), and a lower ratio of FOXP3+ to CD8+ cells (0.08 vs 0.27, P < 0.001). Multivariate analysis showed number of CD4+ cells controlled for differences in number of FOXP3+ cells. Fewer hepatic FOXP3+ and CD4+ cells in HIV/HCV coinfection compared with HCV monoinfection suggests lower Treg activity, driven by an overall loss of CD4+ cells. Higher number of CD8+ cells in HIV/HCV coinfection suggests higher cytotoxic activity. This may explain poorer outcomes in HIV/HCV coinfected patients and suggests a potential mechanism by which highly active antiretroviral therapy may benefit these patients.

Penile intraepithelial neoplasia: important lessons from a case series

Summary

Seven men presenting to our genitourinary (GU) medicine clinic over a period of 22 months had a histopathological diagnosis of penile intraepithelial neoplasia (PIN). Median duration of symptoms was eight months (range 2–216 months). Macroscopic appearances were different in all cases. All histology was reviewed locally and at a tertiary centre. Six of seven had severe dysplasia (PIN III). Interestingly, only one individual was HIV-positive and one, who was immunocompetent, had multifocal disease. These cases highlight the importance of a full anogenital examination and early biopsy in patients presenting with atypical or persistent penile lesions.

Illustrations of mathematical modeling in biology: epigenetics, meiosis, and an outlook

In the past few years, mathematical modeling approaches in biology have begun to fulfill their promise by assisting in the dissection of complex biological systems. Here, we review two recent examples of predictive mathematical modeling in plant biology. The first involves the quantitative epigenetic silencing of the floral repressor gene FLC in Arabidopsis, mediated by a Polycomb-based system. The second involves the spatiotemporal dynamics of telomere bouquet formation in wheat-rye meiosis. Although both the biology and the modeling framework of the two systems are different, both exemplify how mathematical modeling can help to accelerate discovery of the underlying mechanisms in complex biological systems. In both cases, the models that developed were relatively minimal, including only essential features, but both nevertheless yielded fundamental insights. We also briefly review the current state of mathematical modeling in biology, difficulties inherent in its application, and its potential future development.

Collagen-like proteins in pathogenic E. coli strains

The genome sequences of enterohaemorrhagic E. coli O157:H7 strains show multiple open-reading frames with collagen-like sequences that are absent from the common laboratory strain K-12. These putative collagens are included in prophages embedded in O157:H7 genomes. These prophages carry numerous genes related to strain virulence and have been shown to be inducible and capable of disseminating virulence factors by horizontal gene transfer. We have cloned two collagen-like proteins from E. coli O157:H7 into a laboratory strain and analysed the structure and conformation of the recombinant proteins and several of their constituting domains by a variety of spectroscopic, biophysical, and electron microscopy techniques. We show that these molecules exhibit many of the characteristics of vertebrate collagens, including trimer formation and the presence of a collagen triple helical domain. They also contain a C-terminal trimerization domain, and a trimeric α-helical coiled-coil domain with an unusual amino acid sequence almost completely lacking leucine, valine or isoleucine residues. Intriguingly, these molecules show high thermal stability, with the collagen domain being more stable than those of vertebrate fibrillar collagens, which are much longer and post-translationally modified. Under the electron microscope, collagen-like proteins from E. coli O157:H7 show a dumbbell shape, with two globular domains joined by a hinged stalk. This morphology is consistent with their likely role as trimeric phage side-tail proteins that participate in the attachment of phage particles to E. coli target cells, either directly or through assembly with other phage tail proteins. Thus, collagen-like proteins in enterohaemorrhagic E. coli genomes may have a direct role in the dissemination of virulence-related genes through infection of harmless strains by induced bacteriophages.

Do not forget to examine the genitals: a case of anal cancer and anogenital intraepithelial neoplasia in an immunocompetent man

A 46-year-old Caucasian heterosexual male was referred to a dedicated AIN clinic from colorectal multidisciplinary meeting (MDM) with AIN 3 following complete resection of anal squamous cell carcinoma (SCC). On further questioning, he revealed that he also had a lesion on his penis. Histology of the penile lesion demonstrated full thickness penile intraepithelial neoplasia (PIN 3). This case illustrates the importance of thorough genital examination in patients found to have one genital pathology.

Olfactory discrimination predicts cognitive decline among community-dwelling older adults

The presence of olfactory dysfunction in individuals at higher risk of Alzheimer's disease has significant diagnostic and screening implications for preventive and ameliorative drug trials. Olfactory threshold, discrimination and identification can be reliably recorded in the early stages of neurodegenerative diseases. The current study has examined the ability of various olfactory functions in predicting cognitive decline in a community-dwelling sample. A group of 308 participants, aged 46-86 years old, were recruited for this study. After 3 years of follow-up, participants were divided into cognitively declined and non-declined groups based on their performance on a neuropsychological battery. Assessment of olfactory functions using the Sniffin' Sticks battery indicated that, contrary to previous findings, olfactory discrimination, but not olfactory identification, significantly predicted subsequent cognitive decline (odds ratio = 0.869; P<0.05; 95% confidence interval = 0.764-0.988). The current study findings confirm previously reported associations between olfactory and cognitive functions, and indicate that impairment in olfactory discrimination can predict future cognitive decline. These findings further our current understanding of the association between cognition and olfaction, and support olfactory assessment in screening those at higher risk of dementia.