Fetal cardiovascular changes during open and fetoscopic in-utero spina bifida closure

OBJECTIVE

Laparotomy-assisted fetoscopic closure of spina bifida utilizing heated-humidified carbon dioxide gas has been associated with less maternal morbidity than open in-utero spina bifida closure. Fetal cardiovascular changes during these surgical interventions are not well defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR)<110 bpm over 10 minutes) and changes in umbilical artery Doppler parameters throughout open in-utero closure with those observed during laparotomy-assisted fetoscopic closure.

METHODS

We conducted a prospective cohort study of 22 open and 46 fetoscopic consecutive in-utero closures between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and umbilical artery velocimetry were systematically obtained during preoperative assessment, every 5 minutes during the intraoperative period, and in the postoperative assessment. FHR, pulsatility indexes and end-diastolic flows were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocities were measured in the fetoscopic cohort. Each fetal heart rate recording time point was correlated to maternal parameters, including heart rate, systolic and diastolic blood pressures.

RESULTS

Fetal bradycardia occurred in 4/22 cases (18.2%) of open in-utero closure and in 21/46 cases (45.7%) of fetoscopic closure. FHR gradually decreased in both cohorts after general anesthesia and decreased further during surgery. FHR were significantly lower after two hours of surgery in the fetoscopic closure than in the open in-utero closure group. In addition, the FHR (BPM) change in the final stages of the fetal surgery from the baseline FHR was significantly lower in the fetoscopic cohort (-32.3 (-35.7, -29.1)) compared to the open cohort (-23.5 (-28.1, -18.8)) (p=0.002). Abnormal end-diastolic flow (defined as absent or reversed end-diastolic flow) in the umbilical artery Doppler velocity occurred in 3/22 (13.6%) of the open closure cohort and in 23/46 (50%) of the fetoscopic closure cohort (p=0.004). There were no differences in umbilical artery end-diastolic flow and pulsatility index between closure techniques during the various stages of assessment.

CONCLUSIONS

We observed a decrease in the FHR and abnormalities in umbilical artery Doppler parameters in both open in-utero and fetoscopic closure groups. Fetal bradycardia was more prominent during fetoscopic closure following heated-humidified carbon dioxide insufflation, but the FHR recovered after cessation of the heated-humidified carbon dioxide. Changes in FHR and umbilical artery Doppler parameters during in-utero spina bifida closure were observed to be transient, no cases required emergency delivery and no fetoscopic closure were converted to open closure. These observations should inform algorithms for perioperative management of fetal bradycardia associated with in-utero spina bifida closure. This article is protected by copyright. All rights reserved.

Implementation of a Systematic, Digital Oncology Workflow for Patient Distress Screening in a National, Multi-Site Radiotherapy Outpatient Setting

PURPOSE/OBJECTIVE(S)

Distress screening is recommended as standard of care in oncology to improve the quality of personalized care for patients, however previously reported barriers have led to poor uptake and reporting of clinician follow up and interventions. Our purpose was to improve the quality of personalized care for patients with high patient participation rate (>50%), clinical and nurse workflow compliance rate (>70%) and create structured data for practice improvement. To achieve this purpose, an in-house systematic digital screen and templated well-being plan (WBP) workflow was implemented across 33 outpatient Radiation Oncology sites in a multi-institutional center.

MATERIALS/METHODS

An in-house digital version of the NCCN Distress Thermometer and Problem Checklist (DT) was built in the integrated web-based portal for patients to complete at home or in a clinic setting. A digital workflow was co-designed with clinicians with automatic integration of the DT PDF document into the Electronic Medical Record (EMR), assigned for doctor review. Nurses subsequently recorded screening actions in the WBP. An extensive engagement, education and support program was completed nationally with phased implementation after an initial pilot at 3 sites. Staff and patient feedback were documented and presented with the collated data for review.

RESULTS

The program was successfully implemented at 33 centers across Australia in the multi-site organization between March and October 2022. A total of 7788 distress screening forms were submitted with an uptake rate of 78% at baseline and 53% at end of treatment (EOT). DT document approval rates by doctors varied (41%-98%), and WBP was completed for 48-100% of patients, with variations of rates and use noted between states and individuals for both. Referrals were recorded in the WBP for 3% of patients, however, as up to 52% of documentation was not in a WBP (for some states), true referral numbers require further manual analysis. Pairwise analysis of screening scores between time points saw 42% of scores reduced, 34% increased and 24% with no change. Analysis of a subset of patients with increased or no change in score showed 57% had some change in categories of distress, 22% had complete change and 10% had no change.

CONCLUSION

With an increasing global focus on improving patient centered care, implementation of a systematic digital workflow for distress screening and supportive care was achieved resulting in patient identified stressors being addressed as standard of care. Key barriers reported, include confidence discussing screening results with patients and manual workflows at EOT. The provision of a rich data set can also highlight opportunities for clinical practice improvement, cohort-based focus, clinical quality indicators, benchmarking and reporting.

Diagnosing the pedestal magnetic field and magnetohydrodynamics radial structure with pedestal-scrape of layer electron cyclotron emission radiation inversion in H-mode plasma (invited)

Forward modeling is used to interpret inversion patterns of the pedestal-Scrape of Layer (SOL) Electron Cyclotron Emission (ECE) in DIII-D H-mode experiments. The modeling not only significantly improves the ECE data interpretation quality but also leads to the potential measurements of (1) the magnetic field strength |B| at the separatrix, (2) the pedestal |B| evolution during an inter-Edge Localized Mode (ELM) period, and (3) the pedestal Magnetohydrodynamics (MHD) radial structure. The ECE shine-through effect leads to three types of pedestal-SOL radiation inversions that are discussed in this paper. The first type of inversion is the non-monotonic T_e,rad profile with respect to the major radius. Using the ECE frequency at the minimum T_e,rad, the inversion can be applied to measure the magnetic field |B| at the separatrix and calibrate the mapping of the ECE channels with respect to the separatrix. The second type of inversion refers to the opposite phase between the radiation fluctuations δT_e,rad at the pedestal and SOL. This δT_e,rad phase inversion is sensitive to density and temperature fluctuations at the pedestal foot and, thus, can be used to qualitatively measure the MHD radial structure. The third type of inversion appears when the pedestal and SOL T_e,rad evolve in an opposite trend, which can be used to infer the pedestal |B| field change during an inter-ELM period. The bandwidth effect on measuring δT_e,rad due to pedestal MHD is also investigated in the radiation modeling.

Complexities of Long-Term Care With Gastro-Jejunal (GJ) Feeding Tubes and Enteral Migration During COVID-19 Pandemic Times: A Case Report

Gastro-jejunostomy tubes, or percutaneous endoscopic gastrostomy tubes with jejunal extension (PEG-J), hold a significant role in the long-term nutritional management of patients with poor oral intake. This can be for a variety of reasons; ranging from metabolic conditions, including diabetes mellitus, inherited or congenital conditions like Ehler Danlos syndrome, or patients with neurological disorders, such as stroke, advanced Parkinson's disease or multiple sclerosis. Although they are very helpful for the overall nutritional needs of such patients, they are associated with complications, including the dislodging of jejunal tubes. The need to promptly recognise, investigate and manage this, in a timely manner, is vital, particularly during the COVID-19 pandemic times, as such patients may be associated with multiple comorbidities.

Adipocytes disrupt the translational programme of acute lymphoblastic leukaemia to favour tumour survival and persistence

The specific niche adaptations that facilitate primary disease and Acute Lymphoblastic Leukaemia (ALL) survival after induction chemotherapy remain unclear. Here, we show that Bone Marrow (BM) adipocytes dynamically evolve during ALL pathogenesis and therapy, transitioning from cellular depletion in the primary leukaemia niche to a fully reconstituted state upon remission induction. Functionally, adipocyte niches elicit a fate switch in ALL cells towards slow-proliferation and cellular quiescence, highlighting the critical contribution of the adipocyte dynamic to disease establishment and chemotherapy resistance. Mechanistically, adipocyte niche interaction targets posttranscriptional networks and suppresses protein biosynthesis in ALL cells. Treatment with general control nonderepressible 2 inhibitor (GCN2ib) alleviates adipocyte-mediated translational repression and rescues ALL cell quiescence thereby significantly reducing the cytoprotective effect of adipocytes against chemotherapy and other extrinsic stressors. These data establish how adipocyte driven restrictions of the ALL proteome benefit ALL tumours, preventing their elimination, and suggest ways to manipulate adipocyte-mediated ALL resistance.

Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes

CONTEXT

Palliative care remains suboptimal in end-stage liver disease (ESLD).

OBJECTIVES

We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage).

METHODS

Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12).

RESULTS

Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care.

CONCLUSION

Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible.

TRIAL REGISTRATION

ISRCTN30697116, date assigned: 07/10/2015.

EPEN-14. GENERATION OF A C11orf95-RELA FUSION TARGETING ANTIBODY AS A DIAGNOSTIC TOOL FOR SUPRATENTORIAL EPENDYMOMA

Ependymomas account for 10% of paediatric brain tumours and arise in the ventricular walls of the central nervous system. Ependymomas were previously classified as one tumour type and all patients received similar treatment. However, recent genomic studies have identified nine different molecular subgroups of the disease, including one supratentorial subtype characterized by a novel fusion gene C11ORF95-RELA. When introduced into neural stem cells, this fusion is a potent driver of tumorigenesis and its presence in patient samples has previously also been shown to negatively correlate with overall survival. Accurate diagnosis of this subgroup is currently limited to sophisticated approaches such as break-apart FISH or RNA sequencing. Here, we report the generation of a C11ORF95-RELA Fusion-specific antibody that can be used for routine immunohistochemistry (IHC). Candidate antibodies were first selected using phage display and favourable leads were subjected to affinity maturation using ribosome display after a screening process involving immunoblotting and IHC. Further IHC-based screening of affinity-matured candidates using fusion-positive and -negative mouse tissue as well as human fusion-negative ependymoma tumour tissue produced one lead antibody. The antibody detects fusion-specific nuclear staining pattern on fusion-positive tissue and does not react with fusion-negative tissues. This candidate antibody is currently being tested on human fusion-positive ependymoma tissue. This accurate diagnostic tool holds great promise to transform the management of patients with supratentorial ependymoma.

Extensive sequence and structural evolution of Arginase 2 inhibitory antibodies enabled by an unbiased approach to affinity maturation

Affinity maturation is a powerful technique in antibody engineering for the in vitro evolution of antigen binding interactions. Key to the success of this process is the expansion of sequence and combinatorial diversity to increase the structural repertoire from which superior binding variants may be selected. However, conventional strategies are often restrictive and only focus on small regions of the antibody at a time. In this study, we used a method that combined antibody chain shuffling and a staggered-extension process to produce unbiased libraries, which recombined beneficial mutations from all six complementarity-determining regions (CDRs) in the affinity maturation of an inhibitory antibody to Arginase 2 (ARG2). We made use of the vast display capacity of ribosome display to accommodate the sequence space required for the diverse library builds. Further diversity was introduced through pool maturation to optimize seven leads of interest simultaneously. This resulted in antibodies with substantial improvements in binding properties and inhibition potency. The extensive sequence changes resulting from this approach were translated into striking structural changes for parent and affinity-matured antibodies bound to ARG2, with a large reorientation of the binding paratope facilitating increases in contact surface and shape complementarity to the antigen. The considerable gains in therapeutic properties seen from extensive sequence and structural evolution of the parent ARG2 inhibitory antibody clearly illustrate the advantages of the unbiased approach developed, which was key to the identification of high-affinity antibodies with the desired inhibitory potency and specificity.

Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis

BACKGROUND

Palliative care remains suboptimal in end-stage liver disease.

AIM

To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison.

METHODS

A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion.

RESULTS

Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway.

CONCLUSIONS

The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation.

TRIAL REGISTRATION

ISRCTN30697116, date assigned: 07/10/2015.

Structural and functional characterization of C0021158, a high-affinity monoclonal antibody that inhibits Arginase 2 function via a novel non-competitive mechanism of action

Arginase 2 (ARG2) is a binuclear manganese metalloenzyme that catalyzes the hydrolysis of L-arginine. The dysregulated expression of ARG2 within specific tumor microenvironments generates an immunosuppressive niche that effectively renders the tumor 'invisible' to the host's immune system. Increased ARG2 expression leads to a concomitant depletion of local L-arginine levels, which in turn leads to suppression of anti-tumor T-cell-mediated immune responses. Here we describe the isolation and characterization of a high affinity antibody (C0021158) that inhibits ARG2 enzymatic function completely, effectively restoring T-cell proliferation in vitro. Enzyme kinetic studies confirmed that C0021158 exhibits a noncompetitive mechanism of action, inhibiting ARG2 independently of L-arginine concentrations. To elucidate C0021158's inhibitory mechanism at a structural level, the co-crystal structure of the Fab in complex with trimeric ARG2 was solved. C0021158's epitope was consequently mapped to an area some distance from the enzyme's substrate binding cleft, indicating an allosteric mechanism was being employed. Following C0021158 binding, distinct regions of ARG2 undergo major conformational changes. Notably, the backbone structure of a surface-exposed loop is completely rearranged, leading to the formation of a new short helix structure at the Fab-ARG2 interface. Moreover, this large-scale structural remodeling at ARG2's epitope translates into more subtle changes within the enzyme's active site. An arginine residue at position 39 is reoriented inwards, sterically impeding the binding of L-arginine. Arg39 is also predicted to alter the pKA of a key catalytic histidine residue at position 160, further attenuating ARG2's enzymatic function. In silico molecular docking simulations predict that L-arginine is unable to bind effectively when antibody is bound, a prediction supported by isothermal calorimetry experiments using an L-arginine mimetic. Specifically, targeting ARG2 in the tumor microenvironment through the application of C0021158, potentially in combination with standard chemotherapy regimens or alternate immunotherapies, represents a potential new strategy to target immune cold tumors.

Strategies for interfacing with the trigeminal nerves in rodents for bioelectric medicine

BACKGROUND

Bioelectric medicine seeks to modulate neural activity via targeted electrical stimulation to treat disease. Recent clinical evidence supports trigeminal nerve stimulation as a bioelectric treatment for several neurological disorders; however, the mechanisms of trigeminal nerve stimulation and potential side effects remain largely unknown. The goal of this study is to optimize the methodology and reproducibility of neural interface implantation for mechanistic studies in rodents.

NEW METHOD(S)

This article describes a single incision surgical approach to the infraorbital nerve of rats and mice and the supraorbital nerve in rats for trigeminal nerve stimulation studies. This article also presents the use of cortical evoked potentials and electromyography as methods for demonstrating effective engagement between the implanted electrode and target nerve.

COMPARISON WITH EXISTING METHOD(S)

A number of surgical approaches to the infraorbital nerve in rats exist, many of which are technically difficult. A simple, standardized approach to infraorbital nerve in rats and mice, as well as the supraorbital nerve of rats is integral to reproducibility of future trigeminal nerve stimulation studies.

CONCLUSION

The infraorbital nerve of rats and mice can be easily accessed from a single dorsal incision on the bridge of the nose that avoids major anatomical structures such as the facial nerve. The supraorbital nerve is also accessible in rats from a single dorsal incision, but not mice due to size. Successful interfacing and engagement of the infra- and supraorbital nerves using the described methodology is demonstrated by recording of evoked cortical potentials and electromyography.

Palliative long-term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis: study protocol for a feasibility randomised controlled trial

Background

UK deaths due to chronic liver diseases such as cirrhosis have quadrupled over the last 40 years, making this condition now the third most common cause of premature death. Most patients with advanced cirrhosis (end-stage liver disease [ESLD]) develop ascites. This is often managed with diuretics, but if refractory, then the fluid is drained from the peritoneal cavity every 10–14 days by large volume paracentesis (LVP), a procedure requiring hospital admissions. As the life expectancy of patients with ESLD and refractory ascites (if ineligible for liver transplantation) is on average ≤ 6 months, frequent hospital visits are inappropriate from a palliative perspective. One alternative is long-term abdominal drains (LTADs), used successfully in patients whose ascites is due to malignancy. Although inserted in hospital, these drains allow ascites management outside of a hospital setting. LTADs have not been formally evaluated in patients with refractory ascites due to ESLD.

Methods/design

Due to uncertainty about appropriate outcome measures and whether patients with ESLD would wish or be able to participate in a study, a feasibility randomised controlled trial (RCT) was designed. Patients were consulted on trial design. We plan to recruit 48 patients with refractory ascites and randomise them (1:1) to either (1) LTAD or (2) current standard of care (LVP) for 12 weeks. Outcomes of interest include acceptability of the LTAD to patients, carers and healthcare professionals as well as recruitment and retention rates. The Integrated Palliative care Outcome Scale, the Short Form Liver Disease Quality of Life questionnaire, the EuroQol 5 dimensions instrument and carer-reported (Zarit Burden Interview) outcomes will also be assessed. Preliminary data on cost-effectiveness will be collected, and patients and healthcare professionals will be interviewed about their experience of the trial with a view to identifying barriers to recruitment.

Discussion

LTADs could potentially improve end-of-life care in patients with refractory ascites due to ESLD by improving symptom control, reducing hospital visits and enabling some self-management. Our trial is designed to see if such patients can be recruited, as well as to inform the design of a subsequent definitive trial.

Trial registration

ISRCTN, ISRCTN30697116. Registered on 7 October 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2779-0) contains supplementary material, which is available to authorized users.

Detector for positronium temperature measurements by two-photon angular correlation

We report on the design and characterization of a modular γ-ray detector assembly developed for accurate and efficient detection of coincident 511 keV back-to-back γ-rays following electron-positron annihilation. Each modular detector consists of 16 narrow lutetium yttrium oxyorthosilicate scintillators coupled to a multi-anode Hamamatsu H12700B photomultiplier tube. We discuss the operation and optimization of 511 keV γ-ray detection resulting from testing various scintillators and detector arrangements concluding with an estimate of the coincident 511 keV detection efficiency for the intended experiment and a preliminary test representing one-quarter of the completed array.

High Signal Intensity in the Dentate Nucleus and Globus Pallidus on Unenhanced T1-Weighted MR Images: Comparison between Gadobutrol and Linear Gadolinium-Based Contrast Agents

BACKGROUND AND PURPOSE

In view of the recent observations that gadolinium deposits in brain tissue after intravenous injection, our aim of this study was to compare signal changes in the globus pallidus and dentate nucleus on unenhanced T1-weighted MR images in patients receiving serial doses of gadobutrol, a macrocyclic gadolinium-based contrast agent, with those seen in patients receiving linear gadolinium-based contrast agents.

MATERIALS AND METHODS

This was a retrospective analysis of on-site patients with brain tumors. Fifty-nine patients received only gadobutrol, and 60 patients received only linear gadolinium-based contrast agents. Linear gadolinium-based contrast agents included gadoversetamide, gadobenate dimeglumine, and gadodiamide. T1 signal intensity in the globus pallidus, dentate nucleus, and pons was measured on the precontrast portions of patients' first and seventh brain MRIs. Ratios of signal intensity comparing the globus pallidus with the pons (globus pallidus/pons) and dentate nucleus with the pons (dentate nucleus/pons) were calculated. Changes in the above signal intensity ratios were compared within the gadobutrol and linear agent groups, as well as between groups.

RESULTS

The dentate nucleus/pons signal ratio increased in the linear gadolinium-based contrast agent group (t = 4.215, P < .001), while no significant increase was seen in the gadobutrol group (t = -1.422, P = .08). The globus pallidus/pons ratios followed similarly, with an increase in the linear gadolinium-based contrast agent group (t = 2.931, P < .0001) and no significant change in those receiving gadobutrol (t = 0.684, P = .25).

CONCLUSIONS

Successive doses of gadobutrol do not result in T1 shortening compared with changes seen in linear gadolinium-based contrast agents.

Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series

BACKGROUND

Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease.

CASE PRESENTATION

A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening.

CONCLUSION

Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.

The impact of automated hippocampal volumetry on diagnostic confidence in patients with suspected Alzheimer's disease: A European Alzheimer's Disease Consortium study

INTRODUCTION

Hippocampal volume is a core biomarker of Alzheimer's disease (AD). However, its contribution over the standard diagnostic workup is unclear.

METHODS

Three hundred fifty-six patients, under clinical evaluation for cognitive impairment, with suspected AD and Mini-Mental State Examination ≥20, were recruited across 17 European memory clinics. After the traditional diagnostic workup, diagnostic confidence of AD pathology (DCAD) was estimated by the physicians in charge. The latter were provided with the results of automated hippocampal volumetry in standardized format and DCAD was reassessed.

RESULTS

An increment of one interquartile range in hippocampal volume was associated with a mean change of DCAD of -8.0% (95% credible interval: [-11.5, -5.0]). Automated hippocampal volumetry showed a statistically significant impact on DCAD beyond the contributions of neuropsychology, ¹⁸F-fluorodeoxyglucose positron emission tomography/single-photon emission computed tomography, and cerebrospinal fluid markers (-8.5, CrI: [-11.5, -5.6]; -14.1, CrI: [-19.3, -8.8]; -10.6, CrI: [-14.6, -6.1], respectively).

DISCUSSION

There is a measurable effect of hippocampal volume on DCAD even when used on top of the traditional diagnostic workup.

Monozygotic twins with NASH cirrhosis: cumulative effect of multiple single nucleotide polymorphisms?

 Multiple genetic and environmental factors interact to determine an individual's predisposition to non-alcoholic fatty liver disease and its phenotypic characteristics. Association studies have found a number of alleles associated with the development of non-alcoholic steatohepatitis. Our aim was to investigate whether multiple risk-associated alleles may be present in affected monozygotic twins, indicating underlying genetic predisposition to non-alcoholic steatohepatitis. We determined the genotype of 14 candidate gene polymorphisms (at 11 unlinked loci) in a set of monozygotic twins who presented with cirrhosis within 18 months of each other. Genotyping revealed multiple single nucleotide polymorphisms at 9 independent loci in genes PNPLA3, APOC3, GCKR, TRIB1, LYPLAL1, PPP1R3B, COL13A1, and EFCAB4B, previously implicated in contributing to non-alcoholic steatohepatitis pathogenesis. In conclusion, this case series illustrates the potential cumulative effect of multiple polymorphisms in the development and potential progression of a complex trait such as NASH cirrhosis.

A new framework for the interpretation of IgE sensitization tests

IgE sensitization tests, such as skin prick testing and serum-specific IgE, have been used to diagnose IgE-mediated clinical allergy for many years. Their prime drawback is that they detect sensitization which is only loosely related to clinical allergy. Many patients therefore require provocation tests to make a definitive diagnosis; these are often expensive and potentially associated with severe reactions. The likelihood of clinical allergy can be semi-quantified from an IgE sensitization test results. This relationship varies though according to the patients' age, ethnicity, nature of the putative allergic reaction and coexisting clinical diseases such as eczema. The likelihood of clinical allergy can be more precisely estimated from an IgE sensitization test result, by taking into account the patient's presenting features (pretest probability). The presence of each of these patient-specific factors may mean that a patient is more or less likely to have clinical allergy with a given test result (post-test probability). We present two approaches to include pretest probabilities in the interpretation of results. These approaches are currently limited by a lack of data to allow us to derive pretest probabilities for diverse setting, regions and allergens. Also, cofactors, such as exercise, may be necessary for exposure to an allergen to result in an allergic reaction in specific IgE-positive patients. The diagnosis of IgE-mediated allergy is now being aided by the introduction of allergen component testing which may identify clinically relevant sensitization. Other approaches are in development with basophil activation testing being closest to clinical application.

Precautionary allergen labelling: perspectives from key stakeholder groups

Precautionary allergen labelling (PAL) was introduced by the food industry to help manage and communicate the possibility of reaction from the unintended presence of allergens in foods. However, in its current form, PAL is counterproductive for consumers with food allergies. This review aims to summarize the perspectives of all the key stakeholders (including clinicians, patients, food industry and regulators), with the aim of defining common health protection and risk minimization goals. The lack of agreed reference doses has resulted in inconsistent application of PAL by the food industry and in levels of contamination that prompt withdrawal action by enforcement officers. So there is a poor relationship between the presence or absence of PAL and actual reaction risk. This has led to a loss of trust in PAL, reducing the ability of consumers with food allergies to make informed choices. The result has been reduced avoidance, reduced quality of life and increased risk-taking by consumers who often ignore PAL. All contributing stakeholders agree that PAL must reflect actual risk. PAL should be transparent and consistent with rules underpinning decision-making process being communicated clearly to all stakeholders. The use of PAL should indicate the possible, unintended presence of an allergen in a consumed portion of a food product at or above any proposed action level. This will require combined work by all stakeholders to ensure everyone understands the approach and its limitations. Consumers with food allergy then need to be educated to undertake individualized risk assessments in relation to any PAL present.

Sickle cell solubility test: evaluation of an in-house method

This study aims to assess the performance of an in-house sickle cell solubility test (SCT) and compare it against data published on other in-house and commercial methods. Also assessed are the effects of possible interference due to haemoglobin (Hb) level, Hb F and Hb S levels, as well as lipaemia, icterus and haemolysis index. A total of 1030 patient samples were tested by the SCT and subsequently confirmed by high-performance liquid chromatography (HPLC). Seventy-five (7.3%) samples revealed a positive SCT whereas 955 (92.7%) were negative. The sensitivity and specificity of the method was 100% and it was shown to detect low levels of Hb S (12.1%). These data show that the authors' in-house SCT method has an excellent performance against other documented methods (including some commercial kits), which is probably explained by its robustness against low levels of Hb S and interfering substances such as lipaemia. The authors believe this shows that in-house tests are able to produce highly reliable results comparable to, if not better than, certain commercially available CE-marked kits.

Rapidly building global health security capacity--Uganda demonstration project, 2013

Increasingly, the need to strengthen global capacity to prevent, detect, and respond to public health threats around the globe is being recognized. CDC, in partnership with the World Health Organization (WHO), has committed to building capacity by assisting member states with strengthening their national capacity for integrated disease surveillance and response as required by International Health Regulations (IHR). CDC and other U.S. agencies have reinforced their pledge through creation of global health security (GHS) demonstration projects. One such project was conducted during March-September 2013, when the Uganda Ministry of Health (MoH) and CDC implemented upgrades in three areas: 1) strengthening the public health laboratory system by increasing the capacity of diagnostic and specimen referral networks, 2) enhancing the existing communications and information systems for outbreak response, and 3) developing a public health emergency operations center (EOC) (Figure 1). The GHS demonstration project outcomes included development of an outbreak response module that allowed reporting of suspected cases of illness caused by priority pathogens via short messaging service (SMS; i.e., text messaging) to the Uganda District Health Information System (DHIS-2) and expansion of the biologic specimen transport and laboratory reporting system supported by the President's Emergency Plan for AIDS Relief (PEPFAR). Other enhancements included strengthening laboratory management, establishing and equipping the EOC, and evaluating these enhancements during an outbreak exercise. In 6 months, the project demonstrated that targeted enhancements resulted in substantial improvements to the ability of Uganda's public health system to detect and respond to health threats.

RhoA-Rho kinase and platelet-activating factor stimulation of ovine foetal pulmonary vascular smooth muscle cell proliferation

OBJECTIVES

Platelet-activating factor (PAF) is produced by pulmonary vascular smooth muscle cells (PVSMC). We studied effects of Rho kinase on PAF stimulation of PVSMC proliferation in an attempt to understand the role of RhoA/Rho kinase on PAF-induced ovine foetal pulmonary vascular remodelling. Our hypothesis is that PAF acts through Rho kinase, as one of its downstream signals, to induce arterial (SMC-PA) and venous (SMC-PV) cell proliferation in the hypoxic lung environment of the foetus, in utero.

MATERIALS AND METHODS

Rho kinase and MAPK effects on PAF receptor (PAFR)-mediated cell population expansion, and PAFR expression, were studied by DNA synthesis, western blot analysis and immunocytochemistry. Effects of constructs T19N and G14V on PAF-induced cell proliferation were also investigated.

RESULTS

Hypoxia increased PVSMC proliferation and Rho kinase inhibitors, Y-27632 and Fasudil (HA-1077) as well as MAPK inhibitors PD 98059 and SB 203580 attenuated PAF stimulation of cell proliferation. RhoA T19N and G14V stimulated cell proliferation, but co-incubation with PAF did not affect proliferative effects of the constructs. PAFR protein expression was significantly downregulated in both cell types by both Y-27632 and HA-1077, with comparable profiles. Also, cells treated with Y-27632 had less PAF receptor fluorescence with significant disruption of cell morphology.

CONCLUSIONS

Our results show that Rho kinase non-specifically modulated PAFR-mediated responses by a translational modification of PAFR protein, and suggest that, in vivo, activation of Rho kinase by PAF may be a further pathway to sustain PAFR-mediated PVSMC proliferation.

Hepatitis E infection is an under recognized cause of acute decompensation in patients with chronic liver disease

BACKGROUND/AIMS

We aimed to assess characteristics of patients with a positive hepatitis E virus serology with emphasis on acute on chronic liver disease.

METHODS

This was a retrospective audit performed at a large teaching hospital.

RESULTS

Of the 164 patients tested, 15(9.1%) had a positive serology (hepatitis E virus IgG and or IgM) of whom two also had a positive hepatitis E virus RNA. Six (42.8%) had underlying chronic liver disease and presented with deteriorating liver tests±decompensation. In one patient (16%) acute hepatitis E virus infection was the aetiology for the decompensation and in three the positive hepatitis E virus IgG was a reflection of prior subclinical infection. However, in two of the six patients with unexplained decompensation there was delay (150-270 days) in obtaining a hepatitis E virus serology, which may have resulted in a negative hepatitis E virus IgM at time of testing.

CONCLUSIONS

9.1% of patients presenting with abnormal liver tests at a large teaching hospital in south east England have a positive hepatitis E virus serology of whom 42.8% have acute on chronic liver disease. In 16% hepatitis E virus infection is the aetiology for the acute decompensation. This may be an under representation as in >30% of patients with unexplained decompensation there is considerable delay in requesting a hepatitis E virus serology.

Electron cyclotron emission diagnostic for ITER

Electron temperature measurements and electron thermal transport inferences will be critical to the nonactive and deuterium phases of ITER operation and will take on added importance during the alpha heating phase. The diagnostic must meet stringent criteria on spatial coverage and spatial resolution during full field operation. During the early phases of operation, it must operate equally well at half field. The key to the diagnostic is the front end design. It consists of a quasioptical antenna and a pair of calibration sources. The radial resolution of the diagnostic is less than 0.06 m. The spatial coverage extends at least from the core to the separatrix with first harmonic O-mode being used for the core and second harmonic X-mode being used for the pedestal. The instrumentation used for the core measurement at full field can be used for detection at half field by changing the detected polarization. Intermediate fields are accessible. The electron cyclotron emission systems require in situ calibration, which is provided by a novel hot calibration source. The critical component for the hot calibration source, the emissive surface, has been successfully tested. A prototype hot calibration source has been designed, making use of extensive thermal and mechanical modeling.

Denosumab improves density and strength parameters as measured by QCT of the radius in postmenopausal women with low bone mineral density

BACKGROUND

Bone strength is determined by both cortical and trabecular bone compartments and can be evaluated radiologically through measurement of bone density and geometry. Quantitative computed tomography (QCT) separately assesses cortical and trabecular bone reliably at various sites, including the distal radius where there is a gradation of cortical and trabecular bone. We evaluated the effect of denosumab, a fully human monoclonal antibody that inhibits RANK ligand, on distal radius QCT in women with low bone mass to assess the impact of this novel therapy separately on trabecular and cortical bone.

METHODS

Postmenopausal women (n=332) with spine areal bone mineral density (BMD) T-scores between -1.0 and -2.5 received denosumab 60 mg or placebo every 6 months during the 24-month study. QCT measurements along the distal radius were made using a whole-body computed tomography scanner and were used to determine the percentage change from baseline in volumetric BMD; volumetric bone mineral content (BMC); cortical thickness; volume; circumference; and density-weighted polar moment of inertia (PMI), a derived index of bone strength.

RESULTS

Denosumab treatment significantly increased total BMD and BMC along the radius (proximal, distal, and ultradistal sections). At 24 months, the ultradistal region had the greatest percentage increase in total BMD (4.7% [95% CI, 3.6-5.7]; P<0.001) and total BMC (5.7% [95% CI, 4.8-6.6]; P<0.001) over placebo. When cortical and trabecular bone at the proximal and distal regions were separately assessed, cortical bone had significant (P<0.001) increases in BMD, BMC, and thickness, and trabecular bone had a significant increase in BMD relative to placebo (P<0.05). Bone strength, estimated by density-weighted PMI, significantly increased compared with placebo after 6 months of treatment, with the largest percentage increase occurring at 24 months in the ultradistal region (6.6% [95% CI, 5.6-7.6]; P<0.0001).

CONCLUSIONS

QCT measurements demonstrated that denosumab significantly increased BMD, BMC, and PMI along the radius over 24 months. Additionally, denosumab prevented the decrease in QCT-measured cortical thickness observed in the placebo group. These data extend the evidence from previous dual-energy X-ray absorptiometry studies for a positive effect of denosumab on both the cortical and trabecular bone compartments and propose a possible mechanism for the reduction in fracture risk achieved with denosumab therapy.

Applying cognitive debriefing to pre-test patient-reported outcomes in older people with multiple sclerosis

PURPOSE

The aim of this study was to reduce respondent burden and decrease data errors in patient-reported outcomes (PROs) intended for a postal survey measuring health and lifestyle factors that may affect quality of life in older people with multiple sclerosis (MS).

METHODS

Participants (n = 18) were recruited from a database of outpatient visits. Using the qualitative diagnostic method, cognitive debriefing, participants completed five standardized questionnaires; Frenchay Activities Index, Barthel Index, Simple Lifestyle Indicator Questionnaire, EuroQoL EQ-5D and Personal Resources Questionnaire 2000. PRO item issues and respondent behaviors such as skipping items were recorded. Data collection was an iterative process whereby difficulties experienced by 2-3 subjects were used to modify the survey for following respondents until data saturation was reached.

RESULTS

Most respondents had serious difficulties with at least one PRO item. Response errors fell into three main categories: (1) respondents did not read instructions and completed the item incorrectly, (2) respondents did not understand the question and required examples to clarify and (3) respondents felt that the pre-determined response options did not apply to them. PRO reformatting, minor modifications to item wording and addition of item examples improved precision and reduced respondent burden.

CONCLUSION

Our findings support the notion that methods such as cognitive debriefing help improve precision of self-reported measures in a special population such as ours.