Recurrence of new-onset post-operative AF after cardiac surgery: detected by implantable loop recorders: A systematic review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. New-onset post-operative AF may signal an elevated risk of AF and associated outcomes in long-term follow-up. We aimed to estimate the rate of AF recurrence as detected by an implantable loop recorder (ILR) in patients experiencing post-operative AF within 30 days after cardiac surgery.

METHODS

We searched MEDLINE, Embase and Cochrane CENTRAL to April 2023 for studies of adults who did not have known AF, experienced new-onset AF within 30 days of cardiac surgery and received an ILR. We pooled individual participant data on timing of AF recurrence using a random-effects model with a frailty model applied to a Cox proportional hazard analysis.

RESULTS

From 8671 citations, 8 single-centre prospective cohort studies met eligibility criteria. Data were available from 185 participants in 7 studies, with a median follow-up of 1.7 (IQR: 1.3-2.8) years. All included studies were at a low risk of bias. Pooled AF recurrence rates following 30 post-operative days were 17.8% (95% CI 11.9%-23.2%) at 3 months, 24.4% (17.7%-30.6%) at 6 months, 30.1% (22.8%-36.7%) at 12 months and 35.3% (27.6%-42.2%) at 18 months.

CONCLUSIONS

In patients who experience new-onset post-operative AF after cardiac surgery, AF recurrence lasting at least 30 s occurs in approximately 1 in 3 in the first year after surgery. The optimal frequency and modality to use for monitoring for AF recurrence in this population remain uncertain.

The association between physical availability of cannabis retail outlets and frequent cannabis use and related health harms: a systematic review

An increasing number of regions have or are considering legalising the sale of cannabis for adult use. Experience from tobacco and alcohol regulation has found that greater access to physical retail stores is positively associated with increased substance use and harm. Whether this association exists for cannabis is unclear. We completed a systematic review examining the association between cannabis retail store access and adverse health outcomes. We identified articles up until July 20, 2023 by searching four databases. We included studies examining the association between measures of cannabis store access and adverse outcomes: frequent or problematic cannabis use, healthcare encounters due to cannabis use (e.g., cannabis-induced psychosis), and healthcare encounters potentially related to cannabis (e.g., self-harm episodes). Results were compared by study design type, retail access measure, and by subgroups including: children, adolescents, young adults, adults, and pregnant individuals. This review was registered with PROSPERO (CRD42021281788). The search generated 5750 citations of which we included 32 studies containing 44 unique primary analyses (unique retail measure and outcome pairs). Studies come from 4 countries (United States, Canada, Netherlands and Uruguay). Among the included analyses, there were consistent positive associations between greater cannabis retail access and 1) increased healthcare service use or poison control calls directly due to cannabis (10/12 analyses; 83%) (2) increased cannabis use and cannabis-related hospitalization during pregnancy (4/4; 100%) and 3) frequent cannabis use in adults and young adults (7/11; 64%). There was no consistent positive association between greater cannabis retail and increased frequent cannabis use in adolescents (1/4; 25%), healthcare service use potentially related to cannabis (2/6; 33%) or increased adverse neonatal birth outcomes (2/7; 26.8%). There is a positive association between greater cannabis store access and increases in cannabis harm. In countries with legal cannabis, retail restrictions may reduce use and harm.

Funding

Canadian Centre on Substance Use and Addiction (CCSA).

Use of remote patient monitoring in the care of COVID-positive patients in oncology

1554

Background: Cancer patients face an increased risk of developing acute complications from COVID-19. Remote monitoring can help with the critical need for early detection of symptoms among those diagnosed with COVID-19, enabling timely symptom management that can mitigate clinical deterioration. In response to this need, Memorial Sloan Kettering Cancer Center fast-tracked a program to monitor patients with COVID-19 from home, using an electronic symptom-tracking questionnaire and digital pulse oximeter to track patients’ status and alert care teams to intervene if symptoms worsened. A multi-disciplinary group composed of Oncology providers, advanced practice providers, nursing, nursing informatics and biomedical informatics formed to manage the program. Methods: Memorial Sloan Kettering launched a remote monitoring program for patients diagnosed with COVID-19 on March 25, 2020. All patients testing positive for COVID-19 were enrolled in the program and asked to complete a daily symptom tracking questionnaire accessed through their patient portal or administered verbally over the phone. A subset of high risk patients were also provided with a digital pulse oximeter linked to their patient portal and capable of transmitting readings directly to the care team. Clinicians received alerts for patients reporting symptoms or an oxygen saturation below 92%. Alerts resulted in an immediate response from the care team to determine if the patient needed additional care. We retrospectively evaluated the program usage, outcomes and learnings from March 25, 2020 to December 22, 2020. Results: In total, 1,721 patients were enrolled in the program from March 25, 2020 to December 22, 2020. Among these, 210 were deemed high risk patients who received a pulse oximeter in addition the daily symptom questionnaire. Over this period, 27% of patients triggered an alert from an electronic symptom questionnaire, and 63% of patients with a pulse oximeter triggered an alert from their device. Among patients who triggered an alert of any kind, 3% were triaged to a higher level of care. Patients reported that the program was highly valued and alleviated anxiety about their care. Iterative improvements were made to the program over time in response to the evolving knowledge about care for patients with COVID-19. Conclusions: Memorial Sloan Kettering was able to quickly implement a program to detect and triage symptoms among patients with COVID-19 and cancer. Refinements were made over time to many aspects of the program in response to learnings about care related to COVID-19, including to clinical eligibility, alert criteria, monitoring duration and workflows. The program also demonstrated value for patients who felt more comfortable with their care while being monitored remotely. This program established a successful model for remote monitoring of patients with COVID-19 with the potential to be scaled to other institutions or clinical areas.

Feasibility of diffusion and probabilistic white matter analysis in patients implanted with a deep brain stimulator

Deep brain stimulation (DBS) for Parkinson's disease (PD) is an established advanced therapy that produces therapeutic effects through high frequency stimulation. Although this therapeutic option leads to improved clinical outcomes, the mechanisms of the underlying efficacy of this treatment are not well understood. Therefore, investigation of DBS and its postoperative effects on brain architecture is of great interest. Diffusion weighted imaging (DWI) is an advanced imaging technique, which has the ability to estimate the structure of white matter fibers; however, clinical application of DWI after DBS implantation is challenging due to the strong susceptibility artifacts caused by implanted devices. This study aims to evaluate the feasibility of generating meaningful white matter reconstructions after DBS implantation; and to subsequently quantify the degree to which these tracts are affected by post-operative device-related artifacts. DWI was safely performed before and after implanting electrodes for DBS in 9 PD patients. Differences within each subject between pre- and post-implantation FA, MD, and RD values for 123 regions of interest (ROIs) were calculated. While differences were noted globally, they were larger in regions directly affected by the artifact. White matter tracts were generated from each ROI with probabilistic tractography, revealing significant differences in the reconstruction of several white matter structures after DBS. Tracts pertinent to PD, such as regions of the substantia nigra and nigrostriatal tracts, were largely unaffected. The aim of this study was to demonstrate the feasibility and clinical applicability of acquiring and processing DWI post-operatively in PD patients after DBS implantation. The presence of global differences provides an impetus for acquiring DWI shortly after implantation to establish a new baseline against which longitudinal changes in brain connectivity in DBS patients can be compared. Understanding that post-operative fiber tracking in patients is feasible on a clinically-relevant scale has significant implications for increasing our current understanding of the pathophysiology of movement disorders, and may provide insights into better defining the pathophysiology and therapeutic effects of DBS.

Supporting Families in Reviewing and Communicating about Radiology Imaging Studies

Diagnostic radiology reports are increasingly being made available to patients and their family members. However, these reports are not typically comprehensible to lay recipients, impeding effective communication about report findings. In this paper, we present three studies informing the design of a prototype to foster patient-clinician communication about radiology report content. First, analysis of questions posted in online health forums helped us identify patients' information needs. Findings from an elicitation study with seven radiologists provided necessary domain knowledge to guide prototype design. Finally, a clinical field study with 14 pediatric patients, their parents and clinicians, revealed positive responses of each stakeholder when using the prototype to interact with and discuss the patient's current CT or MRI report and allowed us to distill three use cases: co-located communication, preparing for the consultation, and reviewing radiology data. We draw on our findings to discuss design considerations for supporting each of these use cases.

Assessing the Performance of Clostridium perfringens Cooling Models for Cooked, Uncured Meat and Poultry Products

Heat-resistant spores of Clostridium perfringens may germinate and multiply in cooked meat and poultry products when the rate and extent of cooling does not occur in a timely manner. Therefore, six cooling models (PMP 7.0 broth model; PMIP uncured beef, chicken, and pork models; Smith-Schaffner version 3; and UK IFR ComBase Perfringens Predictor) were evaluated for relative performance in predicting growth of C. perfringens under dynamic temperature conditions encountered during cooling of cooked, uncured meat and poultry products. The predicted growth responses from the models were extensively compared with those observed in food. Data from 188 time-temperature cooling profiles (176 for single-rate exponential cooling and 12 for dual-rate exponential cooling) were collected from 17 independent sources (16 peer-reviewed publications and one report) for model evaluation. Data were obtained for a variety of cooked products, including meat and poultry slurries, ground meat and poultry products with and without added ingredients (e.g., potato starch, sodium triphosphate, and potassium tetrapyrophosphate), and processed products such as ham and roast beef. Performance of the models was evaluated using three sets of criteria, and accuracy was defined within a 1- to 2-log range. The percentages of accurate, fail-safe, or fail-dangerous predictions for each cooling model differed depending on which criterion was used to evaluate the data set. Nevertheless, the combined percentages of accurate and fail-safe predictions based on the three performance criteria were 34.66 to 42.61% for the PMP 7.0 beef broth model, 100% for the PMIP cooling models for uncured beef, uncured pork and uncured chicken, 80.11 to 93.18% for the Smith-Schaffner cooling model, and 74.43 to 85.23% for the UK IFR ComBase Perfringens Predictor model during single-rate exponential chilling. Except for the PMP 7.0 broth model, the other five cooling models (PMIP, Smith-Schaffner, and UK IFR ComBase) are useful and reliable tools that food processors and regulatory agencies can use to evaluate the safety of cooked or heat-treated uncured meat and poultry products exposed to cooling deviations or to develop customized cooling schedules.

Glomerular haemodynamic profile of patients with Type 1 diabetes compared with healthy control subjects

AIMS

To evaluate the glomerular haemodynamic profile of patients with Type 1 diabetes with either renal hyperfiltration (GFR ≥ 135 ml/min/1.73 m2 ) or renal normofiltration (GFR 90-134 ml/min/1.73 m2 ) during euglycaemic and hyperglycaemic conditions, and to compare this profile with that of a similar group of healthy control subjects.

METHODS

Gomez's equations were used to derive afferent and efferent arteriolar resistances, glomerular hydrostatic pressure and filtration pressure.

RESULTS

At baseline, during clamped euglycaemia, patients with Type 1 diabetes and hyperfiltration had lower mean ± sd afferent arteriolar resistance than both those with Type 1 diabetes and normofiltration (914 ± 494 vs. 2065 ± 597 dyne/s/cm5 ; P < 0.001) and healthy control subjects (1676 ± 707 dyne/s/cm(5) ; p < 0.001). By contrast, efferent arteriolar resistance was similar in the three groups. Patients with Type 1 diabetes and hyperfiltration also had higher mean ± sd glomerular hydrostatic pressure than both healthy control subjects and patients with Type 1 diabetes and normofiltration (66 ± 6 vs. 60 ± 3 vs. 55 ± 3 mmHg; P < 0.05). Similar findings for afferent arteriolar resistance, efferent arteriolar resistance, glomerular hydrostatic pressure and filtration pressure were observed during clamped hyperglycaemia.

CONCLUSION

Hyperfiltration in Type 1 diabetes is primarily driven by alterations in afferent arteriolar resistance rather than efferent arteriolar resistance. Renal protective therapies should focus on afferent renal arteriolar mechanisms through the use of pharmacological agents that target tubuloglomerular feedback, including sodium-glucose cotransporter 2 inhibitors and incretins.

CPR in the nursing home: fool's errand or looming dilemma?

BACKGROUND

The indications for CPR (cardiopulmonary resuscitation) have expanded greatly since the technique was introduced and theoretically it can be attempted on all prior to death. Policy initiatives (such as the British Medical Association/Royal College of Nursing guidelines) have attempted to provide a clinical rationale for the withholding of inappropriate CPR. Traditionally a care home was felt to be an inappropriate environment to attempt CPR but increased use of advance directives may bring the issue to the fore in this setting.

AIMS

We elicited the views of managers of care homes regarding resuscitation strategies in hypothetical situations and in actual practice.

METHOD

A purpose designed questionnaire in two parts was compiled, gathering factual information and employing a Likert scale to gauge opinion about this issue. The survey was conducted among 187 continuing care homes in South London the subjects being the care managers of the homes surveyed.

RESULTS AND CONCLUSION

Responses were obtained from 86 care homes. Care managers would resuscitate 66% of cases of witnessed cardiac arrest but few efforts were reported. Policies in assigning 'Do not resuscitate' orders were referred to by only 9% of homes but 80% of facilities would welcome them, yet 50% would exclude the patient from this discussion. Clear policy guidelines are required for continuing care homes, and advance statements about CPR as part of residents care plans could reduce inappropriate resuscitative efforts and hospital transfers.

Variable expression of extracellular polysaccharide in the marine bacterium Pseudomonas atlantica is controlled by genome rearrangement

Production of extracellular polysaccharide by the marine bacterium Pseudomonas atlantica is a variable trait. Strains that produce extracellular polysaccharide (EPS(+)) have a mucoid colony phenotype, but during cultivation in the laboratory nonmucoid, EPS(-) variants arise that have a crenated colony morphology. This change is reversible since crenated variants rapidly switch to the original mucoid phenotype. We have cloned the locus (eps) controlling variable expression of EPS production by screening a recombinant cosmid library for clones that restore EPS production in the crenated variant. By using eps as a probe of genomic structure in variant strains, expression of EPS production was found to be controlled by a specific DNA rearrangement. Insertion of a 1.2-kilobase-pair DNA sequence in the eps locus results in EPS(-), whereas excision of the sequence restores the EPS(+) phenotype. Properties of the rearrangement suggest the involvement of a mobile genetic element. The possible significance of this DNA rearrangement to the survival of P. atlantica in the ocean is discussed.

Phenotypes of childhood asthma: are they real?

It has been suggested that there are several distinct phenotypes of childhood asthma or childhood wheezing. Here, we review the research relating to these phenotypes, with a focus on the methods used to define and validate them. Childhood wheezing disorders manifest themselves in a range of observable (phenotypic) features such as lung function, bronchial responsiveness, atopy and a highly variable time course (prognosis). The underlying causes are not sufficiently understood to define disease entities based on aetiology. Nevertheless, there is a need for a classification that would (i) facilitate research into aetiology and pathophysiology, (ii) allow targeted treatment and preventive measures and (iii) improve the prediction of long-term outcome. Classical attempts to define phenotypes have been one-dimensional, relying on few or single features such as triggers (exclusive viral wheeze vs. multiple trigger wheeze) or time course (early transient wheeze, persistent and late onset wheeze). These definitions are simple but essentially subjective. Recently, a multi-dimensional approach has been adopted. This approach is based on a wide range of features and relies on multivariate methods such as cluster or latent class analysis. Phenotypes identified in this manner are more complex but arguably more objective. Although phenotypes have an undisputed standing in current research on childhood asthma and wheezing, there is confusion about the meaning of the term 'phenotype' causing much circular debate. If phenotypes are meant to represent 'real' underlying disease entities rather than superficial features, there is a need for validation and harmonization of definitions. The multi-dimensional approach allows validation by replication across different populations and may contribute to a more reliable classification of childhood wheezing disorders and to improved precision of research relying on phenotype recognition, particularly in genetics. Ultimately, the underlying pathophysiology and aetiology will need to be understood to properly characterize the diseases causing recurrent wheeze in children.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Wheeze and asthma prevalence and related health-service use in white and south Asian pre-schoolchildren in the United Kingdom

BACKGROUND

Epidemiological data for south Asian children in the United Kingdom are contradictory, showing a lower prevalence of wheeze, but a higher rate of medical consultations and admissions for asthma compared with white children. These studies have not distinguished different asthma phenotypes or controlled for varying environmental exposures.

OBJECTIVE

To compare the prevalence of wheeze and related health-service use in south Asian and white pre-schoolchildren in the United Kingdom, taking into account wheeze phenotype (viral and multiple wheeze) and environmental exposures.

METHODS

A postal questionnaire was completed by parents of a population-based sample of 4366 white and 1714 south Asian children aged 1-4 years in Leicestershire, UK. Children were classified as having viral wheeze or multiple trigger wheeze.

RESULTS

The prevalence of current wheeze was 35.6% in white and 25.5% in south Asian 1-year-olds (P<0.001), and 21.9% and 20.9%, respectively, in children aged 2-4 years. Odds ratios (ORs) (95% confidence interval) for multiple wheeze and for viral wheeze, comparing south Asian with white children, were 2.21 (1.19-4.09) and 1.43 (0.77-2.65) in 2-4-year-olds after controlling for socio-economic conditions, environmental exposures and family history. In 1-year-olds, the respective ORs for multiple and viral wheeze were 0.66 (0.47-0.92) and 0.81 (0.64-1.03). Reported GP consultation rates for wheeze and hospital admissions were greater in south Asian children aged 2-4 years, even after adjustment for severity, but the use of inhaled corticosteroids was lower.

CONCLUSIONS

South Asian 2-4-year-olds are more likely than white children to have multiple wheeze (a condition with many features of chronic atopic asthma), after taking into account ethnic differences in exposure to some environmental agents. Undertreatment with inhaled corticosteroids might partly explain their greater use of health services.

Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey

BACKGROUND

The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices.

METHODS

We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds.

RESULTS

Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves.

CONCLUSION

Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.

Distinguishing phenotypes of childhood wheeze and cough using latent class analysis

Airway disease in childhood comprises a heterogeneous group of disorders. Attempts to distinguish different phenotypes have generally considered few disease dimensions. The present study examines phenotypes of childhood wheeze and chronic cough, by fitting a statistical model to data representing multiple disease dimensions. From a population-based, longitudinal cohort study of 1,650 preschool children, 319 with parent-reported wheeze or chronic cough were included. Phenotypes were identified by latent class analysis using data on symptoms, skin-prick tests, lung function and airway responsiveness from two preschool surveys. These phenotypes were then compared with respect to outcome at school age. The model distinguished three phenotypes of wheeze and two phenotypes of chronic cough. Subsequent wheeze, chronic cough and inhaler use at school age differed clearly between the five phenotypes. The wheeze phenotypes shared features with previously described entities and partly reconciled discrepancies between existing sets of phenotype labels. This novel, multidimensional approach has the potential to identify clinically relevant phenotypes, not only in paediatric disorders but also in adult obstructive airway diseases, where phenotype definition is an equally important issue.

Factor analysis in the Genetics of Asthma International Network family study identifies five major quantitative asthma phenotypes

BACKGROUND

Asthma is a clinically heterogeneous disease caused by a complex interaction between genetic susceptibility and diverse environmental factors. In common with other complex diseases the lack of a standardized scheme to evaluate the phenotypic variability poses challenges in identifying the contribution of genes and environments to disease expression.

OBJECTIVE

To determine the minimum number of sets of features required to characterize subjects with asthma which will be useful in identifying important genetic and environmental contributors. Methods Probands aged 7-35 years with physician diagnosed asthma and symptomatic siblings were identified in 1022 nuclear families from 11 centres in six countries forming the Genetics of Asthma International Network. Factor analysis was used to identify distinct phenotypes from questionnaire, clinical, and laboratory data, including baseline pulmonary function, allergen skin prick test (SPT).

RESULTS

Five distinct factors were identified:(1) baseline pulmonary function measures [forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC)], (2) specific allergen sensitization by SPT, (3) self-reported allergies, (4) symptoms characteristic of rhinitis and (5) symptoms characteristic of asthma. Replication in symptomatic siblings was consistent with shared genetic and/or environmental effects, and was robust across age groups, gender, and centres. Cronbach's alpha ranged from 0.719 to 0.983 suggesting acceptable internal scale consistencies. Derived scales were correlated with serum IgE, methacholine PC(20), age and asthma severity (interrupted sleep). IgE correlated with all three atopy-related factors, the strongest with the SPT factor whereas severity only correlated with baseline lung function, and with symptoms characteristic of rhinitis and of asthma.

CONCLUSION

In children and adolescents with established asthma, five distinct sets of correlated patient characteristics appear to represent important aspects of the disease. Factor scores as quantitative traits may be better phenotypes in epidemiological and genetic analyses than those categories derived from the presence or absence of combinations of +ve SPTs and/or elevated IgE.

Asthma in young south Asian women living in the United Kingdom: the importance of early life

BACKGROUND

Studies of immigrants suggest that the environment during fetal life and duration of residence in the host country might influence the development of asthma. Little is known about the importance of the timing of the exposure in the host country and whether migrants might be especially vulnerable in certain age windows.

OBJECTIVE

We compared the reported prevalence of asthma between young white and south Asian women in the United Kingdom, and investigated associations with country of birth and age at immigration.

METHODS

A questionnaire on atopic disorders was posted to 2380 south Asian and 5796 white young mothers randomly sampled in Leicestershire. Data on ethnicity were also available from maternity records. Data were analysed using multivariable logistic regression and a propensity score approach. Results The reported prevalence of asthma was 10.9% in south Asian and 21.8% in white women. South Asian women who migrated to the United Kingdom aged 5 years or older reported less asthma (6.5%) than those born in the United Kingdom or who migrated before age 5 (16.0%), with an adjusted odds ratio of 0.38 [95% Confidence Interval 0.23-0.64, P<0.001]. For those who migrated aged over 5 years, the prevalence did not alter with the duration of residence in the United Kingdom. Current exposure to common environmental risk factors had relatively little effect on prevalence estimates.

CONCLUSION

These data from a large population-based study support the hypothesis that early life environmental factors influence the risk of adult asthma.

A phase II randomized, double-blind, placebo-controlled trial of clinical activity and safety of Å6 in patients with asymptomatic CA 125 progression of epithelial ovarian, fallopian tube, or primary peritoneal cancer

16014

Background: Patients (pts) with epithelial ovarian cancer (EOC) often relapse and rising CA 125 levels predate clinical or radiological appearance of tumor. High tumor and serum levels of urokinase plasminogen activator (uPA) in EOC correlate to adverse outcomes. Å6 is a novel peptide derived from human uPA that down-regulates the uPA system and has anti-angiogenic and anti-metastatic activity in animals. Methods: Pts with EOC, fallopian tube, or primary peritoneal cancer in clinical remission after first line chemotherapy had to have 2 consecutive rises of CA 125 levels above normal with no disease on physical examination or imaging studies. Pts were randomized to receive daily subcutaneous injections of placebo, 150 mg Å6, or 300 mg Å6 until disease progression. The primary objectives were to assess safety and clinical activity of Å6 by the effect on the onset of disease progression. Results: 48 pts were planned for the study. The trial ended early with 24 patients {12 pts (50%) placebo, 8 pts (33%) low dose Å6, 4 pts (17%) high dose Å6} randomized, treated and followed for up to 9 months. Despite early study termination and small sample size, A6 therapy was associated with a statistically significant progression free survival (PFS) (log rank p value=0.01) with a median PFS of 100 days (95% CI 64,168) compared to 49 days (95% CI 29,67) in pts who received the placebo. The treatments were well tolerated with one serious adverse event (transient nausea and dyspnea ) possibly related to study drug. Treatment was not associated with CA 125 response (Fisher exact test p value= 0.44). Conclusions: Å6 therapy increases PFS of patients with EOC and asymptomatic progression of CA 125. This therapy is novel, safe, feasible and deserves further investigation

[Table: see text]

Association of PTGDR gene polymorphisms with asthma in two Caucasian populations

The prostanoid DP receptor (PTGDR) is shown to be involved in the asthma patho-physiology and the results from the published genetic association studies are inconsistent. Four single nucleotide polymorphisms (SNPs) in PTGDR were genotyped in 342 and 294 families from UK and Denmark respectively. Asthma and asthma-related phenotypes were analyzed using family-based association analyses. In the UK families, a promoter polymorphism (-731A/G) showed significant associations with asthma (P=0.0022), atopic asthma (P=0.0044), bronchial hyperreactivity or BHR (P=0.00120) and strict asthma (P=0.0008). The P-values for asthma, BHR and strict asthma were significant even after the most stringent correction for the number of markers and the number of phenotypes analyzed (<0.0031). An intronic polymorphism (+6651C/T) also showed significant associations with asthma (P=0.0302), atopic asthma (P=0.0131), BHR (P=0.0249) and strict asthma (P=0.0261). In the Danish families, an intronic polymorphism (+6541C/T) showed significant associations with asthma (P=0.0071), atopic asthma (P=0.0348), BHR (P=0.0033) and strict asthma (P=0.0381). The results of haplotype analyses supported the ones of the single SNP analyses. Thus, we demonstrated significant evidence of association between polymorphisms in PTGDR with asthma phenotypes in the two Caucasian populations.

Transmission of Mycobacterium tuberculosis from an infant

SETTING

This report investigates the unusual transmission of Mycobacterium tuberculosis from a 12-week-old infant with nosocomially acquired tuberculosis (TB). Compliance with recommendations on the post-exposure management of young children is described.

DESIGN

Contacts of an infant case of TB were identified and recommended to undergo baseline and post-exposure tuberculin skin tests (TST) as per Canadian TB standards. TST conversion was measured at least 8 weeks post exposure. Children aged <6 years were recommended to initiate preventive treatment with isoniazid (INH) until their post-exposure TST. Information on TST results and adherence to therapy were analysed from existing medical records.

RESULTS

Overall, 17 TST conversions were documented among 732 contacts: both parents, two health care workers (HCWs) who provided close care, and several patients, visitors and one staff member without obvious close contact. Of 65 eligible children, 46% completed post-exposure therapy as recommended. The most common reasons for treatment failure were concern about side effects, perception of low risk and lack of physician support.

CONCLUSION

This investigation suggests that all children, including infants, with cough and numerous bacilli or extensive pulmonary disease should be considered infectious. Health care provider education is necessary to resolve the observed low compliance with current post-exposure management guidelines.

The therapy of pre-school wheeze: appropriate and fair?

The current study aimed to assess prevalence and distribution of use of asthma medication for wheeze in pre-school children in the community. We sent a postal questionnaire to the parents of a random population-based sample of 4,277 UK children aged 1-5 years; 3,410 participated (children of south Asian decent were deliberately over-represented). During the previous 12 months, 18% of the children were reported to have received bronchodilators, 8% inhaled corticosteroids (ICS) and 3% oral corticosteroids. Among current wheezers these proportions were 55%, 25%, and 12%, respectively. Use of ICS increased with reported severity of wheeze, but did not reach 60% even in the most severe category. In contrast, 42% of children receiving ICS reported no or very infrequent recent wheeze. Among children with the episodic viral wheeze phenotype, 17% received ICS compared with 40% among multiple-trigger wheezers. Use of ICS by current wheezers was less common in children of South Asian ethnicity and in girls. Although a high proportion of pre-school children in the community used asthma inhalers, treatment seemed to be insufficiently adjusted to severity or phenotype of wheeze, with relative under-treatment of severe wheeze with ICS, especially in girls and South Asian children, but apparent over-treatment of mild and episodic viral wheeze and chronic cough.

Parental understanding of wheeze and its impact on asthma prevalence estimates

The epidemiology of wheeze in children, when assessed by questionnaires, is dependent on parents' understanding of the term "wheeze". In a questionnaire survey of a random population sample of 4,236 children aged 6-10 yrs, parents' definition of wheeze was assessed. Predictors of a correct definition were determined and the potential impact of incorrect answers on prevalence estimates from the survey was assessed. Current wheeze was reported by 13.2% of children. Overall, 83.5% of parents correctly identified "whistling or squeaking" as the definition of wheeze; the proportion was higher for parents reporting wheezy children (90.4%). Frequent attacks of reported wheeze (adjusted odds ratio (OR) 3.0), maternal history of asthma (OR 1.5) and maternal education (OR 1.5) were significantly associated with a correct answer, while the converse was found for South Asian ethnicity (OR 0.6), first language not English (OR 0.6) and living in a deprived neighbourhood (OR 0.6). In summary, the present study showed that misunderstanding could lead to an important bias in assessing the prevalence of wheeze, resulting in an underestimation in children from South Asian and deprived family backgrounds. Prevalence estimates for the most severe categories of wheeze might be less affected by this bias and questionnaire surveys on wheeze should incorporate measures of parents' understanding of the term wheeze.

A phase II, multi-center study of a new non-cytotoxic A3 adenosine receptor agonist CF101, dose-finding (randomized blinded) in patients (pts) with refractory metastatic colorectal cancer

13082

Background: The A3 adenosine Gi protein-coupled receptor is highly expressed in malignant compared to normal cells. Activating the A3 adenosine receptor (A3AR) with the highly selective non-cytotoxic agonist, CF101 (IB-MECA), inhibit of colon, prostate, melanoma, pancreatic and hepatocellular cancer growth in experimental animal models, via down-regulation of the Wnt and NF-κB signal transduction pathways. Oral CF101 has been shown to inhibit colon, prostate, melanoma, pancreatic and hepatocellular cancer growth in experimental animal models. Methods: A phase II dose-finding, randomized, blinded study of oral CF101 (0.1, 1& 4 mg PO BID), was conducted to define activity and safety in heavily pre-treated metastatic colorectal cancer pts. From 6/1/2003–7/4/2004, 70 pts, median age 62 with measurable colorectal cancer, PS ≤2 were enrolled, 21 pts progressed after irinotecan and 49 pts after both irinotecan and oxaliplatin-based regimens. Results: The median time on treatment was 10.3 weeks. No objective response was observed; however, SD for 8 wks duration was achieved in 24 pts (34%), for 16 weeks in 8 pts (11%) and 2 pts were treated for more than 24 weeks. The median time to treatment progression was 72 days and for overall survival was 254 days without any significant difference among the 3 trial doses [8 survivors till today]. There were no obvious treatment related serious adverse events. Conclusions: The final results of the study show that CF101 is well tolerated and may stabilize disease for at least 2 months in 35% of the pts. The median survival time (8 months) compared with other targeted therapy investigated lately is encouraging. Combining CF101 with chemotherapy may be beneficial in the treatment of metastatic colorectal cancer.

No significant financial relationships to disclose.

Multi-dimensional phenotyping: towards a new taxonomy for airway disease

All the real knowledge which we possess, depends on methods by which we distinguish the similar from the dissimilar. The greater the number of natural distinctions this method comprehends the clearer becomes our idea of things. The more numerous the objects which employ our attention the more difficult it becomes to form such a method and the more necessary. Classification is a fundamental part of medicine. Diseases are often categorized according to pre-20th century descriptions and concepts of disease based on symptoms, signs and functional abnormalities rather than on underlying pathogenesis. Where the aetiology of disease has been revealed (for example in the infectious diseases) a more precise classification has become possible, but in the chronic inflammatory diseases, and in the inflammatory airway diseases in particular, where pathogenesis has been stubbornly difficult to elucidate, we still use broad descriptive terms such as asthma and chronic obstructive pulmonary disease, which defy precise definition because they encompass a wide spectrum of presentations and physiological and cellular abnormalities. It is our contention that these broad-brush terms have outlived their usefulness and that we should be looking to create a new taxonomy of airway disease-a taxonomy that more closely reflects the spectrum of phenotypes that are encompassed within the term airway inflammatory diseases, and that gives full recognition to late 20th and 21st century insights into the disordered physiology and cell biology that characterizes these conditions in the expectation that these will map more closely to both aetiology and response to treatment. Development of this taxonomy will require a much more complete and sophisticated correlation of the many variables that make up a condition than has been usual to employ in an approach that encompasses multi-dimensional phenotyping and uses complex statistical tools such as cluster analysis.

Locally generated particulate pollution and respiratory symptoms in young children

BACKGROUND

Particulate matter <10 mum (PM(10)) from fossil fuel combustion is associated with an increased prevalence of respiratory symptoms in children and adolescents. However, the effect of PM(10) on respiratory symptoms in young children is unclear.

METHODS

The association between primary PM(10) (particles directly emitted from local sources) and the prevalence and incidence of respiratory symptoms was studied in a random sample cohort of 4400 Leicestershire children aged 1-5 years surveyed in 1998 and again in 2001. Annual exposure to primary PM(10) was calculated for the home address using the Airviro dispersion model and adjusted odds ratios (ORS) and 95% confidence intervals were calculated for each microg/m(3) increase.

RESULTS

Exposure to primary PM(10) was associated with the prevalence of cough without a cold in both 1998 and 2001, with adjusted ORs of 1.21 (1.07 to 1.38) and 1.56 (1.32 to 1.84) respectively. For night time cough the ORs were 1.06 (0.94 to 1.19) and 1.25 (1.06 to 1.47), and for current wheeze 0.99 (0.88 to 1.12) and 1.28 (1.04 to 1.58), respectively. There was also an association between primary PM(10) and new onset symptoms. The ORs for incident symptoms were 1.62 (1.31 to 2.00) for cough without a cold and 1.42 (1.02 to 1.97) for wheeze.

CONCLUSION

In young children there was a consistent association between locally generated primary PM(10) and the prevalence and incidence of cough without a cold and the incidence of wheeze which was independent of potential confounders.