PLS3 missense variants affecting the actin-binding domains cause X-linked congenital diaphragmatic hernia and body-wall defects

Congenital diaphragmatic hernia (CDH) is a relatively common and genetically heterogeneous structural birth defect associated with high mortality and morbidity. We describe eight unrelated families with an X-linked condition characterized by diaphragm defects, variable anterior body-wall anomalies, and/or facial dysmorphism. Using linkage analysis and exome or genome sequencing, we found that missense variants in plastin 3 (PLS3), a gene encoding an actin bundling protein, co-segregate with disease in all families. Loss-of-function variants in PLS3 have been previously associated with X-linked osteoporosis (MIM: 300910), so we used in silico protein modeling and a mouse model to address these seemingly disparate clinical phenotypes. The missense variants in individuals with CDH are located within the actin-binding domains of the protein but are not predicted to affect protein structure, whereas the variants in individuals with osteoporosis are predicted to result in loss of function. A mouse knockin model of a variant identified in one of the CDH-affected families, c.1497G>C (p.Trp499Cys), shows partial perinatal lethality and recapitulates the key findings of the human phenotype, including diaphragm and abdominal-wall defects. Both the mouse model and one adult human male with a CDH-associated PLS3 variant were observed to have increased rather than decreased bone mineral density. Together, these clinical and functional data in humans and mice reveal that specific missense variants affecting the actin-binding domains of PLS3 might have a gain-of-function effect and cause a Mendelian congenital disorder.

Application of multi-criteria decision analysis techniques and decision support framework for informing plant select agent designation and decision making

The United States Department of Agriculture (USDA) Division of Agricultural Select Agents and Toxins (DASAT) established a list of biological agents (Select Agents List) that threaten crops of economic importance to the United States and regulates the procedures governing containment, incident response, and the security of entities working with them. Every 2 years the USDA DASAT reviews their select agent list, utilizing assessments by subject matter experts (SMEs) to rank the agents. We explored the applicability of multi-criteria decision analysis (MCDA) techniques and a decision support framework (DSF) to support the USDA DASAT biennial review process. The evaluation includes both current and non-select agents to provide a robust assessment. We initially conducted a literature review of 16 pathogens against 9 criteria for assessing plant health and bioterrorism risk and documented the findings to support this analysis. Technical review of published data and associated scoring recommendations by pathogen-specific SMEs was found to be critical for ensuring accuracy. Scoring criteria were adopted to ensure consistency. The MCDA supported the expectation that select agents would rank high on the relative risk scale when considering the agricultural consequences of a bioterrorism attack; however, application of analytical thresholds as a basis for designating select agents led to some exceptions to current designations. A second analytical approach used agent-specific data to designate key criteria in a DSF logic tree format to identify pathogens of low concern that can be ruled out for further consideration as select agents. Both the MCDA and DSF approaches arrived at similar conclusions, suggesting the value of employing the two analytical approaches to add robustness for decision making.

The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial

BACKGROUND

Permanent supportive housing (PSH)-subsidized housing paired with support services such as case management-is a key part of national strategic plans to end homelessness. PSH tenants face high overdose risk due to a confluence of individual and environmental risk factors, yet little research has examined overdose prevention in PSH.

METHODS

We describe the protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial (RCT) of overdose prevention practice implementation in PSH. We adapted evidence-based overdose prevention practices and implementation strategies for PSH using input from stakeholder focus groups. The trial will include 20 PSH buildings (with building size ranging from 20 to over 150 tenants) across New York City and New York's Capital Region. Buildings will be randomized to one of four 6-month intervention waves during which they will receive a package of implementation support including training in using a PSH Overdose Prevention (POP) Toolkit, time-limited practice facilitation, and learning collaboratives delivered to staff and tenant implementation champions appointed by each building. The primary outcome is building-level fidelity to a defined list of overdose prevention practices. Secondary and exploratory implementation and effectiveness outcomes will be examined using PSH staff and tenant survey questionnaires, and analysis of tenant Medicaid data. We will explore factors related to implementation success, including barriers and facilitators, using qualitative interviews with key stakeholders. The project is being conducted through an academic-community partnership, and an Advisory Board including PSH tenants and other key stakeholders will be engaged in all stages of the project.

DISCUSSION

We describe the protocol for a hybrid type 3 stepped-wedge cluster RCT of overdose prevention practice implementation in PSH. This study will be the first controlled trial of overdose prevention implementation in PSH settings. The research will make a significant impact by testing and informing future implementation strategies to prevent overdose for a population at particularly high risk for overdose mortality. Findings from this PSH-focused research are expected to be broadly applicable to other housing settings and settings serving people experiencing homelessness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05786222 , registered 27 March 2023.

Application of multi-criteria decision analysis techniques and decision support framework for informing select agent designation for agricultural animal pathogens

The United States Department of Agriculture (USDA), Division of Agricultural Select Agents and Toxins (DASAT) established a list of biological agents and toxins (Select Agent List) that potentially threaten agricultural health and safety, the procedures governing the transfer of those agents, and training requirements for entities working with them. Every 2 years the USDA DASAT reviews the Select Agent List, using subject matter experts (SMEs) to perform an assessment and rank the agents. To assist the USDA DASAT biennial review process, we explored the applicability of multi-criteria decision analysis (MCDA) techniques and a Decision Support Framework (DSF) in a logic tree format to identify pathogens for consideration as select agents, applying the approach broadly to include non-select agents to evaluate its robustness and generality. We conducted a literature review of 41 pathogens against 21 criteria for assessing agricultural threat, economic impact, and bioterrorism risk and documented the findings to support this assessment. The most prominent data gaps were those for aerosol stability and animal infectious dose by inhalation and ingestion routes. Technical review of published data and associated scoring recommendations by pathogen-specific SMEs was found to be critical for accuracy, particularly for pathogens with very few known cases, or where proxy data (e.g., from animal models or similar organisms) were used to address data gaps. The MCDA analysis supported the intuitive sense that select agents should rank high on the relative risk scale when considering agricultural health consequences of a bioterrorism attack. However, comparing select agents with non-select agents indicated that there was not a clean break in scores to suggest thresholds for designating select agents, requiring subject matter expertise collectively to establish which analytical results were in good agreement to support the intended purpose in designating select agents. The DSF utilized a logic tree approach to identify pathogens that are of sufficiently low concern that they can be ruled out from consideration as a select agent. In contrast to the MCDA approach, the DSF rules out a pathogen if it fails to meet even one criteria threshold. Both the MCDA and DSF approaches arrived at similar conclusions, suggesting the value of employing the two analytical approaches to add robustness for decision making.

A strategy for detecting an anomalous batch of kappa serum free light chains measurements using nonparametric analysis of patient deltas

Patient-based quality control (PBQC) involves monitoring for shifts in patient results to detect analytical problems. Established methods perform well, but only for assays with high volumes and approximately normal result distributions. Recent publications have described monitoring the average of patient deltas (AOD) as a way generalize PBQC methods more broadly. Here we propose a nonparametric analysis of patient deltas (NPAOD). To illustrate the concept we present a case of an analytical issue in the kappa serum free light chain assay (kappa sFLC) caused by a bad reagent pack and how it could have been detected using NPAOD. We were alerted to a possible issue by the ordering clinicians who noticed a series of unexpectedly high results. Significantly lower values were observed when the samples were repeated with a new reagent pack (median [IQR]: 5.3 [3.12-13.52] versus 2.52 [0.95-4.25], p < 0.5 e-7 by paired Wilcoxon test). To evaluate the use of PBQC in detecting this error, we analyzed one year of retrospective data comprising 7657 results from 3061 patients. The distribution of kappa sFLC values was positively skewed (mean = 14.5 g/dL, median = 2.2 g/dL, skew = 26.6). Both volumes and distributions varied significantly by day of the week following the scheduling of subspecialty clinics. These properties make the conventional approach of simple moving averages poorly suited for monitoring kappa sFLC at our institution. We computed delta values as the difference between the current result and the most recent previous result and produced delta values for 4596/7657 (60%) of the samples. The distribution of deltas was zero centered and symmetric (mean = 0.03 g/dL, median = 0.01 g/dL). Using the historical distribution as a reference, we found that the average of deltas was not significantly different for the results of the bad reagent pack (p = 0.78 by Student’s T test). In contrast, a nonparametric approach yielded a significant difference whether by comparison of medians using a Wilcoxon test (p = 0.0004) or comparison of empirical distributions using a Kolmogorov-Smirnov test (p = 1e-7). The latter approach may offer several benefits. First, the Komogorov-Smirnov test has greater statistical power because it considers both the position and the shape of the distribution. Second, an algorithm based on comparison of empirical distributions may have fewer hyperparameters to tune. We continue this work with an in-silico characterization of detection and false alarm rates at different magnitudes of analytical bias. In conclusion, this case study provides initial evidence that a nonparametric analysis of patient deltas may help to extend PBQC to additional assays that have unfavorable distributions and volumes for the simple moving average algorithm.

Clinical Utility of Next-Generation Sequencing Panel Testing in the Evaluation of Arteriovenous Malformations

Arteriovenous malformations (AVMs) are vascular lesions in which an overgrowth of blood vessels of varying sizes develops with one or more direct connections between the arterial and venous circulation. AVMs are seen in sporadic and syndromic conditions that are caused by a variety of genomic alterations. Here, we performed a retrospective review of the cases sent for next-generation sequencing (NGS) analysis for diseases of somatic mosaicism (DoSM). Specimens from 54 patients with clinical indication of AVMs were submitted for the DoSM NGS panel between October 2013 and Dec 2021. DNA extraction and sequence analysis were performed on affected tissues, including fresh tissue, formalin-fixed paraffin-embedded tissue, fibroblast cultures, and buccal specimens. Single-nucleotide variants (SNVs) with variant allele fractions (VAFs) greater than 3% and small insertions and deletions (indels, <21 bp) were called using VarScan2, Genome Analysis Toolkit (GATK), and Pindel. Variants with VAFs between 1-3% were manually reviewed based on the sequencing data quality and the known clinical significance. 38/54 (69.1%) patients were females and 16/54 (30.9%) were males. Ages ranged from 1 month to 73 years (median age 17 years). Most of the patients were indicated with sporadic AVM (81%), although additional clinical indications were noticed, including unspecified congenital vascular malformation (9.1%), capillary malformation (5.5%), arteriovenous fistula, and AVM associated with capillary and lymphatic malformations (1.8% each). The biopsied lesion was most often located in the head (43.6%), followed by the limbs (30.9%), and unspecified areas of the body in the remaining 25.5%. Among the 54 cases, 37 (68.5%) cases had pathogenic and/or likely pathogenic (P/LP) variants identified, 2 cases (3.7%) had variants of unknown significance, and the remaining 15 cases (27.8%) had negative results. MAP2K1 variants were found in 12 samples, followed by KRAS (8), TEK (7), PTEN (5), BRAF (4), TSC2 (2), HRAS (2), RASA1 (2), and PDGFRB (1). Of note, four cases had two P/LP variants. Among the 37 positive cases, 32 cases had somatic alterations; the remaining 5 cases had at least one germline P/LP variant, including PTEN (4) and RASA1 (1). In summary, the diagnostic yield of cases with clinical indication of AVMs was 68.5% using our in-house DoSM NGS panel. This study demonstrates the clinical utility of the DoSM NGS panel testing in the evaluation of a cohort with clinical presentations of AVMs.

HLA-B evolutionary divergence is associated with poor outcomes after SARS-CoV-2 infection

Objectives

Human leukocyte antigens (HLA) are highly diverse transmembrane proteins that present viral peptides to T cells and launch pathogen-specific immune responses. We aim to investigate the correlation between HLA evolutionary divergence (HED), a surrogate for the capacity to present different peptides, and the outcomes of SARS-CoV-2 infection in a cohort from the St. Louis Metropolitan area.

Methods

We enrolled adult patients with SARS-CoV-2 infection confirmed by RT-PCR who were hospitalized at two tertiary hospitals in St. Louis between March and July 2020. Genomic DNA was extracted from peripheral blood and genotyped by next-generation sequencing (NGS). HLA alleles were assigned based on key-exon sequences (G group) and limited to the 2-field resolution. HED was calculated by Grantham distance, which considers the difference in composition, polarity, and molecular volume between each pair of amino acids from maternal and paternal HLA. The HED score was obtained for HLA class I (HLA-A, -B, and -C) genotypes using the HLAdivR package in R. Clinical data were collected retrospectively from electronic medical records. A poor outcome was defined as an admission to the intensive care unit (ICU), a need for mechanical ventilation, or death. A favorable outcome was defined as the absence of the above poor outcomes.

Results

A total of 234 patients were enrolled in this study, 96 being females (41%). The median age and BMI were 66 years old and 28.30 kg/m2, respectively. African Americans comprised 71.4% of the cohort. Only 19 patients (8.1%) presented with no comorbidity; the rest had one or more comorbidities, with cardiovascular diseases being the most common. A total of 137 (58.5%) patients had poor outcomes from SARS-CoV-2 infection, while 97 (41.5%) patients had a favorable outcome. We detected a significant association between higher HLA-B HED and favorable outcomes, with each 1-point increase in HLA-B HED associated with 8% increased probability for the composite endpoint (OR 1.08, 95% CI=1.01-1.16, P = 0.04). The HED scores calculated for HLA-A or HLA-C were not significantly different between patients with favorable or poor outcomes. In a multivariate logistic regression analysis, increased HLA-B HED score, younger age, and no comorbidity were independently associated with favorable outcomes (P = 0.02, P = 0.01, and P = 0.05, respectively).

Conclusion

Our study shows a significant correlation between lower HLA-B HED scores and poor outcomes after SARS-CoV-2 infection. This finding suggests that maximizing the presentation of diverse SARS-CoV-2 peptides by HLA-B alleles may improve the clearance of SARS-CoV-2. Further studies are warranted to understand the functional and mechanistic implications of this finding.

Evaluation of Ordering Practices, Microbial Yield, and Clinical Utility of Urinary Stone Cultures

Urinary stones are a global problem. While it has been established that microorganisms can be associated with urinary stone formation, data on best practices for microbial culture and clinical interpretation of microbial culture of urinary stone specimens are limited. Our objective was to investigate the microorganisms present in urinary stone cultures (usc) and companion urine cultures. We conducted a retrospective study at a tertiry hospital examining cultures submitted between October 2018 and October 2021. We collected data from electronic medical records of patients who had at least at least one usc performed. As part of routine clinical workup, all urinary stone specimens submitted for culture were ground using a disposable tissue grinder and inoculated on a tryptic soy agar with 5% sheep blood agar plate (BAP), a chocolate agar plate (CHOC), and a MacConkey agar plate (MAC), streaked for isolation and incubated in 5% CO2 at 35°C for up to three days. Urine cultures were performed using the Kiestra TLA system with 10 µL of inoculum onto each of a BAP and MAC, and plates were examined at 16 and 24 hours of incubation. For urine specimens submitted from a straight or “in and out” catheter, 10,000 CFU/mL was the threshold for workup. From clean-voided, midstream, ileostomy, nephrostomy, or indwelling/Foley catheter specimens, 100,000 CFU/mL was the threshold for workup. The final clinical significance of cultures is determined by evaluating the culture result in light of the patient’s clinical presentation. For usc and urine cultures, clinically insignificant growth was considered no growth or when no pathogens were recovered in culture. Urine cultures with more than 3 species over threshold were considered contaminated. A total of 1,049 usc were performed from 854 patients (55.3% female). The median patient age was 61 years (IQR 49-70). The most frequent microorganisms reported in usc cultures were Proteus mirabilis (N=98), Enterococcus faecalis (N=75), and Escherichia coli (N=73). No pathogen was identified from 57% of usc. 441 usc were performed in a context of urine culture (+/-2 days) in 336 (39.3%) patients. In addition, 138 patients (16.1%) had more than 1 usc, being the maximum as 11 usc performed in one patient. The most common urine/USC concordant result was no growth in 165 of 441 cultures (37.4%), followed by coagulase negative Staphylococcus. Cohen’s kappa obtained from usc and urine culture results was 0.45, which is not the minimum acceptable agreement. A pathogen was identified from usc in 43% of cases. Usc and urine cultures rarely resulted in concordant results, but the most common concordant result was no growth in culture. Additional studies are warranted to evaluate the impact of usc results on patient care, including antimicrobial use and correlation of microbes isolated with stone chemical composition.

Global and regional left ventricular deformation evaluation with feature tracking in transthyretin cardiac amyloidosis. Comparison with echocardiographic findings

Background

Diagnosis of cardiac amyloidosis (CA) is basically based on imaging techniques. Transthoracic echocardiography (TTE) is crucial to raise suspicion of this disease through detection of the classical features. An specific left ventricular (LV) deformation pattern with apical sparing (“cherry on top”) has been described on speckle tracking (ST) TTE. However, there is no data regarding the role of the LV global and regional analysis with the new tool feature tracking (FT) of cardiac magnetic resonance (CMR) in CA.

Purpose

Our aim is to analyze the concordance of LV deformation between ST-TTE and FT-CMR.

Methods

Consecutive patients with definitive diagnosis of transthyretin (TTR) CA, based on DPD scintigraphy, and imaging evaluation with TTE and CMR were retrospectively included. LV volumes and ejection were calculated from both TTE and CMR following the ongoing recommendations. Global and segmental longitudinal strain values were obtained from apical 2-, 3- and 4-chambers projections on TTE, while the same parameters were calculated on the same cine views of CMR using a dedicated software of FT analysis. Student t-test was used to compared mean measurements derived from both imaging techniques. Apical index was calculated as the ratio between apical and basal-mid longitudinal values. Moreover, agreement was established using Passing-Bablok regression analysis.

Results

27 patients (80 years-old, 88% men) with definitive diagnosis of TTR CA from our tertiary hospital were included. Regarding echocardiographic findings, 80% showed concentric LV hypertrophy with low normal ejection fraction in the majority (52±10%). When longitudinal LV strain parameters were compared (Table 1), no differences were noted in global and apical values whereas basal and mid measurements were higher from CRM resulting in different apical indexes. Although 42% showed a typical “cherry on top” pattern in ST analysis, in only 18% of the FT apical sparing was detected. Consistently, decremental pattern was observed in 60% of TTE and in 20% of CMR. Concordance analysis with Passing-Bablok showed no constant or proportional differences, meaning both techniques were comparable.

Conclusions

Among patients with TTR CA there were no differences in global longitudinal LV strain analysis between ST-TTE and FT-CMR. Nevertheless, discordance in regional parameters resulted in a less frequent detection of apical sparing in CMR.

Funding Acknowledgement

Type of funding sources: None.

P-341 The effect of endometriosis on implantation success after single embryo transfer of a high-quality euploid blastocyst

Study question

Does endometriosis limit the embryo competence to implant in patients undergoing transfer of a single high-quality euploid blastocyst?

Summary answer

Although implantation competence of euploid blastocysts after deferred single-embryo transfers (SET) decreases in endometriosis patients, the effect is not observed when high-quality embryos are transferred.

What is known already

Endometriosis, a frequent gynecological disease, is often associated with female infertility and worse IVF clinical outcomes. Multiple factors may be involved in the subfertility of those patients. Although both defective embryo and altered endometrial receptivity may compromise implantation, evidences suggest a major role of embryo in the endometriosis impaired reproductive outcomes. However, few studies examine implantation after transfer of high-quality euploid embryos. Two studies on this issue suggested that endometriosis does not impact on pregnancy rates but either the embryo morphology was not considered, or a small sample size was used even including transfers with more than one single embryo.

Study design, size, duration

Retrospective multicenter cohort study on the competence of euploid embryos from patients with endometriosis (n = 277) compared with disease-free control women (n = 4677). Implantation and other clinical outcomes (positive pregnancy test, live birth: LB, miscarriages) were examined after SET to ascertain the effect of endometriosis on embryo competence. Results were firstly analyzed in single transferred embryos with any morphological graduation but also when only single high-quality blastocyst (A+B according ASEBIR embryo grading) were transferred.

Participants/materials, setting, methods

Our study involved women aged 18-42 years old undergoing IVF after preimplantation genetic testing for aneuploidies (PGT-A) in IVIRMA Clinics between 2012 and 2019. Severe male factors and patients with altered karyotype or chromosomopathies in previous embryos or pregnancies were excluded. Presence of endometriosis was revealed at the time of surgery or after pelvic ultrasound or NMR. Chi-square test for categorical variables or Student’s-test for quantitative variables were used to assess the statistical significance (P < 0.05).

Main results and the role of chance

A total of 394 euploid blastocyst from endometriosis patients were included in the analysis while 6581 belonged to the control group. Up to 91.5 % were transferred after vitrification-warming in a deferred cycle (338 and 6043 in endometriosis and control groups) while the rest were transferred in the same cycle of embryo biopsy or even the oocyte retrieval. Among the frozen-transferred blastocysts, 76.85% and 74.93% from endometriosis and control women were high-quality embryos on the day of transfer (p = 0.51). Data showed slight but not significant differences in the positive pregnancy test (57.76% vs. 61.37%) and implantation outcomes (49.11% vs. 53.74%) between endometriosis and control group when both frozen and fresh SET were considered. Focusing on deferred SET of euploid blastocysts with any ASEBIR grade, both the proportion of positive test (56.08% vs. 61.82%; p = 0.04) and implanted blastocyst (47.77% vs. 54.34%, p = 0.02) were significantly lower in endometriosis than in the control group. However, they did result in similar amounts of LB (39.14% vs. 43.39%; p = 0.15). Moreover, when the top-quality embryos were examined, none of the clinical outcomes after deferred SET of euploid blastocysts where significantly different between endometriosis and control group (implantation: 50.88% vs. 57.43%; LB: 41.55% vs. 45.60%; p > 0.05).

Limitations, reasons for caution

Results should be interpreted with caution due to the retrospective nature of the study. Although groups were as homogeneous as possible, multivariate regression models to avoid confounding factors are still pending. Reproductive outcomes only after fresh SET or considering to the severity of the disease have not been evaluated yet.

Wider implications of the findings

Although further research is required to surely state no association between endometriosis and embryo reproductive competence, our results suggest a similar pregnancy prognosis in women with or without endometriosis when a high-quality euploid blastocyst is available for transfer. Future prospective studies should take into consideration the quality of the embryo.

Trial registration number

Not applicable

Application of Multi-Criteria Decision Analysis Techniques for Informing Select Agent Designation and Decision Making

The Centers for Disease Control and Prevention (CDC) Select Agent Program establishes a list of biological agents and toxins that potentially threaten public health and safety, the procedures governing the possession, utilization, and transfer of those agents, and training requirements for entities working with them. Every 2 years the Program reviews the select agent list, utilizing subject matter expert (SME) assessments to rank the agents. In this study, we explore the applicability of multi-criteria decision analysis (MCDA) techniques and logic tree analysis to support the CDC Select Agent Program biennial review process, applying the approach broadly to include non-select agents to evaluate its generality. We conducted a literature search for over 70 pathogens against 15 criteria for assessing public health and bioterrorism risk and documented the findings for archiving. The most prominent data gaps were found for aerosol stability and human infectious dose by inhalation and ingestion routes. Technical review of published data and associated scoring recommendations by pathogen-specific SMEs was found to be critical for accuracy, particularly for pathogens with very few known cases, or where proxy data (e.g., from animal models or similar organisms) were used to address data gaps. Analysis of results obtained from a two-dimensional plot of weighted scores for difficulty of attack (i.e., exposure and production criteria) vs. consequences of an attack (i.e., consequence and mitigation criteria) provided greater fidelity for understanding agent placement compared to a 1-to-n ranking and was used to define a region in the upper right-hand quadrant for identifying pathogens for consideration as select agents. A sensitivity analysis varied the numerical weights attributed to various properties of the pathogens to identify potential quantitative (x and y) thresholds for classifying select agents. The results indicate while there is some clustering of agent scores to suggest thresholds, there are still pathogens that score close to any threshold, suggesting that thresholding “by eye” may not be sufficient. The sensitivity analysis indicates quantitative thresholds are plausible, and there is good agreement of the analytical results with select agent designations. A second analytical approach that applied the data using a logic tree format to rule out pathogens for consideration as select agents arrived at similar conclusions.

Buntanetap, a Novel Translational Inhibitor of Multiple Neurotoxic Proteins, Proves to Be Safe and Promising in Both Alzheimer's and Parkinson's Patients

BACKGROUND

Previously we reported the clinical safety and pharmacological activity of buntanetap (known as Posiphen or ANVS401) in healthy volunteers and mild cognitive impaired (MCI) patients (21). The data supported continued clinical evaluation of buntanetap for treating Alzheimer's Disease (AD). Neurodegenerative diseases such as AD and Parkinson's disease (PD) share several pathological manifestations, including increased levels of multiple neurotoxic protein aggregates. Therefore, a treatment strategy that targets toxic species common to both disorders can potentially provide better clinical outcomes than attacking one neurotoxic protein alone. To test this hypothesis, we recently completed a clinical study in early AD and early PD participants and report the data here.

OBJECTIVES

We evaluated safety, pharmacokinetics, biomarkers, and efficacy of buntanetap in treating early AD and PD patients.

DESIGN

Double-blind, placebo-controlled, multi-center study.

SETTING

13 sites in the US participated in this clinical trial. The registration number is NCT04524351 at ClinicalTrials.gov.

PARTICIPANTS

14 early AD patients and 54 early PD patients.

INTERVENTION

AD patients were given either 80mg buntanetap or placebo QD. PD patients were given 5mg, 10mg, 20mg, 40mg, 80mg buntanetap or placebo QD.

MEASUREMENTS

Primary endpoint is safety and tolerability; secondary endpoint is pharmacokinetics of buntanetap in plasma; exploratory endpoints are 1) biomarkers in cerebrospinal fluid (CSF) in both AD and PD patients 2) psychometric tests specific for AD (ADAS-Cogs and WAIS coding test) or PD (MDS-UPDRS and WAIS coding test).

RESULTS

Buntanetap was safe and well tolerated. Biomarker data indicated a trend in lowering levels of neurotoxic proteins and inflammatory factors and improving axonal integrity and synaptic function in both AD and PD cohorts. Psychometric tests showed statistically significant improvements in ADAS-Cog11 and WAIS coding in AD patients and MDS-UPDRS and WAIS coding in PD patients.

CONCLUSIONS

Buntanetap is well tolerated and safe at doses up to 80mg QD in both AD and PD patients. Cmax and AUC increase with dose without evidence for a plateau up to 80mg QD. The drug shows promising evidence in exploratory biomarker and efficacy measures. Further evaluation of buntanetap in larger, longer-term clinical trials for the treatment of AD and PD are warranted.

Site Readiness Framework to Improve Health System Preparedness for a Potential New Alzheimer’s Disease Treatment Paradigm

New therapies that address the underlying pathophysiology of Alzheimer’s Disease (AD), coupled with the growth of the AD population, will transform the AD care pathway and present significant challenges to health systems. We explored real-world challenges health systems may face in delivering potential new AD therapies with diverse stakeholders. Key challenges in care included integrating primary care providers into assessment and management, availability of memory care specialists, understanding payment and coverage issues and training mid-level providers to help coordinate care and serve as a shared resource across the system. This input informed a novel Site Readiness Framework for AD, comprising self-assessment exercises to identify health system capabilities and gaps and a framework of core strategies and responsive tools to help prepare to integrate new AD therapies. These resources may help health systems improve readiness to modify care pathways to integrate new therapies for AD.

Correlation between cardiac magnetic resonance feature tracking derived left ventricular strain and morphological characteristics of non-ischemic dilated cardiomyopathy at baseline and follow-up

Background

Left ventricular (LV) strain from echocardiography is a known useful predictor of LVEF recovery in non-ischemic dilated cardiomyopathy (NIDCM). More recently, feature tracking (FT) has allowed LV myocardial deformation analysis using conventional cardiac magnetic resonance (CMR) cine sequences.

Purpose

Our aim is to establish the correlation between LV strain values from CMR-FT at diagnosis and morphological parameters at baseline and during follow-up.

Methods

Consecutive patients with NIDCM who underwent CMR were retrospectively collected. All the studies were performed in a 1.5 Tesla magnet following a standard acquisition protocol of conventional SSFP cine sequences in long and short axis. Global longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively) were obtained with a dedicated FT software. Correlation with CMR morphological parameters at baseline were evaluated. Likewise, in the cases with follow-up echocardiogram association between FT LV strain and evolution of morphofunctional variables was explored.

Results

CMR-FT strain analysis was performed in 98 patients (age 68±13 years, 72% males) with NIDCM. They showed severe LV dilatation (LVEDVi= 133.6±33.4 mL/m2) and systolic dysfunction (LVEF= 29.5±9.6%) at baseline. Myocardial fibrosis was detected in 38.8% of the patients with late gadolium enhancement (LGE) sequence. All the basal CMR morphological characteristics were significantly correlated with FT strain analysis (Table), even more markedly for GCS. However, there was no association of baseline morphofunctional parameters with LGE. An echocardiogram was performed in 85.7% of the patients during the follow-up (2.4 [1.8–3.4] years), with an LVEF >50% in the 25.5% of the cases. These patients with preserved LVEF in the evolution showed better GCS (−9 vs −7.1%; p=0.019) at baseline, with no differences in the other FT LV strain parameters. Despite less fibrosis in LGE (16.1% vs 37.7%; p=0.037), none of the baseline morphofunctional CMR parameters (LVEF, LVEDVi...) were associated with systolic function restoration. In multivariate analysis, GCS was the only independent predictor (OR 1.16; p=0.045) of LVEF recovery among imaging variables.

Conclusions

All the FT derived LV strain values were correlated with the degree of basal morphofunctional involvement in NIDCM. Furthermore, GCS emerged as an independent imaging predictor of LV systolic function restoration in our series.

Funding Acknowledgement

Type of funding sources: None. Table 1. Correlation between myocardial deformation values by feature tracking and morphofunctional variables in basal CMR.

Positive Airway Pressure for the Treatment of OSA in Infants

BACKGROUND

Positive airway pressure (PAP) is a standard therapy for the treatment of OSA in children, but objective data on the effectiveness of PAP in infants are sparse. The aim of this study was to compare the effectiveness of PAP in infants younger than 6 months of age with that in school-aged children.

RESEARCH QUESTION

Compared with PAP in school-aged children, can PAP be titrated as successfully in infants, and is adherence to PAP similar in both age groups?

STUDY DESIGN AND METHODS

Single-center retrospective study. For consecutive infants younger than 6 months of age and school-aged children 5 to 10 years of age with OSA treated with PAP, baseline and titration polysomnography data, PAP adherence data, and parent-reported barriers to adherence were compared between groups.

RESULTS

Forty-one infants and 109 school-aged children were included. Median obstructive apnea hypopnea index (OAHI) in infants was 25.7/h (interquartile range [IQR], 17.8-35.9/h) and was greater than that in school-aged children (12.1/hr; IQR, 7.6-21.5/h; P < .0001). After PAP titration, OAHI was reduced by a median of 92.1% in infants, similar to the median 93.4% reduction in school-aged children (P = .67). PAP was used in infants on 94.7% of nights, which was more than the 83% in school-aged children (P = .003). No differences were found in barriers to adherence between infants and school-aged children, with behavioral barriers being most common in both groups.

INTERPRETATION

Objective data demonstrate that PAP is both highly effective at treating OSA and well-tolerated in infants. Like older patients, PAP should be considered along with other therapies for the treatment of OSA in even the youngest children.

Quantitative bone imaging biomarkers to diagnose temporomandibular joint osteoarthritis

Bone degradation of the condylar surface is seen in temporomandibular joint osteoarthritis (TMJ OA); however, the initial changes occur in the subchondral bone. This cross-sectional study was performed to evaluate 23 subchondral bone imaging biomarkers for TMJ OA. The sample consisted of high-resolution cone beam computed tomography scans of 84 subjects, divided into two groups: TMJ OA (45 patients with TMJ OA) and control (39 asymptomatic subjects). Six regions of each mandibular condyle scan were extracted for computation of five bone morphometric and 18 grey-level texture-based variables. The groups were compared using the Mann-Whitney U-test, and the receiver operating characteristics (ROC) curve was determined for each variable that showed a statically significance difference. The results showed statistically significant differences in the subchondral bone microstructure in the lateral and central condylar regions between the control and TMJ OA groups (P< 0.05). The area under the ROC curve (AUC) for these variables was between 0.620 and 0.710. In conclusion, 13 imaging bone biomarkers presented an acceptable diagnostic performance for the diagnosis of TMJ OA, indicating that the texture and geometry of the subchondral bone microarchitecture may be useful for quantitative grading of the disease.

AB0118 FREQUENCY OF INTESTINAL PARASITES AND THEIR ASSOCIATION WITH CLINICAL DISEASE ACTIVITY AND TREATMENT-DECISION IN PATIENTS WITH SPONDYLOARTHRITIS

Background:

Studies of human intestinal microbiota have focused mainly on bacteria and scarce information on how eukaryotic parasites fit in the gut context or its role in human health and disease.

Objectives:

This is an approach to explore if intestinal parasites represent a significant factor concerning the treatment-decisions or disease activity in inflammatory conditions such as SpA

Methods:

A Cross-sectional study including 65 patients with SpA according to ASAS classification criteria was performed. Clinical evaluation was made by rheumatologists and gastroenterologists. Stool samples were collected and microscopically analyzed by direct saline, Mini Parasep concentration and Kato Katz. Most prevalent protozoa in Colombia were also analyzed using PCR/qPCR. Lab tests included fecal calprotectin, CRP, ESR, and HLA-B*27. The association between intestinal parasite infection and clinical/treatment variables were evaluated using the Chi-square or Fisher’s exact test. (Ethical/Cod.2017-023)

Results:

SpA patients had a mean age of 43.9±11.5 years, 61.5% were male, 52.5% were positive for HLA-B*27 and 87.7% had axial involvement. In total, 67.7% of the patients were receiving biological treatment, 64.6% had ASDAS-CRP ≥2.1. In total, 75.4% of patients were positive for ≥2 gastrointestinal symptoms with a predominance of abdominal pain (66.2%), abdominal inflammation (63.1%), diarrhea (47.7%) and intolerance to some food (58.5%). Interestingly, 21.3% have high levels of calprotectin, 20% of patients with high calprotectin were receiving biological treatment against IL-17 (p=0.086) and 80% of these patients had BASDAI >4 (p=0.017) and ASDAS-VSG >2.1 (p=0.03).

The parasites found in SpA patients wereEndolimax nana(98%),Blastocystisssp. (63.8%),Entamoeba coli(8.6%),Entamoeba histolytica(6.9%),Chilomastix mesnili(6.4%),E. dispar/moshkovskii(1.7%) andGiardia intestinalis(3.7%). Patients positive forE coli(80%) were treated with NSAIDs (p=0.003). 3/4 of patients positive forE histolyticapresented HLAB*27:05:02 positive. Likewise, the only patient who was positive forG intestinalisexpressed this allele. 5/7 of patients treated with Sulfasalazine presentedBlastocystisssp and 33.3%E coli. The presence of intestinal parasites in SpA patients was not associated with gastrointestinal symptoms, either disease-activity measures.

Conclusion:

The intestinal parasitism in the tropical countries as Colombia have shown an interesting pattern in SpA patients. The treatment may modulate the presence of some parasites; however, the presence of intestinal parasites in SpA does not seem to influence clinical disease activity

Acknowledgments:

The Government Institute of Science, Technology,and Innovation,Francisco Jose de Caldas—COLCIENCIAS(Grant No. 130877757442). Universidad El Bosque (PCI-2018-10091),Hospital Militar Central (Grant 2017-023), Clínicos IPS, Gastroadvanced, Fundación Instituto de Reumatología Fernando Chalem-Bogota,Colombia and Biomedicina de Chihuahua, México

Disclosure of Interests:

None declared

0896 Nutritional Status Improves Following The Implementation Of Positive Airway Pressure For The Treatment Of Obstructive Sleep Apnea In Youth With Down Syndrome

Introduction

In typically developing youth, increases in body mass index (BMI) and rates of obesity accompany treatment of obstructive sleep apnea syndrome (OSAS) with adenotonsillectomy regardless of baseline BMI and OSAS severity. Residual OSAS following adenotonsillectomy and overweight/obesity are common in Down syndrome (DS). We sought to examine the impact of positive airway pressure (PAP) on BMIZ in youth with DS and OSAS.

Methods

Baseline, 6, and 12 month height/length and weight as well as pre-PAP PSG data were abstracted from the Children’s Hospital of Philadelphia Sleep Center for patients with DS and OSAS initiated on PAP between 01/01/2014-07/11/01/2017 (N=73; Median age=6.6y IQR: 3.6-12.1; 52% White, 29% Black; 42% Male). BMIZ was calculated. Longitudinal mixed effects models adjusted for adherence from 0-6 months, baseline BMIZ, and baseline SpO2 nadir were used to evaluate change in BMIZ at months 6 and 12 and the impact of baseline BMIZ on trajectories.

Results

OAHI (median; IQR) at initiation was 15.9 (8.1-28.9) events/hour, SpO2 nadir was 83% (77-88), and BMIZ was 1.50 (0.94-2.34). No differences in BMIZ at 6 and 12 months compared to baseline BMIZ were found (p&gt;0.2 for both). Baseline BMIZ was associated with BMIZ at 6- and 12 months (β-coefficient=0.99; p&lt;0.0001); the increase in BMIZ at 12 mo (β-coefficient= 0.49, p=0.001) was offset with decreasing BMIZ (12mo*baseline BMIZ β-coefficient= -0.3; p&lt;0.0001); such that lower BMIZ was associated with increases in BMIZ while higher BMIZ was associated with decreases in BMIZ.

Conclusion

Initiation of PAP has a beneficial impact on nutritional status in youth with DS and OSAS. In youth who are at the lower end of BMIZ, BMIZ increases to a healthier status following the initiation of PAP, and in youth who are at the higher side of BMIZ, BMIZ decreases to a healthier status. Prospective studies are needed to elaborate on these associations.

Support

None

Functional recovery in senior adults undergoing surgery for colorectal cancer: Assessment tools and strategies to preserve functional status

Colorectal cancer is a widely-recognized aging-associated disease. Recent advances in the care of senior colorectal cancer patients has led to similar cancer-related life expectancy for older patients when compared to their younger counterparts. Recent data suggests that onco-geriatric patients place as much value on maintenance of functional independence and quality of life after treatment as they do on the potential improvements in survival that a treatment might offer. As a result, there has been significant interest in the geriatric literature surrounding the concept of "functional recovery," a multidimensional outcome metric that takes into account several domains, including physical, physiologic, psychological, social, and economic wellbeing. This review introduces the concept of functional recovery and highlights a number of predictors of post-treatment functional trajectory, including several office-based tools that clinicians can use to help guide informed decision making surrounding potential treatment options. This review also highlights a number of validated metrics that can be used to assess a patient's progress in functional recovery after surgery. While the timeline of each individual's functional recovery may vary, most data suggests that if patients are to return to their pre-operative functional status, this could occur up to 6 months post-surgery. For those patients identified to be at risk for post-operative functional decline this review also delineates strategies for prehabilitation and rehabilitation that may improve functional outcomes.

Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial)

BACKGROUND

Several non-randomized and retrospective studies have suggested that intracorporeal anastomosis (IA) has advantages over extracorporeal anastomosis (EA) in laparoscopic right colectomy, but scientific evidence is lacking. The aim was to compare short-term outcomes and to define the possible benefits of IA compared with EA in elective laparoscopic right colectomy.

METHODS

An RCT was conducted from May 2015 to June 2018. The primary endpoint was duration of hospital stay. Secondary endpoints were intraoperative technical events and postoperative clinical outcomes.

RESULTS

A total of 140 patients were randomized. Duration of surgery was longer for procedures with an IA than in those with an EA (median 149 (range 95-215) versus 123 (60-240) min; P < 0·001). Wound length was shorter in the IA group (median 6·7 (4-9·5) versus 8·7 (5-13) cm; P < 0·001). Digestive function recovered earlier in patients with an IA (median 2·3 versus 3·3 days; P = 0·003) and the incidence of paralytic ileus was lower (13 versus 30 per cent; P = 0·022). Less postoperative analgesia was needed in the IA group (mean(s.d.) weighted analgesia requirement 39(24) versus 53(26); P = 0·001) and the pain score was also lower (P = 0·035). The postoperative decrease in haemoglobin level was smaller (mean(s.d.) 8·8(1·7) versus 17·1(1·7) mg/dl; P = 0·001) and there was less lower gastrointestinal bleeding (3 versus 14 per cent; P = 0·031) in the IA group. IA was associated with a significantly better rate of grade I and II complications (P = 0·016 and P = 0·037 respectively). The duration of hospital stay was slightly shorter in the IA group (median 5·7 (range 2-19) versus 6·6 (2-23) days; P = 0·194).

CONCLUSION

Duration of hospital stay was similar, but IA was associated with less pain and fewer complications. Registration number: NCT02667860 ( http://www.clinicaltrials.gov).

Reactance and elastance as measures of small airways response to bronchodilator in asthma

Bronchodilation alters both respiratory system resistance (Rrs) and reactance (Xrs) in asthma, but how changes in Rrs and Xrs compare, and respond differently in health and asthma, in reflecting the contributions from the large and small airways has not been assessed. We assessed reversibility using spirometry and oscillometry in healthy and asthma subjects. Using a multibranch airway-tree model with the mechanics of upper airway shunt, we compared the effects of airway dilation and small airways recruitment to explain the changes in Rrs and Xrs. Bronchodilator decreased Rrs by 23.0 (19.0)% in 18 asthma subjects and by 13.5 (19.5)% in 18 healthy subjects. Estimated respiratory system elastance (Ers) decreased by 23.2 (21.4)% in asthma, with no significant decrease in healthy subjects. With the use of the model, airway recruitment of 15% across a generation of the small airways could explain the changes in Ers in asthma with no recruitment in healthy subjects. In asthma, recruitment accounted for 40% of the changes in Rrs, with the remaining explained by airway dilation of 6.8% attributable largely to the central airways. Interestingly, the same dilation magnitude explained the changes in Rrs in healthy subjects. Shunt only affected Rrs of the model. Ers was unaltered in health and unaffected by shunt in both groups. In asthma, Ers changed comparably to Rrs and could be attributed to small airways, while the change in Rrs was split between large and small airways. This implies that in asthma Ers sensed through Xrs may be a more effective measure of small airways obstruction and recruitment than Rrs.NEW & NOTEWORTHY This is the first study to quantify to relative contributions of small and large airways to bronchodilator response in healthy subjects and patients with asthma. The response of the central airways to bronchodilator was similar in magnitude in both study groups, whereas the response of the small airways was significant among patients with asthma. These results suggest that low-frequency reactance and derived elastance are both sensitive measures of small airway function in asthma.

DNA-encoded bispecific T cell engagers and antibodies present long-term antitumor activity

Specific antibody therapy, including mAbs and bispecific T cell engagers (BiTEs), are important new tools for cancer immunotherapy. However, these approaches are slow to develop and may be limited in their production, thus restricting the patients who can access these treatments. BiTEs exhibit a particularly short half-life and difficult production. The development of an approach allowing simplified development, delivery, and in vivo production would be an important advance. Here we describe the development of a designed synthetic DNA plasmid, which we optimized to permit high expression of an anti-HER2 antibody (HER2dMAb) and delivered it into animals through adaptive electroporation. HER2dMAb was efficiently expressed in vitro and in vivo, reaching levels of 50 μg/ml in mouse sera. Mechanistically, HER2dMAb blocked HER2 signaling and induced antibody-dependent cytotoxicity. HER2dMAb delayed tumor progression for HER2-expressing ovarian and breast cancer models. We next used the HER2dMAb single-chain variable fragment portion to engineer a DNA-encoded BiTE (DBiTE). This HER2DBiTE was expressed in vivo for approximately 4 months after a single administration. The HER2DBiTE was highly cytolytic and delayed cancer progression in mice. These studies illustrate an approach to generate DBiTEs in vivo, which represent promising immunotherapies for HER2+ tumors, including ovarian and potentially other cancers.

Aberrant DNA methylation as a diagnostic biomarker of diabetic embryopathy

PURPOSE

Maternal diabetes is a known teratogen that can cause a wide spectrum of birth defects, collectively referred to as diabetic embryopathy (DE). However, the pathogenic mechanisms underlying DE remain uncertain and there are no definitive tests to establish the diagnosis. Here, we explore the potential of DNA methylation as a diagnostic biomarker for DE and to inform disease pathogenesis.

METHODS

Bisulfite sequencing was used to identify gene regions with differential methylation between DE neonates and healthy infants born with or without prenatal exposure to maternal diabetes, and to investigate the role of allele-specific methylation at implicated sites.

RESULTS

We identified a methylation signature consisting of 237 differentially methylated loci that distinguished infants with DE from control infants. These loci were found proximal to genes associated with Mendelian syndromes that overlap the DE phenotype (e.g., CACNA1C, TRIO, ANKRD11) or genes known to influence embryonic development (e.g., BRAX1, RASA3). Further, we identified allele-specific methylation (ASM) at 11 of these loci, within which 61.5% of ASM single-nucleotide variants are known expression quantitative trait loci (eQTLs).

CONCLUSIONS

Our study suggests a role for aberrant DNA methylation and cis-sequence variation in the pathogenesis of DE and highlights the diagnostic potential of DNA methylation for teratogenic birth defects.

Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes

Objectives

The purpose of this study was to examine the bactericidal efficacy of hydrogen peroxide (H₂O₂) on Cutibacterium acnes (C. acnes). We hypothesize that H₂O₂ reduces the bacterial burden of C. acnes.

Methods

The effect of H₂O₂ was assessed by testing bactericidal effect, time course analysis, growth inhibition, and minimum bactericidal concentration. To assess the bactericidal effect, bacteria were treated for 30 minutes with 0%, 1%, 3%, 4%, 6%, 8%, or 10% H₂O₂ in saline or water and compared with 3% topical H₂O₂ solution. For time course analysis, bacteria were treated with water or saline (controls), 3% H₂O₂ in water, 3% H₂O₂ in saline, or 3% topical solution for 5, 10, 15, 20, and 30 minutes. Results were analyzed with a two-way analysis of variance (ANOVA) (p < 0.05).

Results

Minimum inhibitory concentration of H₂O₂ after 30 minutes is 1% for H₂O₂ prepared in saline and water. The 3% topical solution was as effective when compared with the 1% H₂O₂ prepared in saline or water. The controls of both saline and water showed no reduction of bacteria. After five minutes of exposure, all mixtures of H₂O₂ reduced the percentage of live bacteria, with the topical solution being most effective (p < 0.0001). Maximum growth inhibition was achieved with topical 3% H₂O₂.

Conclusion

The inexpensive and commercially available topical solution of 3% H₂O₂ demonstrated superior bactericidal effect as observed in the minimum bactericidal inhibitory concentration, time course, and colony-forming unit (CFU) inhibition assays. These results support the use of topical 3% H₂O₂ for five minutes before surgical skin preparation prior to shoulder surgery to achieve eradication of C. acnes for the skin.Cite this article: P. Hernandez, B. Sager, A. Fa, T. Liang, C. Lozano, M. Khazzam. Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes. Bone Joint Res 2019;8:3-10. DOI: 10.1302/2046-3758.81.BJR-2018-0145.R1.

Sex prediction by metric and non-metric analysis of the hard palate and the pyriform aperture

BACKGROUND

Analysis of the bones and bone fragments of the cranium may be a useful tool for sex diagnosis in the identification of human remains which have been exposed to adverse conditions. The object of the present study was to evaluate sex prediction through metric and non-metric analysis of the hard palate (HP) and the pyriform aperture (PA), using macerated skulls of adult individuals.

MATERIALS AND METHODS

We analysed 312 dry skulls of adult individuals of both sexes, studying the metric and non-metric characteristics of the HP and PA. The accuracy, sensitivity, specificity and positive and negative predictive values were evaluated. A binary logistic regression and a linear regression were performed. The receiver operating characteristic curve was constructed to analyse the perfor- mance of sex diagnosis. Measurements of the HP and the PA were analysed by ANOVA and Tukey's test. The SPSS v. 20.0 software was used, with a significance threshold of 5%.

RESULTS

The shape of the PA presented 61.9% accuracy, 54.4% sensitivity and 65.7% specificity. The shape of the HP presented 51.5% accuracy, 65.6% sen- sitivity and 44.7% specificity. Only the height of the PA functioned as a good predictor of sex.

CONCLUSIONS

The height of the PA produced good diagnostic performance (area under curve = 0.764). The height of the PA was the most reliable indicator for sex prediction, and could be used by forensic scientists to identify sex.

Understanding drivers of domestic public expenditure on reproductive, maternal, neonatal and child health in Peru at district level: an ecological study

Background

Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru.

Methods

We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis.

Results

Public expenditure increased in all departments, particularly for maternal-neonatal and child health activities, with a different pace across departments. The multilevel analysis did not reveal consistently influential factors, except for previous year expenditure on reproductive and maternal-neonatal health. Our findings may be explained by a combination of inertial expenditure, a results-based budgeting approach to increase expenditure efficiency and effectiveness, and by a mixed-effects decentralization process. Sample size, interactions and collinearity cannot be ruled out completely.

Conclusions

Public district-level RMNCH expenditure has increased remarkably in Peru. Evidence on underlying factors influencing such trends warrants further research, most likely through a combination of quantitative and qualitative approaches.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3649-x) contains supplementary material, which is available to authorized users.

Intracorporeal versus extracorporeal anastomosis in right hemicolectomy assisted by laparoscopy: study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the third most frequent cancer diagnosed in men and the second in women. Laparoscopic surgery has been a technical revolution in colorectal surgery, facilitating a better recovery of patients with lower morbidity and better esthetic results, compared to traditional surgery via laparotomy, without compromising safety and long-term oncological results.

PURPOSE

The trial is a randomized controlled trial indented to evaluate the two interventions with thorough measurements of the postoperative variables and complications to improve the evaluation of the surgical technique. The primary endpoint is to compare the hospital stay, which will be measured in days between both groups. The purpose of the study at secondary endpoints is to compare intraoperative and postoperative events between both groups in terms of operating time, anastomotic performance time, intraoperative complications, number of harvested lymph nodes, need for blood transfusion, length of the surgical wound, start and tolerance of oral intake, beginning of digestive functionality, postoperative pain, need for analgesic administration, surgical wound infection, paralytic ileus, anastomosis leakage or dehiscence, need for surgical reintervention, and hospital readmission within the first 30 days after surgery.

METHODS

This trial is a prospective, randomized, single-blind, and single-center clinical trial comparing intracorporeal anastomosis versus extracorporeal anastomosis for right laparoscopic hemicolectomy.

CONCLUSIONS

Nowadays, there are several retrospective trials comparing the benefits for extracorporeal anastomosis versus intracorporeal anastomosis in right colon cancer patients. Considering the impact for laparoscopic surgery, we think it is necessary to do a randomized trial comparing extracorporeal versus intracorporeal anastomosis modalities.

TRIAL REGISTRATION

www.clinicaltrials.gov No. NCT02667860 and Hospital de la Santa Creu i Sant Pau Research Institute No. IIBSP-AIE-2015-01.

Enabling reproductive, maternal, neonatal and child health interventions: Time trends and driving factors of health expenditure in the successful story of Peru

We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing.

The association between anthropometric measures and lung function in a population-based study of Canadian adults

BACKGROUND

Decreased lung function has health impacts beyond diagnosable lung disease. It is therefore important to understand the factors that may influence even small changes in lung function including obesity, physical fitness and physical activity. The aim of this study was to determine the anthropometric measure most useful in examining the association with lung function and to determine how physical activity and physical fitness influence this association.

METHODS

The current study used cross-sectional data on 4662 adults aged 40-79 years from the Canadian Health Measures Survey Cycles 1 and 2. Linear regression models were used to examine the association between the anthropometric and lung function measures (forced expiratory volume in 1 s [FEV₁] and forced vital capacity [FVC]); R² values were compared among models. Physical fitness and physical activity terms were added to the models and potential confounding was assessed.

RESULTS

Models using sum of 5 skinfolds and waist circumference consistently had the highest R² values for FEV₁ and FVC, while models using body mass index consistently had among the lowest R² values for FEV₁ and FVC and for men and women. Physical activity and physical fitness were confounders of the relationships between waist circumference and the lung function measures. Waist circumference remained a significant predictor of FVC but not FEV₁ after adjustment for physical activity or physical fitness.

CONCLUSIONS

Waist circumference is an important predictor of lung function. Physical activity and physical fitness should be considered as potential confounders of the relationship between anthropometric measures and lung function.

Assessment of large copy number variants in patients with apparently isolated congenital left-sided cardiac lesions reveals clinically relevant genomic events

Congenital left-sided cardiac lesions (LSLs) are a significant contributor to the mortality and morbidity of congenital heart disease (CHD). Structural copy number variants (CNVs) have been implicated in LSL without extra-cardiac features; however, non-penetrance and variable expressivity have created uncertainty over the use of CNV analyses in such patients. High-density SNP microarray genotyping data were used to infer large, likely-pathogenic, autosomal CNVs in a cohort of 1,139 probands with LSL and their families. CNVs were molecularly confirmed and the medical records of individual carriers reviewed. The gene content of novel CNVs was then compared with public CNV data from CHD patients. Large CNVs (>1 MB) were observed in 33 probands (∼3%). Six of these were de novo and 14 were not observed in the only available parent sample. Associated cardiac phenotypes spanned a broad spectrum without clear predilection. Candidate CNVs were largely non-recurrent, associated with heterozygous loss of copy number, and overlapped known CHD genomic regions. Novel CNV regions were enriched for cardiac development genes, including seven that have not been previously associated with human CHD. CNV analysis can be a clinically useful and molecularly informative tool in LSLs without obvious extra-cardiac defects, and may identify a clinically relevant genomic disorder in a small but important proportion of these individuals.

A genome-wide association study of congenital cardiovascular left-sided lesions shows association with a locus on chromosome 20

Congenital heart defects involving left-sided lesions (LSLs) are relatively common birth defects with substantial morbidity and mortality. Previous studies have suggested a high heritability with a complex genetic architecture, such that only a few LSL loci have been identified. We performed a genome-wide case-control association study to address the role of common variants using a discovery cohort of 778 cases and 2756 controls. We identified a genome-wide significant association mapping to a 200 kb region on chromosome 20q11 [P= 1.72 × 10^-8 for rs3746446; imputed Single Nucleotide Polymorphism (SNP) rs6088703 P= 3.01 × 10^-9, odds ratio (OR)= 1.6 for both]. This result was supported by transmission disequilibrium analyses using a subset of 541 case families (lowest P in region= 4.51 × 10^-5, OR= 1.5). Replication in a cohort of 367 LSL cases and 5159 controls showed nominal association (P= 0.03 for rs3746446) resulting in P= 9.49 × 10^-9 for rs3746446 upon meta-analysis of the combined cohorts. In addition, a group of seven SNPs on chromosome 1q21.3 met threshold for suggestive association (lowest P= 9.35 × 10^-7 for rs12045807). Both regions include genes involved in cardiac development-MYH7B/miR499A on chromosome 20 and CTSK, CTSS and ARNT on chromosome 1. Genome-wide heritability analysis using case-control genotyped SNPs suggested that the mean heritability of LSLs attributable to common variants is moderately high ([Formula: see text] range= 0.26-0.34) and consistent with previous assertions. These results provide evidence for the role of common variation in LSLs, proffer new genes as potential biological candidates, and give further insight to the complex genetic architecture of congenital heart disease.

Recurrent Muscle Weakness with Rhabdomyolysis, Metabolic Crises, and Cardiac Arrhythmia Due to Bi-allelic TANGO2 Mutations

The underlying genetic etiology of rhabdomyolysis remains elusive in a significant fraction of individuals presenting with recurrent metabolic crises and muscle weakness. Using exome sequencing, we identified bi-allelic mutations in TANGO2 encoding transport and Golgi organization 2 homolog (Drosophila) in 12 subjects with episodic rhabdomyolysis, hypoglycemia, hyperammonemia, and susceptibility to life-threatening cardiac tachyarrhythmias. A recurrent homozygous c.460G>A (p.Gly154Arg) mutation was found in four unrelated individuals of Hispanic/Latino origin, and a homozygous ∼34 kb deletion affecting exons 3-9 was observed in two families of European ancestry. One individual of mixed Hispanic/European descent was found to be compound heterozygous for c.460G>A (p.Gly154Arg) and the deletion of exons 3-9. Additionally, a homozygous exons 4-6 deletion was identified in a consanguineous Middle Eastern Arab family. No homozygotes have been reported for these changes in control databases. Fibroblasts derived from a subject with the recurrent c.460G>A (p.Gly154Arg) mutation showed evidence of increased endoplasmic reticulum stress and a reduction in Golgi volume density in comparison to control. Our results show that the c.460G>A (p.Gly154Arg) mutation and the exons 3-9 heterozygous deletion in TANGO2 are recurrent pathogenic alleles present in the Latino/Hispanic and European populations, respectively, causing considerable morbidity in the homozygotes in these populations.

Characteristics of COPD in never-smokers and ever-smokers in the general population: results from the CanCOLD study

BACKGROUND

There is limited data on the risk factors and phenotypical characteristics associated with spirometrically confirmed COPD in never-smokers in the general population.

AIMS

To compare the characteristics associated with COPD by gender and by severity of airway obstruction in never-smokers and in ever-smokers.

METHOD

We analysed the data from 5176 adults aged 40 years and older who participated in the initial cross-sectional phase of the population-based, prospective, multisite Canadian Cohort of Obstructive Lung Disease study. Never-smokers were defined as those with a lifetime exposure of <1/20 pack year. Logistic regressions were constructed to evaluate associations for 'mild' and 'moderate-severe' COPD defined by FEV1/FVC <5th centile (lower limits of normal). Analyses were performed using SAS V.9.1 (SAS Institute, Cary, North Carolina, USA).

RESULTS

The prevalence of COPD (FEV1/FVC<lower limits of normal) in never-smokers was 6.4%, constituting 27% of all COPD subjects. The common independent predictors of COPD in never-smokers and ever-smokers were older age, self reported asthma and lower education. In never-smokers a history of hospitalisation in childhood for respiratory illness was discriminative, while exposure to passive smoke and biomass fuel for heating were discriminative for women. COPD in never-smokers and ever-smokers was characterised by increased respiratory symptoms, 'respiratory exacerbation' events and increased residual volume/total lung capacity, but only smokers had reduced DLCO/Va and emphysema on chest CT scans.

CONCLUSIONS

The study confirmed the substantial burden of COPD among never-smokers, defined the common and gender-specific risk factors for COPD in never-smokers and provided early insight into potential phenotypical differences in COPD between lifelong never-smokers and ever-smokers.

TRIAL REGISTRATION NUMBER

NCT00920348 (ClinicalTrials.gov); study ID number: IRO-93326.