Reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy in Canada: A national prospective cohort study

OBJECTIVE

To describe self-reported reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy.

DESIGN

National, prospective cohort study.

SETTING

Participants across Canada were enrolled from July 2021 until June 2022.

POPULATION

Individuals pregnant during the COVID-19 pandemic, regardless of vaccination status, were included.

METHODS

The Canadian COVID-19 Vaccine Registry for Pregnant and Lactating Individuals (COVERED) was advertised through traditional and social media. Surveys were administered at baseline, following each vaccine dose if vaccinated, pregnancy conclusion, and every two months for 14 months. Changes to pregnancy or vaccination status, SARS-CoV-2 infections, or significant health events were recorded.

MAIN OUTCOME MEASURES

Reactogenicity (local and systemic adverse events, and serious adverse events) within 1 week post-vaccination, pregnancy and neonatal outcomes, and subsequent SARS-CoV-2 infection.

RESULTS

Among 2868 participants who received 1-2 doses of a COVID-19 vaccine during pregnancy, adverse events described included: headache (19.5-33.9%), nausea (4.8-13.8%), fever (2.7-10.2%), and myalgia (33.4-42.2%). Reactogenicity was highest after the 2nd dose of vaccine in pregnancy. Compared to 1660 unvaccinated participants, there were no statistically significant differences in adverse pregnancy or infant outcomes, aside from an increased risk of NICU admission ≥ 24 h among the unvaccinated group. During follow-up, there was a higher rate of participant-reported SARS-CoV-2 infection in the unvaccinated compared to the vaccinated group (18[47.4%] vs. 786[27.3%]).

CONCLUSIONS

Participant-reported reactogenicity was similar to reports from non-pregnant adults. There was no increase in adverse pregnancy and birth outcomes among vaccinated vs. unvaccinated participants and lower rates of SARS-CoV-2 infection were reported in vaccinated participants.

TWEETABLE ABSTRACT

No significant increase in adverse pregnancy or infant outcomes among vaccinated versus unvaccinated pregnant women in Canada.

Improving levodopa delivery: IPX203, a novel extended-release carbidopa-levodopa formulation

Introduction

IPX203 is a novel oral extended-release (ER) formulation of carbidopa (CD) and levodopa (LD) developed to address the short half-life and limited area for absorption of LD in the gastrointestinal tract. This paper presents the formulation strategy of IPX203 and its relationship to the pharmacokinetics (PK) and pharmacodynamic profile of IPX203 in Parkinson's disease (PD) patients.

Methods

IPX203 was developed with an innovative technology containing immediate-release (IR) granules and ER beads that provides rapid LD absorption to achieve desired plasma concentration and maintaining it within the therapeutic range for longer than can be achieved with current oral LD formulations. The PK and pharmacodynamics of IPX203 were compared with IR CD-LD in a Phase 2, open-label, rater-blinded, multicenter, crossover study in patients with advanced PD.

Results

Pharmacokinetic data showed that on Day 15, LD concentrations were sustained above 50% of peak for 6.2 h with IPX203 vs. 3.9 h with IR CD-LD (P = 0.0002). Pharmacodynamic analysis demonstrated that mean MDS-UPDRS Part III scores prior to administration of the first daily dose were significantly lower among patients receiving IPX203 than IR CD-LD (LS mean difference -8.1 [25.0], P = 0.0255). In a study conducted in healthy volunteers, a high-fat, high-calorie meal delayed plasma LD T_max by 2 h, and increased C_max and AUC_tau by approximately 20% compared with a fasted state. Sprinkling capsule contents on applesauce did not affect PK parameters.

Conclusion

These data confirm that the unique design of IPX203 addresses some of the limitations of oral LD delivery.

Long-term efficacy and safety of renal denervation in the presence of antihypertensive drugs (SPYRAL HTN-ON MED): a randomised, sham-controlled trial

BACKGROUND

Renal denervation has been shown to lower blood pressure in the presence of antihypertensive medications; however, long-term safety and efficacy data from randomised trials of renal denervation are lacking. In this pre-specified analysis of the SPYRAL HTN-ON MED study, we compared changes in blood pressure, antihypertensive drug use, and safety up to 36 months in renal denervation versus a sham control group.

METHODS

This randomised, single-blind, sham-controlled trial enrolled patients from 25 clinical centres in the USA, Germany, Japan, the UK, Australia, Austria, and Greece, with uncontrolled hypertension and office systolic blood pressure between 150 mm Hg and 180 mm Hg and diastolic blood pressure of 90 mm Hg or higher. Eligible patients had to have 24-h ambulatory systolic blood pressure between 140 mm Hg and less than 170 mm Hg, while taking one to three antihypertensive drugs with stable doses for at least 6 weeks. Patients underwent renal angiography and were randomly assigned (1:1) to radiofrequency renal denervation or a sham control procedure. Patients and physicians were unmasked after 12-month follow-up and sham control patients could cross over after 12-month follow-up completion. The primary endpoint was the treatment difference in mean 24-h systolic blood pressure at 6 months between the renal denervation group and the sham control group. Statistical analyses were done on the intention-to-treat population. Long-term efficacy was assessed using ambulatory and office blood pressure measurements up to 36 months. Drug surveillance was used to assess medication use. Safety events were assessed up to 36 months. This trial is registered with ClinicalTrials.gov, NCT02439775; prospectively, an additional 260 patients are currently being randomly assigned as part of the SPYRAL HTN-ON MED Expansion trial.

FINDINGS

Between July 22, 2015, and June 14, 2017, among 467 enrolled patients, 80 patients fulfilled the qualifying criteria and were randomly assigned to undergo renal denervation (n=38) or a sham control procedure (n=42). Mean ambulatory systolic and diastolic blood pressure were significantly reduced from baseline in the renal denervation group, and were significantly lower than the sham control group at 24 and 36 months, despite a similar treatment intensity of antihypertensive drugs. The medication burden at 36 months was 2·13 medications (SD 1·15) in the renal denervation group and 2·55 medications (2·19) in the sham control group (p=0·26). 24 (77%) of 31 patients in the renal denervation group and 25 (93%) of 27 patients in the sham control group adhered to medication at 36 months. At 36 months, the ambulatory systolic blood pressure reduction was -18·7 mm Hg (SD 12·4) for the renal denervation group (n=30) and -8·6 mm Hg (14·6) for the sham control group (n=32; adjusted treatment difference -10·0 mm Hg, 95% CI -16·6 to -3·3; p=0·0039). Treatment differences between the renal denervation group and sham control group at 36 months were -5·9 mm Hg (95% CI -10·1 to -1·8; p=0·0055) for mean ambulatory diastolic blood pressure, -11·0 mm Hg (-19·8 to -2·1; p=0·016) for morning systolic blood pressure, and -11·8 mm Hg (-19·0 to -4·7; p=0·0017) for night-time systolic blood pressure. There were no short-term or long-term safety issues associated with renal denervation.

INTERPRETATION

Radiofrequency renal denervation compared with sham control produced a clinically meaningful and lasting blood pressure reduction up to 36 months of follow-up, independent of concomitant antihypertensive medications and without major safety events. Renal denervation could provide an adjunctive treatment modality in the management of patients with hypertension.

FUNDING

Medtronic.

293 A Reflection of Experience Gained in Emergency General Surgery During The COVID-19 Pandemic at A London University Hospital

Background

During COVID-19, acute surgical services witnessed an overhaul of practice due to constraints on staff and resource (beds, imaging, and theater) availability. Fear of COVID-19, among general population potentially added to delay in patients seeking medical assistance. This study describes experiences of acute general surgery at a COVID-19 designated tertiary institution wherein elective surgical work was put on hold and emergency on-call rota was modified during the pandemic.

Method

A retrospective analysis (March-April 2019 vs 2020) of the surgical work from a prospectively maintained surgical database during COVID-19 was performed.

Results

Emergency surgical admissions during March 2020 vs 2019 was 106 vs 207. Comparing the workload March-April 2020 vs 2019, emergency referrals were 266 vs 341, operations performed 71 vs 92. 31.5% (84/266) of patients were tested for COVID and 30% (25/84) were positive. Emergency surgery was performed in 71 patients (including appendectomies (28), hernia repair(3), laparotomy(3), Hartman’s procedure(3), hemicolectomy(7) and anterior resection with covering ileostomy(2)). In this group, a male preponderance was noted (M:F 1.84:1), the average age was 43.2 years (6-91), length of stay 4.8 days (<23 hours-34 days). In the operative group, the 30-day mortality was 4.23% (3/71) and the morbidity was 31%.

Conclusions

With local changes, stopping elective services, modifying on-call rota, a surgical department can continue to be functional and offer emergency surgical service for a sustained period during a pandemic. During the COVID pandemic, the average number of referrals, admissions and surgeries were lower when compared to the non-covid period.

248 Rectus flap for repair of Strangulated Obturator Hernia

Introduction

Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH.

Case report

An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently.

Conclusions

In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.

249 Laparoscopic Assisted Enterolithotomy: A Viable Option in The Management of Gallstone Ileus

Introduction

Gallstone ileus (GSI) is a rare cause of small bowel obstruction in patients over the age of 65 years. We report a case of GSI treated successfully with a laparoscopic assisted enterolithotomy.

Case report

A 75-year-old female presented with two days of abdominal distension and vomiting with a non-peritonitic abdomen on examination. A computerised tomography scan demonstrated small bowel obstruction due to an obstructing stone in the distal ileum. Three port laparoscopy and small bowel assessment confirmed a solitary enterolith (4cms) in the distal ileum with upstream dilated loops. An infra-umbilical 6 cm midline incision was made and the localised bowel loop was delivered. An enterotomy was made proximal to the point of obstruction, stone retrieved, and a single layer interrupted closure was performed. Ten weeks post-operatively, patient had a virtual follow-up consultation and is doing well.

Conclusions

GSI often presents in elderly patients with multiple co-morbidities. A laparotomy with enterolithotomy is the initial treatment of choice with biliary intervention as a second operation, if needed, at a later date. Clearly, a conventional exploratory laparotomy in this cohort of patients carries a high risk and therefore the use of less morbid and less invasive procedure like laparoscopy should be considered. Although a total laparoscopic approach would require advanced laparoscopic skills particularly due to dilated bowel loops limiting the intra-abdominal space for suturing, a laparoscopic assisted approach as described above should be considered as a reasonable option within the remits of an emergency general surgeon.

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Duration of benefit per Dose: Carbidopa-Levodopa immediate release vs. extended release capsules (Rytary®)

BACKGROUND

For patients with Parkinson's disease, clinicians commonly assess duration of benefit for individual doses of levodopa in order to consider medication changes.

OBJECTIVE

To determine the mean duration of ON time per dose and mean duration of ON time without troublesome dyskinesia (WoTD) per dose of CD-LD IR vs. CD-LD ER in the ADVANCE-PD trial.

METHODS

We performed a post hoc analysis of the ADVANCE-PD trial. Mean ON time per dose and ON time WoTD was calculated at baseline and end-of-study (EOS). Changes were compared between CD-LD IR and CD-LD ER (Rytary®) treatment groups using an ANCOVA model.

RESULTS

Mean (SD) baseline ON time per dose of CD-LD IR (n = 393) was 2.20 h. Patients randomized to double-blind treatment with CD-LD IR (n = 192) experienced an increase in mean ON time per dose from baseline to EOS from 2.24 h to 2.38 h. In comparison, patients randomized to double-blind treatment with CD-LD ER (n = 201) experienced an increase in mean ON time per dose from baseline (on CD-LD IR) to EOS (on CD-LD ER) from 2.17 h to 3.55 h. Conversion and optimization with CD-LD ER increased ON time per dose by 1.21 h more than optimization of CD-LD IR (p < 0.0001). Similarly, CD-LD ER increased ON time WoTD per dose by 1.16 h more than CD-LD IR (p < 0.0001).

CONCLUSION

In the ADVANCE-PD trial, CD-LD ER significantly increased ON time per dose compared to CD-LD IR (+1.21 h, p < 0.0001) and provided significantly more ON time per dose (3.55 h vs 2.38 h, p < 0.0001).

Carbidopa and Levodopa Extended Release Capsules in Patients with and without Troublesome and Non-Troublesome Dyskinesia

BACKGROUND

Carbidopa (CD) and levodopa (LD) extended release (CD-LD ER) capsules are designed to combine both immediate and extended release pharmacokinetics. In the phase 3, randomized, double-blind, ADVANCE-PD trial, patients randomized to CD-LD ER experienced a 1.17-hour greater reduction in OFF time compared to patients randomized to CD-LD IR (p < 0.0001).

OBJECTIVE

To compare CD-LD IR optimization to CD-LD ER conversion based on patient dyskinesia status at baseline using data from the ADVANCE-PD trial.

METHODS

This was a retrospective analysis of the ADVANCE-PD study. Patients were categorized by dyskinesia status at baseline into 1) those who had No Dyskinesia (ND), 2) those who had Non-Troublesome Dyskinesia Only (NTDO), and 3) those who had Troublesome Dyskinesia (TD).

RESULTS

Comparative reductions in OFF time favoring CD-LD ER over CD-LD IR were similar for the ND (-1.08 h, p = 0.0071, n = 183) and NTDO (-1.12 h, p = 0.0104, n = 131) groups, and smaller for the TD group (-0.82 h, p = 0.2382, n = 79). Reductions in OFF time for both CD-LD ER conversion and CD-LD IR adjustment were largest within the ND group and smallest within the TD group (CD-LD ER: ND -2.86 h, NTDO -2.11 h, TD -1.36 h; CD-LD IR: ND -1.78 h, NTDO -0.99 h, TD -0.55 h).

CONCLUSION

Responses to both CD-LD IR adjustment and CD-LD ER conversion depended on baseline dyskinesia status. Significant reductions in OFF time with CD-LD ER compared to CD-LD IR were observed in the ND and NTDO groups. In the TD group, comparing CD-LD ER conversion to CD-LD IR optimization, benefits were still observed, but there was less reduction in OFF time, less reduction in troublesome dyskinesia, and fewer patients self-rated themselves much or very much improved than in the ND and NTDO groups. These data suggest that in clinical practice, the best chances for success with conversion from CD-LD IR to CD-LD ER are in patients without TD.

Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial

BACKGROUND

Catheter-based renal denervation has significantly reduced blood pressure in previous studies. Following a positive pilot trial, the SPYRAL HTN-OFF MED (SPYRAL Pivotal) trial was designed to assess the efficacy of renal denervation in the absence of antihypertensive medications.

METHODS

In this international, prospective, single-blinded, sham-controlled trial, done at 44 study sites in Australia, Austria, Canada, Germany, Greece, Ireland, Japan, the UK, and the USA, hypertensive patients with office systolic blood pressure of 150 mm Hg to less than 180 mm Hg were randomly assigned 1:1 to either a renal denervation or sham procedure. The primary efficacy endpoint was baseline-adjusted change in 24-h systolic blood pressure and the secondary efficacy endpoint was baseline-adjusted change in office systolic blood pressure from baseline to 3 months after the procedure. We used a Bayesian design with an informative prior, so the primary analysis combines evidence from the pilot and Pivotal trials. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02439749.

FINDINGS

From June 25, 2015, to Oct 15, 2019, 331 patients were randomly assigned to either renal denervation (n=166) or a sham procedure (n=165). The primary and secondary efficacy endpoints were met, with posterior probability of superiority more than 0·999 for both. The treatment difference between the two groups for 24-h systolic blood pressure was -3·9 mm Hg (Bayesian 95% credible interval -6·2 to -1·6) and for office systolic blood pressure the difference was -6·5 mm Hg (-9·6 to -3·5). No major device-related or procedural-related safety events occurred up to 3 months.

INTERPRETATION

SPYRAL Pivotal showed the superiority of catheter-based renal denervation compared with a sham procedure to safely lower blood pressure in the absence of antihypertensive medications.

FUNDING

Medtronic.

P6312Pregnancy outcomes in women with cardiothoracic transplants: a systematic review and meta-analysis

Background

Increasing numbers of women with heart-lung transplants (HLT) are now planning and continuing with pregnancies. The risks of pregnancies in these women have not been systematically assessed.

Methods

A search strategy was designed for MEDLINE, EMBASE, and Cochrane Central from inception to January 2018 to identify studies reporting outcomes in three or more pregnancies following HLT. Pooled incidence of maternal outcomes and fetal and neonatal outcomes were calculated using random-effects meta-analysis and reported per 100 pregnancies with 95% confidence intervals (CI). Risk-of-bias was determined using the Joanna Briggs Checklist for Case Series. Subgroup analysis was conducted based on transplanted organ.

Results

A total of 3658 records were identified, 172 full texts reviewed, and 12 studies included. The included studies reported on 385 pregnancies in 272 transplant recipients. Maternal complications included mortality during pregnancy [0.5% (0, 1.1%)], mortality during the specified follow-up period [15.4% (10,4, 20.3%)], graft rejection during pregnancy [7.4% (4.2, 10.5%)], preeclampsia [12.3% (7.2%, 17.5%)], gestational diabetes [6.4% (2.6, 10.1%)], and caesarean deliveries [41.4% (33.4, 48.7%)]. As many as 78.4% (69.8, 86.9%) pregnancies resulted in live births. Of the remainder, 13.6% (6.3, 20.9%) resulted in miscarriages (fetal loss under 20 weeks of gestation), 2% (0.3, 3.7%) resulted in stillbirths (fetal loss after 20 weeks of gestation), and 6.8% (4.3, 9.3%) in pregnancy terminations for various reasons. Of those born live, 3.4% (1.3, 5.6%) succumbed in the neonatal period. Over half the pregnancies [51.2% (31, 71.3%)] resulted in preterm deliveries (<37 weeks of gestation). There were subgroup-specific variations in the prevalence of complications. For example, lung transplant recipients were less likely than heart transplant recipients to have pregnancies complicated by preeclampsia [8.3% (3.0, 13.6%) vs. 17.8% (10.8, 24.8%)] suffer maternal mortality during the follow up period [41.4% (23.4, 59.3%) vs. 10.8% (5.9, 15.8%)]. Studies had a moderate risk-of-bias.

Conclusions

Although large proportions of pregnancies in women with HLT result in live births and few maternal deaths occur during pregnancy, these women are at increased risk for preeclampsia, preterm birth, perinatal mortality and maternal mortality following childbirth. Subgroup-specific variations should be taken into account while counselling HLT recipients contemplating pregnancies.

Acknowledgement/Funding

None

Acute Kidney Injury of Infectious Etiology in Monsoon Season: A Prospective Study Using Acute Kidney Injury Network Criteria

The epidemiological pattern of acute kidney injury (AKI) in tropical countries during monsoon reflects infectious disease as the most important cause. AKI is a confounding factor and may be overlooked by primary health-care providers and underreported in health statistics. The present study prospectively helps estimate the burden of disease and analyze etiology, clinical profile, and outcome in a tertiary care hospital of a metropolitan city in a tropical country. The study period included monsoon season of 2012 and 2013, a total of 8 months. AKI staging was done as per the AKI Network (AKIN) criteria. Patients were treated for primary disease. Renal replacement therapy (RRT) was given as required. Patients were followed up during hospitalization till recovery/death. Out of a total of 9930 admissions during this period, 1740 (17.52%) were for infections and 230 (2.31%) had AKI secondary to infectious diseases during monsoon. The incidence of AKI (230/1740) in infectious diseases during monsoon was 13.21%. The study population (n = 230) comprised 79.5% of males and the mean age was 40.95 ± 16.55 years. Severe AKI: AKIN Stage III was seen in 48.26% of patients and AKIN Stage I in 41.74%. The most common etiology of AKI was malaria (28.3%) followed by acute gastroenteritis (23%), dengue (16.5%), leptospirosis (13%), undifferentiated fever (10.4%), more than one etiology (5.4%), and enteric fever (3.5%). RRT was required in 44.78% of patients. Requirement for RRT was maximum in patients with more than one etiology followed by leptospirosis, malaria, dengue, and least in typhoid. The overall mortality was 12.17%. In multivariate analysis, vasopressor support and assisted ventilation were risk factors for mortality.

Clinical Features and HLA Association of 5-Aminosalicylate (5-ASA)-induced Nephrotoxicity in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Nephrotoxicity is a rare idiosyncratic reaction to 5-aminosalicylate (5-ASA) therapies. The aims of this study were to describe the clinical features of this complication and identify clinically useful genetic markers so that these drugs can be avoided or so that monitoring can be intensified in high-risk patients.

METHODS

Inflammatory bowel disease patients were recruited from 89 sites around the world. Inclusion criteria included normal renal function prior to commencing 5-ASA, ≥50% rise in creatinine any time after starting 5-ASA, and physician opinion implicating 5-ASA strong enough to justify drug withdrawal. An adjudication panel identified definite and probable cases from structured case report forms. A genome-wide association study was then undertaken with these cases and 4109 disease controls.

RESULTS

After adjudication, 151 cases of 5-ASA-induced nephrotoxicity were identified. Sixty-eight percent of cases were males, with nephrotoxicity occurring at a median age of 39.4 years (range 6-79 years). The median time for development of renal injury after commencing 5-ASA was 3.0 years (95% confidence interval [CI] 2.3-3.7). Only 30% of cases recovered completely after drug withdrawal, with 15 patients requiring permanent renal replacement therapy. A genome-wide association study identified a suggestive association in the HLA region (p = 1×10(-7)) with 5-ASA-induced nephrotoxicity. A sub-group analysis of patients who had a renal biopsy demonstrating interstitial nephritis (n = 55) significantly strengthened this association (p = 4×10(-9), odds ratio 3.1).

CONCLUSIONS

This is the largest and most detailed study of 5-ASA-induced nephrotoxicity to date. It highlights the morbidity associated with this condition and identifies for the first time a significant genetic predisposition to drug-induced renal injury.

Subcutaneous surprise

Melioidosis is a zoonosis caused by the accidental pathogen Burkholderia pseudomallei, which is endemic in Southeast Asia and northern Australia. The mortality of melioidosis is 20-50% even with treatment. Suppurative lymphadenitis caused by melioidosis has been rarely encountered by clinicians practicing in endemic areas. In the majority of previously described patients, the infected lymph nodes were in the head and neck region, except for four patients who presented with unilateral, inguinal lymphadenitis. Hence, we report a case of unilateral suppurative inguinal lymphadenitis caused by B. pseudomallei in a 48-year-old lady who presented with groin swelling of 2 months duration.

Body weight perception among adolescents in Dubai, United Arab Emirates

This study investigated the body image perceptions among adolescents in Dubai, United Arab Emirates (UAE). A cross-sectional survey was conducted amongst 661 adolescents (324 males; 337 females) aged 12-17 years selected from government schools using a multistage stratified random sampling technique. A pretested validated questionnaire was employed to determine the perception of adolescents toward their weight status. A nine figure silhouette illustration was used to measure perceptions of their ideal body image and how it compares with their current body weight. The results revealed that overweight (18.5%) and obesity (27.2%) were higher among males than in females (13.1% and 20.5% respectively). A high proportion of overweight males and females considered themselves as average (45.0% and 52.3%, respectively). Similarly, 56.9% of obese male and 46.4% of females considered themselves as average weight. Of non-overweight/obese males and females, 27.6% and 39.3% respectively, were pressured by parents to gain weight (p > 0.000). In general overweight and obese adolescents were more likely to face pressure from their parents and teased by friends than non-overweight/obese adolescents. Compared to their current body image, overweight and obese adolescents chose a significantly lighter figure as their ideal (p < 0.000). It is suggested that the current health education curriculum should include information related to healthy body weight and appropriate diet and lifestyle so as to minimize risk of developing distorted body image concerns in adolescence and beyond.

Abstract P4-13-02: Comparing data quality of client intake forms by interview mode: results of a pilot study on the use of audio computer-assisted self-interview (ACASI) in the Avon Breast Health Outreach Program

Background: Numerous studies have documented the relative advantages that computer assisted self-interview (CASI) technology holds over traditional interviewing methods in collecting research data on stigmatized and/or risky health behaviors. However, few studies have explored the broader implications of using CASI to collect basic client-level data during routine health promotion and disease prevention screenings.

Aims: The present study aims to address this gap in research by comparing the quality of client-level data collected via audio-computer assisted self-interview (ACASI) with data collected via face-to-face and self-administered paper-based interviews among a sample of clients served through the Avon Breast Health Outreach Program (Avon BHOP).

Methods: A total of 303 clients served through the Avon BHOP were sampled from three U.S. sites between November 2011 and March 2012. Clients were randomly assigned to complete the Avon BHOP client intake form (CIF) via one of three interview modes: face-to-face interview (FFI), self-administered paper-based interview (SAPI), or ACASI. We conducted logistic regression and determined odds ratios with 95% confidence intervals to test our hypothesis that use of ACASI would result in significantly higher rates of CIF completion than either FFI or SAPI. We compared rates of completion of the entire CIF, as well as completion of each of the three CIF sections: Demographics, Breast Health Information, and Correlates of Breast Health.

Results: Clients were significantly more likely to complete the entire CIF via ACASI than either FFI or SAPI interview modes. The greatest differences were observed when comparing rates of completion between ACASI and SAPI, as clients were almost five times more likely to complete the CIF via ACASI as opposed to SAPI (OR = 4.7, p &lt; 0.001). Additionally, when comparing rates of completion of the three CIF sections on Demographics, Breast Health Information (e.g. mammogram history), and Correlates of Breast Health (e.g., smoking behavior, alcohol consumption), we found that clients were between 3.2 and 7.2 times more likely to complete the sections via ACASI as opposed to SAPI.

Oral Health Disparities and the Future Face of America

The 4th Annual AADR Fall Focused Symposium (FFS), "Oral Health Disparities Research and the Future Face of America", took place on November 3-4, 2011 in Washington, DC. The FFS strategy was developed by the AADR to help provide additional opportunities for members to engage in research discussions during the year by identifying specific research topics of interest among the 21 Scientific Groups and 4 Networks of the IADR and targeting a focused topic area for the FFS. The conference attracted an international group of approximately 120 registrants, including participants from Canada, India, Mexico, and China; 4 oral sessions and 32 poster presentations were offered.

Electromagnetically induced transparency in a Λ-type molecular system with permanent dipole moments revisited

Electromagnetically induced transparency (EIT) in a molecular three-level Λ system with permanent dipole moments and undergoing m- and n-photon transitions by pump and probe lasers is investigated. Analytical expressions are derived for probe absorption spectrum and dispersion for a medium of stationary as well as thermal molecules. Contrary to the earlier study by Zhou et al. [J. Chem. Phys. 131, 034105 (2009)], we observe no amplification in 2 + 2 photon process when the sign of the difference of the permanent moments of the excited and the ground levels is reversed. Reasons for these contrasting observations are discussed. Our study shows that the permanent moments essentially damp the laser-molecule Rabi frequency to result in narrower EIT line width and larger group velocity index. These effects are further enhanced when the order of the multi-photon process is increased. The importance of the virtual mechanism is discussed by considering the special case of 2 + 1 photon EIT.

A comparison of the colorectal surgical research across Europe, USA and Australasia

AIM

The annual scientific meetings of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the American Society of Colon and Rectal Surgeons (ASCRS), the European Society of Coloproctology (ESCP) and the Royal Australasian College of Surgeons (RACS) are the major fora for presentation of colorectal surgical research. Thus, their content could be a proxy of the content and quality of colorectal surgical research worldwide. We aimed to critically appraise the quantity, quality and topics of colorectal surgical research over the previous 5 years for the above meetings.

METHOD

All published abstracts from the ACPGBI, ASCRS, ESCP and the colorectal-specific component of the RACS from 2006 to 2010 were appraised. Abstracts were coded by predefined categories pertaining to study type and topic.

RESULTS

Level 1 evidence (systematic reviews/meta-analyses) and level 2 evidence (randomized controlled trials) comprised 3% (95% CI 1-9%) and 5% (95% CI 2-11%), respectively, of research presented at the meetings. There was a predominance of level 4 evidence (retrospective studies) across all years (mean 54%, 95% CI 44-68%). Operative management was most commonly studied (mean 43%, 95% CI 36-49%). There was minimal research in perioperative care (mean 6%, 95% CI 2-13%) and basic surgical science (mean 6%, 95% CI 2-11%). Research related to perioperative care was significantly higher at the ACPGBI and RACS meetings than the ASCRS and ESCP meetings (P<0.01).

CONCLUSION

The research at these meetings consists largely of retrospective reviews exploring operative management with minimal high quality scientific content. Active steps need to be taken to increase the quantity of high level evidence especially in topics other than operative management.

Determination of oxidative stress markers and their importance in early diagnosis of uremia-related complications

The existence of oxidative stress and the higher incidence of cardiovascular diseases in association with uremia is well proved. The uremic status of serum copper, ceruloplasmin (CP), protein thiols, malonyldialdehyde (MDA), and glutathione S-transferase (GST) levels was studied. The study was carried out on 51 chronic renal failure (CRF) patients who were not on hemodialysis therapy and on 42 healthy controls. Serum urea, creatinine, and MDA levels were found to be significantly increased (P < 0.001), and total protein, albumin, protein thiols, and copper levels were found to be significantly decreased in CRF patients compared to normal controls (P < 0.001). Ceruloplasmin levels were decreased significantly (P < 0.05), and there was no significant change in serum GST levels in CRF patients compared to normal controls. In conclusion, the significant increase in levels of MDA, and the decrease in levels of protein thiols, CP, and copper in uremia patients when compared to controls, reconfirms the presence of stress in this patient population. In view of the changes in other markers of oxidative stress, this absence of any significant change in the activity of GST in uremia patients compared to controls, warrants further study.

Changes in public commons as a consequence of urbanization: the Agara lake in Bangalore, India

The city of Bangalore in southern India is rapidly expanding, resulting in major transformations in land use, wetland management, and the distribution of green spaces. This paper examines how transformations in land use and governance consequent to urbanization can change people's perceptions of and interactions with an urban ecological commons, using the case study of the Agara lake in the south Indian city of Bangalore. In less than four decades, the landscape surrounding the lake has altered from a fundamentally agricultural area, dependent on the lake for irrigation and drinking water, to a densely urbanized area where the lake is used predominantly for recreation. A change in governance from community management to state management has sidelined the fishers, fodder collectors and agricultural users who traditionally maintained this lake. The governmental agencies that are supposed to maintain the lake are unable to do so due to a complex governance structure, with overlapping jurisdictions, compounded by an ongoing litigation. Over the past decades, the lake has largely transitioned into an urban green space primarily used for recreation and nature watching. This case study provides us with a broader understanding of how changes in governance consequent to urbanization and city expansion can impact interactions between people and ecological commons in a rapidly growing Indian city.

Msx1 mutations: how do they cause tooth agenesis?

Mutations in the transcription factors PAX9 and MSX1 cause selective tooth agenesis in humans. In tooth bud mesenchyme of mice, both proteins are required for the expression of Bmp4, which is the key signaling factor for progression to the next step of tooth development. We have previously shown that Pax9 can transactivate a 2.4-kb Bmp4 promoter construct, and that most tooth-agenesis-causing PAX9 mutations impair DNA binding and Bmp4 promoter activation. We also found that Msx1 by itself represses transcription from this proximal Bmp4 promoter, and that, in combination with Pax9, it acts as a potentiator of Pax9-induced Bmp4 transactivation. This synergism of Msx1 with Pax9 is significant, because it is currently the only documented mechanism for Msx1-mediated activation of Bmp4. In this study, we investigated whether the 5 known tooth-agenesis-causing MSX1 missense mutations disrupt this Pax9-potentiation effect, or if they lead to deficiencies in protein stability, protein-protein interactions, nuclear translocation, and DNA-binding. We found that none of the studied molecular mechanisms yielded a satisfactory explanation for the pathogenic effects of the Msx1 mutations, calling for an entirely different approach to the investigation of this step of odontogenesis on the molecular level.

DMP1 processing is essential to dentin and jaw formation

Dentin matrix protein 1 (DMP1), an acidic protein that is essential to the mineralization of bone and dentin, exists as proteolytically processed fragments in the mineralized tissues. In this study, we characterized the tooth and jaw phenotypes in transgenic mice containing no wild-type DMP1, but expressing a mutant DMP1 in which Asp(213), a residue at one cleavage site, was replaced by Ala(213) (named "Dmp1-KO/D213A-Tg" mice). The teeth and mandible of Dmp1-KO/D213A-Tg mice were compared with those of wild-type, Dmp1-knockout (Dmp1-KO), and Dmp1-KO mice expressing the normal Dmp1 transgene. The results showed that D213A-DMP1 was not cleaved in dentin, and the expression of D213A-DMP1 failed to rescue the defects in the dentin, cementum, and alveolar bones in the Dmp1-KO mice. These findings indicate that the proteolytic processing of DMP1 is essential to the formation and mineralization of dentin, cementum, and jaw bones.

Sensitivity of higher, lower and mean second-trimester uterine artery Doppler resistance indices in screening for pre-eclampsia

OBJECTIVES

First-trimester Doppler studies have reported that the lower uterine artery (UtA) resistance index (RI) is better for the prediction of pre-eclampsia (PE) than is either the mean or higher indices. The aim of this study was to determine if this relationship is true in the second trimester.

METHODS

This was a retrospective study of 24 859 singleton pregnancies. During the study period second-trimester UtA Doppler assessment was routinely available to all nulliparous women and to parous women at increased risk of PE. UtA-RI was obtained at the time of the anomaly scan. Receiver-operating characteristics curves for the lower, mean and higher UtA-RI for the prediction of PE were calculated.

RESULTS

There were 1037 cases of PE. There were significant associations between UtA-RI and PE, the association being stronger for early and preterm than late or term PE. There was no significant difference in the strength of the association between lower, mean and higher RI with PE at any gestation.

CONCLUSION

Performance of UtA-RI in predicting PE is no different for the lower, higher or mean RI of the two UtAs. The most likely explanation for the discrepancy with first-trimester studies is that the placental-side effect on Doppler indices may change with advancing gestational age and progressive trophoblast development and invasion.

Regional update: Cambodia

Cambodia is a developing south-east Asian country located in the fertile Mekong delta. Its recent past has been complicated by European colonialism and internal conflict. Health including mental health services are limited and sparse in regional and rural areas. Very constrained public mental health facilities and services are hampered by a shortage of a skilled workforce and insufficient training programs. The recent formation of the Mental Health Association of Cambodia promises to be a positive step forward in promoting mental health throughout the country.

Dietary habits associated with obesity among adolescents in Dubai, United Arab Emirates

AIM

to study the association between the dietary habits and behavioural factors with the increased risk of obesity amongst adolescents in Dubai, United Arab Emirates (UAE).

METHOD

A cross-sectional study was carried out among 661 adolescents (324 boys and 337 girls) aged 12 to 17 years selected by means of a multistage stratified random sampling technique.

RESULTS

The highest percentage of obesity was observed at 14 years of age in boys (30.5%) and at 13 years of age in girls (35.4%). There was a significant association between the frequency of eating breakfast (P =0.048), snacking between breakfast and lunch (P = 0.044), and obesity in girls but not in boys. A high risk of obesity was associated with eating breakfast at school in both boys (OR = 3.0; CI 1.1-8.3) and girls (OR = 3.4; CI 1.6-7.4). Fast foods showed a significant association with obesity in girls (P = 0.007), but not in boys (P = 0.745). The risk of obesity was higher in boys who ate fast foods at home (OR = 1.3; CI 0.5-3.2) but less in girls (OR = 0.2; CI 0.1-1.0).

CONCLUSION

Intervention programs focused on promoting changes in lifestyles, food habits and increasing physical activity need to be implemented at the earliest.

In VitroandIn VivoPreparation Evaluations of Bleomycin Implants and Microspheres Prepared with DL-Poly (Lactide-Co-Glycolide)

In this investigation, poly(lactide-co-glycolide) (PLGA) gel implants and microspheric depot systems of bleomycin (BLM) were formulated and evaluated in vivo in mice bearing transplantable solid tumor (fibrosarcoma). The pharmacodynamic studies showed that both the formulations retarded tumor growth significantly (p<0.05) when compared to the control animals (without any drug treatment). Preliminary pharmacokinetic studies illustrated controlled release of the drug into the systemic circulation to elicit the anti-neoplastic action. The gel implants showed better release characteristics and greater pharmacodynamic action when compared to the microspheres, thus demonstrating the feasibility of employing biodegradable depot polymer gel matrix for chronic cancer therapy.

Genes affecting tooth morphogenesis

The development of dentition is a fascinating process that encompasses a complex series of epithelial-mesenchymal interactions involving growth factors, transcription factors, signal receptors and other soluble morphogens. It is not surprising that such a complex process is prone to disturbances and may result in tooth agenesis. Initial discoveries indicating that the homeo-domain protein MSX1 and the paired-domain transcription factor PAX9 are causative genes in tooth morphogenesis were made in mice. Both genes are co-expressed in dental mesenchyme and either one, when homozygously deleted, results in an arrest at an early developmental stage. Heterozygous Pax9 or Msx1 mice have normal teeth, however, double heterozygous Pax9/Msx1 mice show a phenotype of arrested tooth development which can be rescued by transgenic expression of Bmp4, a very influential signaling factor in many developmental processes. We have obtained mounting evidence for a partnership between PAX9 and MSX1 within the tooth-specific Bmp4 signaling pathway. In humans, unlike in mice, a heterozygous mutation in either PAX9 or MSX1 suffices to cause tooth agenesis of a predominantly molar or more premolar pattern, respectively. Our laboratory and others have identified several PAX9 and MSX1 mutations in families with non-syndromic forms of autosomal dominant posterior tooth agenesis. We have also identified families with tooth agenesis in whom PAX9 and MSX1 mutations have been excluded opening up the possibilities for the discovery of other genes that contribute to human tooth agenesis.

WITHDRAWN: Antibiotics for preventing pneumonia in children with measles

BACKGROUND

Measles causes more than a million deaths a year, of which most are children under five years of age who die from pneumonia.

OBJECTIVES

The objective of this review was to assess the effects of antibiotics given to children with measles on reducing pneumonia or mortality, and to assess whether antibiotics should be given to all children with measles in communities with a high fatality rate.

SEARCH STRATEGY

We searched MEDLINE (1966 - 1999), EMBASE (1980-1999) and the specialized trials register of the Acute Respiratory Infections Group in August 1999, and all relevant journals in the University of Melbourne medical library for the years 1935-46.

SELECTION CRITERIA

Randomised or controlled trials of antibiotics for children with measles.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Six trials with 1304 children were included. All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls.

AUTHORS' CONCLUSIONS

The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation

OBJECTIVES

To establish the effectiveness and cost-effectiveness of cinacalcet for the treatment of secondary hyperparathyroidism (SHPT) for people on dialysis due to end-stage renal disease (ESRD).

DATA SOURCES

Electronic databases were searched up to February 2006.

REVIEW METHODS

Included randomised controlled trials (RCTs) on the clinical effectiveness of cinacalcet for SHPT in ESRD were critically appraised, had relevant data extracted and were summarised narratively. A Markov (state transition) model was developed that compared cinacalcet in addition to current standard treatment with phosphate binders and vitamin D to standard treatment alone. A simulated cohort of 1000 people aged 55 with SHPT was modelled until the whole cohort was dead. Incremental costs and quality-adjusted life-years (QALYs) were calculated. Extensive one-way sensitivity analysis was undertaken as well as probabilistic sensitivity analysis.

RESULTS

Seven trials comparing cinacalcet plus standard treatment with placebo plus standard treatment were included in the systematic review. A total of 846 people were randomised to receive cinacalcet. Cinacalcet was more effective at meeting parathyroid hormone (PTH) target levels (40% vs 5% in placebo, p < 0.001). In those patients meeting PTH targets, 90% also experienced a reduction in calcium-phosphate product levels, compared with 1% in placebo. Significantly fewer people treated with cinacalcet were hospitalised for cardiovascular events, although no difference was seen in all-cause hospitalisation or mortality. Significantly fewer fractures and parathyroidectomies were also seen with cinacalcet. Findings on all patient-based clinical outcomes were based on small numbers. The authors' economic model estimated that, compared to standard treatment alone, cinacalcet in addition to standard care costs an additional 21,167 pounds and confers 0.34 QALYs (or 18 quality-adjusted weeks) per person. The incremental cost-effectiveness ratio (ICER) was 61,890 pounds/QALY. In most cases, even extreme adjustments to individual parameters did not result in an ICER below a willingness-to-pay threshold of 30,000 pounds/QALY with probabilistic analysis showing only 0.5% of simulations to be cost-effective at this threshold. Altering the assumptions in the model through using different data sources for the inputs produced a range of ICERs from 39,000 pounds to 92,000 pounds/QALY.

CONCLUSIONS

Cinacalcet in addition to standard care is more effective than placebo plus standard care at reducing PTH levels without compromising calcium levels. However, there is limited information about the impact of this reduction on patient-relevant clinical outcomes. Given the short follow-up in the trials, it is unclear how data should be extrapolated to the long term. Together with the high drug cost, this leads to cinacalcet being unlikely to be considered cost-effective. Recommendations for future research include obtaining accurate estimates of the multivariate relationship between biochemical disruption in SHPT and long-term clinical outcomes.

The cost-utility of cinacalcet in addition to standard care compared to standard care alone for secondary hyperparathyroidism in end-stage renal disease: a UK perspective

BACKGROUND

Secondary hyperparathyroidism (SHPT) is a common side effect of end-stage renal disease (ESRD) and is associated with increased risk of fracture and cardiovascular events (CV). Current standard treatment includes dietary control, phosphate binders and vitamin D. However, many patients do not have their parathyroid hormone (PTH), calcium and phosphate levels controlled by this regimen. Cinacalcet is the first of a new class of calcimimetic drugs which suppress PTH production. Although there is convincing evidence of the impact of cinacalcet on serum biomarkers, the long-term clinical implications of treatment are less clear. The aim of this study is to estimate the cost-utility of cinacalcet as an addition to standard treatment of SHPT compared with standard treatment alone.

METHODS

A Markov model was developed to estimate the incremental cost-utility of cinacalcet. Uncertainty was explored through extensive sensitivity analysis.

RESULTS

Compared with standard treatment, cinacalcet incurs average additional lifetime costs of pound21,167 per person and confers an additional 0.34 quality adjusted life years, resulting in an incremental cost-effectiveness ratio of pound61,890 (approximately euro89,000) per quality-adjusted life-year (QALY). Extensive one-way sensitivity analysis showed that cinacalcet was only likely to be considered cost-effective if the relative risk of mortality for people with very high levels of PTH was 2.2 compared with people whose PTH reached target levels, or if drug costs were considerably reduced. Probabilistic sensitivity analysis showed cinacalcet was very unlikely to be cost-effective at usual levels of willingness to pay in the National Health Service (NHS).

CONCLUSION

Unless the cost of cinacalcet is considerably reduced, it is unlikely to be considered a cost-effective treatment for people with SHPT.

Sirolimus-Induced Remission of Posttransplantation Lymphoproliferative Disorder

Posttransplantation lymphoproliferative disorder (PTLD) is one of the most serious complications of solid-organ transplantation. It potentially is treatable in most cases, but current methods involve withdrawal or reduction of immunosuppression and the consequent risk for graft rejection. Sirolimus was shown in vivo and in vitro to limit proliferation of a number of malignant cell lines, including those of PTLD-derived cells. We present a case of disseminated PTLD in a patient with a renal transplant that resolved completely with conversion of immunosuppression to sirolimus. Graft function was maintained and improved with treatment. This offers a novel means of treating these patients and minimizing transplant loss.

Insulin resistance plays a significant role in liver fibrosis in chronic hepatitis C and in the response to antiviral therapy

OBJECTIVES

To assess whether insulin resistance is associated with liver fibrosis in a group of patients with chronic hepatitis C virus (HCV) infection and whether there were any differences in insulin resistance between Asians and the indigenous Caucasian population. Secondly, to assess whether insulin resistance is associated with sustained virological response to antiviral therapy.

METHODS

We determined insulin resistance in 59 (30 Caucasians; 29 Asians) consecutive patients with HCV prior to starting antiviral therapy. Insulin resistance was measured using the homeostasis model assessment of insulin resistance (HOMA-IR). The relationship between insulin resistance and biochemical, virological, and histological data together with response to antiviral therapy was assessed.

RESULTS

In multivariable analyses, insulin resistance as measured using the HOMA-IR model correlated positively with the stage of fibrosis, with higher degrees of insulin resistance in those with greater degrees of fibrosis (p < 0.001). This significant relationship remained even after excluding cirrhotic patients, or after adjusting for other factors associated with fibrosis in univariable analyses. Insulin resistance was significantly higher in Asians than Caucasians (p= 0.004). Around half (55.6%) of patients completing a course of antiviral treatment had a sustained virological response. Multivariable logistic regression identified HCV genotype 3, lower fasting glucose levels, and lower aspartate transaminase (AST) levels as being associated with a higher odds of a sustained virological response. After adjusting for these variables, Asian ethnicity, higher fasting insulin levels, and higher HOMA-IR levels were all associated with a poorer virological response to therapy.

CONCLUSIONS

Insulin resistance contributes to liver fibrosis in chronic HCV infection; this relationship is not genotypic specific. Asian patients had higher insulin resistance than Caucasians. Insulin resistance is also an important predictor of sustained response to antiviral therapy.

An unusual form of autoimmune hepatitis in young Somalian men

BACKGROUND

Significant diversity in disease severity has been identified for autoimmune disorders among different ethnic groups. Current knowledge of both the natural history and management of autoimmune hepatitis (AIH) has been derived from European or Japanese patients, and there is limited information about the disease in patients from other ethnic groups.

AIMS

To assess the clinical, histological and immunological features of AIH in patients from Somalia and to determine their response to therapy.

METHODS

Retrospective review of a cohort of young Somalian men with atypical AIH compared with a control group of European patients.

RESULTS

The six Somalian men were younger at presentation (median age 37 (range 24-59) years) than the seven female and three male European controls (55 (34-54) years, P = 0.06). The Somalians had slightly more severe disease at presentation-median modified Ishak stage of 2.5 compared with 2 in Europeans (P = 0.61) and four (66%) had features of cholestasis compared with only one (10%) European patient (P = 0.04). Therapy with prednisolone and azathioprine was completely effective for eight of 10 Europeans but only one of seven Somalians (P = 0.04). Analysis of human leucocyte antigen types revealed differences between the Somalian and European patients, although these differences did not reach statistical significance.

CONCLUSIONS

Somalian men with AIH present with cholestatic features and respond poorly to standard immunosuppressive regimes.

Discontinuation of pegylated interferon plus ribavirin in patients who are not responding to therapy -- patients' views of early cessation of therapy

BACKGROUND

Current therapy for chronic hepatitis C infection involves a course of pegylated interferon and ribavirin. Patients who do not show a virological response after 12 weeks of therapy have a low probability of sustained virological response and it is therefore recommended that such patients stop treatment.

AIM

To assess patients' views of early treatment cessation.

METHODS

We conducted a open-labelled study in three UK centres, in which patients with biopsy-proven chronic hepatitis C requiring therapy were offered the choice of a full course of therapy with 40 kDa pegylated interferon-alpha 2a plus ribavirin (24 or 48 weeks depending on viral genotype) or early cessation if therapy had failed after 12 weeks.

RESULTS

Ninety-five participants were enrolled and the majority (69%) did not wish to discontinue therapy even if it had low probability of success. In this unselected UK population, very few patients (4%) did not achieve an early virological response with the 40-kDa pegylated interferon-alpha 2a plus ribavirin and two of the four early virological non-responders decided to continue therapy.

CONCLUSION

Early discontinuation of 'ineffective' anti-viral therapy may prove less popular with patients than with health care providers, and further patient-directed education regarding the cost-effectiveness of therapy will be needed if early discontinuation of unsuccessful therapy is to be accepted by patients.

Vitamin C for preventing and treating the common cold

BACKGROUND

The role of oral vitamin C (ascorbic acid) in the prevention and treatment of the common cold has been a subject of controversy for at least sixty years. Public interest in the topic continues to be high and vitamin C continues to be widely sold and used as a preventive and therapeutic agent for this common ailment.

OBJECTIVES

To discover whether oral vitamin C in doses of 200 mg or more daily, reduces the incidence, duration or severity of the common cold when used either as continuous prophylaxis or after the onset of cold symptoms.

SEARCH STRATEGY

This updated review added to earlier searches, a full search of the following electronic databases: the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to June 2004); and EMBASE (1990 to June 2004).

SELECTION CRITERIA

Papers were excluded if a dose less than 200 mg daily of vitamin C was used; if there was no placebo comparison; if methods of outcome assessment were inadequately described; and if the report did not record any of the three study outcomes (incidence, duration or severity) in sufficient detail to enter into the meta-analysis. Three criteria of study quality were assessed: Jadad scores, placebo distinguish-ability, and allocation concealment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. 'Incidence' of colds during prophylaxis was assessed as the proportion of participants experiencing one or more colds during the study period. 'Duration' was the mean days of illness of cold episodes and 'severity' of these episodes was assessed by days confined indoors, off work or school. or by symptom severity scores.

MAIN RESULTS

Twenty-nine trial comparisons involving 11,077 study participants contributed to the meta-analysis on the relative risk (RR) of developing a cold while taking prophylaxis. The pooled RR was 0.96 (95% CI 0.92 to 1.00). A subgroup of six trials that involved a total of 642 marathon runners, skiers, and soldiers on sub-arctic exercises reported a pooled RR of 0.50 (95%CI 0.38 to 0.66). Thirty comparisons that involved 9,676 respiratory episodes contributed to the meta-analysis on common cold duration during prophylaxis . A consistent benefit was observed, representing a reduction in cold duration of 8% (95% CI 3% to 13%) for adult participants and 13.5% (95% CI 5% to 21%) for child participants. Fifteen trial comparisons that involved 7,045 respiratory episodes contributed to the meta-analysis of severity of episodes experienced while on prophylaxis. The pooled results revealed a difference favouring those on vitamin C when days confined to home and off work or school were taken as a measure of severity (p = 0.02), and when restricting to studies which used symptom severity scores (p = 0.16), and for the both measures of severity combined (p = 0.004). Seven trial comparisons that involved 3,294 respiratory episodes contributed to the meta-analysis of cold duration during therapy with vitamin C that was initiated after the onset of cold symptoms, and no significant difference from placebo was seen. Four trial comparisons that involved 2,753 respiratory episodes, contributed to the meta-analysis of cold severity during therapy and no significant difference from placebo was seen.In laboratory studies, differing methods of artificial transmission of virus to vitamin C or placebo treated volunteers in residential experiments gave different results. Volunteers infected by nasal installation showed small or no benefit from vitamin C, whereas a group who were infected more naturally, reported less severe symptom severity scores (p = 0.04).

REVIEWERS' CONCLUSIONS

The failure of vitamin C supplementation to reduce the incidence of colds in the normal population indicates that routine mega-dose prophylaxis is not rationally justified for community use. But evidence shows that it could be justified in persons exposed to brief periods of severe physical exercise and/or cold environments. Also, the consistent and statistically significant small benefits on duration and severity for those using regular vitamin C prophylaxis indicates that vitamin C plays some role in respiratory defence mechanisms. The trials in which vitamin C was introduced at the onset of colds as therapy did not show any benefit in doses up to 4 grams daily, but one large trial reported equivocal benefit from an 8 gram therapeutic dose at onset of symptoms.