Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

A multicentre review of the direct-access mammography programme in Ireland for women with breast pain

AIM

To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort.

MATERIALS AND METHODS

A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded.

RESULTS

The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer.

CONCLUSION

There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Research use cases measuring the impact of COVID-19 on population health

Background

Wide variations in COVID-19 infection and outcomes exist across Europe and within countries. PHIRI will look at COVID-19 impacts in specific subgroups by conducting research through use cases of immediate relevance for public health policies focusing on indirect effects of the pandemic related to healthcare and other policies to contain the pandemic. Furthermore, the use cases represent pilot activities for the benefits and added value of a research infrastructure by bringing together data from different European countries.

Methods

Four research use cases will focus on selected aspects of vulnerable population groups and risk factors, delayed medical care in cancer, perinatal health outcomes, as well as mental health outcomes and are selected based on public health importance, geographic coverage, feasibility of producing actionable insights and relevance for the PHIRI infrastructure. The use cases will demonstrate how a broad variety of secondary data (e.g. administrative and survey data) can be pooled and/or reused in a distributed way across Europe.

Results

The outputs of the use cases will be processed by formalizing data models, data management processes and analytical pipelines in an interoperable way to feed in the federated research infrastructure. The use cases facilitate research by making scalable, reproducible methods available within PHIRI and by publishing the FAIRified use cases analysis results on the Health Information Portal. They will provide outcomes to guide policy makers in preparedness and response scenarios and will ensure the development of a format for the timely dissemination of use case results to the targeted groups.

Conclusions

PHIRI will provide insights in real life use cases to generate immediate results on key health impacts of COVID-19 on population health to underpin decision making and will drive the development of the federated research infrastructure that allows rapid cycle analysis.

Prioritising health information needs in Europe: a Policy Delphi survey

Background

Health information (HI) includes data on population health, health determinants, health care systems, and health-relevant policy developments. Duly prioritised HI is essential to inform decision-makers, researchers and the public. Little can be found in the literature on HI prioritisation methods and procedures in Europe. Our study aims to close this gap.

Methods

We designed a two-round online Policy Delphi and addressed 119 contacts, mainly public health and health information experts, in 33 InfAct partner countries. The first round included structured and full-text questions; in the ongoing second round, participants rank prioritisation approaches according to 'desirability', 'feasibility', 'importance' and 'confidence'.

Results

In the first round, 19 questionnaires were fully completed; the presented results also include replies from interrupted surveys and drop-outs. 58% of the participants reported the existence of structured national HI prioritisation processes; 65% indicated stakeholder involvement, and 54% the application of defined criteria. National health targets or strategies played a major role in HI prioritisation. 17 respondents from 13 countries agreed to participate in the second round. Based on analysis of the first round, participants rank approaches to HI prioritisation, preferences for stakeholder involvement and coordination, partners and methods for criteria development, the role of national and international frameworks and options for good-practices in HI development. The expected outcome of our study is not one single recommendation for HI prioritisation, but a list of good practice-approaches.

Conclusions

Health systems in Europe are heterogeneous, and so are health information systems. Mapping, sharing and ranking HI prioritisation approaches will facilitate knowledge exchange in the context of building a sustainable EU HI-system and may inform relevant EU processes.

How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data?

INTRODUCTION

Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma).

METHODS

Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank.

RESULTS

This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result.

CONCLUSION

Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.

A national initiative in data science for health: an evaluation of the UK Farr Institute

OBJECTIVE

To evaluate the extent to which the inter-institutional, inter-disciplinary mobilisation of data and skills in the Farr Institute contributed to establishing the emerging field of data science for health in the UK.

DESIGN AND OUTCOME MEASURES

We evaluated evidence of six domains characterising a new field of science:defining central scientific challenges,demonstrating how the central challenges might be solved,creating novel interactions among groups of scientists,training new types of experts,re-organising universities,demonstrating impacts in society.We carried out citation, network and time trend analyses of publications, and a narrative review of infrastructure, methods and tools.

SETTING

Four UK centres in London, North England, Scotland and Wales (23 university partners), 2013-2018.

RESULTS

1. The Farr Institute helped define a central scientific challenge publishing a research corpus, demonstrating insights from electronic health record (EHR) and administrative data at each stage of the translational cycle in 593 papers with at least one Farr Institute author affiliation on PubMed. 2. The Farr Institute offered some demonstrations of how these scientific challenges might be solved: it established the first four ISO27001 certified trusted research environments in the UK, and approved more than 1000 research users, published on 102 unique EHR and administrative data sources, although there was no clear evidence of an increase in novel, sustained record linkages. The Farr Institute established open platforms for the EHR phenotyping algorithms and validations (>70 diseases, CALIBER). Sample sizes showed some evidence of increase but remained less than 10% of the UK population in primary care-hospital care linked studies. 3.The Farr Institute created novel interactions among researchers: the co-author publication network expanded from 944 unique co-authors (based on 67 publications in the first 30 months) to 3839 unique co-authors (545 papers in the final 30 months). 4. Training expanded substantially with 3 new masters courses, training >400 people at masters, short-course and leadership level and 48 PhD students. 5. Universities reorganised with 4/5 Centres established 27 new faculty (tenured) positions, 3 new university institutes. 6. Emerging evidence of impacts included: > 3200 citations for the 10 most cited papers and Farr research informed eight practice-changing clinical guidelines and policies relevant to the health of millions of UK citizens.

CONCLUSION

The Farr Institute played a major role in establishing and growing the field of data science for health in the UK, with some initial evidence of benefits for health and healthcare. The Farr Institute has now expanded into Health Data Research (HDR) UK but key challenges remain including, how to network such activities internationally.

Prioritizing Health Information in Europe – What do we want and need to know?

Background

Prioritization of Health information (HI) involves the establishment of methodological standards, and the development of political momentum to reliably track health status and health determinants. This is important in order to strengthen the evidence base for public health policies and facilitate effective delivery of healthcare services. In support of the establishment of a sustainable EU-wide Health information system, this consortium explores how HI is prioritized in EU and associated countries.

Methods

The Robert Koch Institute is conducting an online Policy Delphi survey among InfAct project partners, stakeholders from EU-Member States and associated countries. The Delphi methodology allows for rankings and priority-setting among a group of experts. The Policy Delphi facilitates the analysis of the impact and acceptability of a proposed policy option. The survey targets experts in national public health institutes and agencies, ministries of health and research. Participants are invited to provide information regarding their national HI prioritization processes, and to rank prioritization strategies and criteria, according to their degree of “desirability”, “feasibility”, “importance” and “confidence”.

Results

The Delphi survey will compile and assess processes and methods used to prioritize health information at national level in the EU and associated countries. The expected outcome is a list of good-practices in health information development and prioritization within countries, which could be further integrated to a health information prioritization strategy at the European level.

Conclusions

Prioritizing health information ensures that the right data is collected, is used to support ongoing public health policy action, and to capture emerging public health issues. This overview of prioritization strategies and methods aims to promote evidence-based public health by structuring exchanges about national HI prioritization in Europe.

Real world evidence for European health policy-making: making the case for interoperability

Background

The foundations of evidence-based health policy-making are transitioning from the use of partial evidence yielded elsewhere and the application of heuristic rules, to the development of learning systems based on the reuse of routine data collected by the same institutions that have to implement those policies. Supporting that transition, the scientific production of real-world evidence (RWE) is becoming pivotal, particularly in international policy-making. However, leveraging the immense wealth of data curated in European public institutions, requires the development of a new world-class research infrastructure and a supporting interoperability framework (IOF).

Methods

Based on the European Interoperability Framework (EIF) legal, organizational, semantic, and technical issues are being assessed. While legal, organizational and technical topics are analyzed from the perspective of the type of infrastructure, centralized or federated, to be developed, semantic interoperability is explored using three case studies on the linkage of different real world data sources: for characterizing resilient populations, studying the burden of dementia, and the effectiveness of stroke care pathways.

Results

Preliminary assessments advocate for the development of a federated infrastructure where data remain in house and research questions, data access and interoperability services are shared according to the capacity of each specific partner in the federation. Interoperability services for such an infrastructure should cover: a) the development and maintenance of a common data model to assure semantic interoperability, b) the development of self-contained distributed analytical pipelines; and c) the implementation of a training program aimed at increasing the capacity of each RI hub.

Conclusions

An interoperable federated research infrastructure is required to leverage the potential of real world data for European health policy-making. InfAct is paving the way.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Families' experiences of involvement in care planning in mental health services: an integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Current policy advocates for the participation of family carers in care planning. Caring for a person with a mental illness requires a significant commitment from families to support their relative's recovery. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The evidence of family involvement in care planning is generally fraught with conflicting experiences related to different requirements between mental health professionals, families and service users. Confidentiality remains contentious at a practice level in terms of information sharing and decision-making. There is a requirement and need for a shared understanding around care planning between families and mental health professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of written information pertaining to families regarding confidentiality is required at service level. Educational workshops concerning care planning and treatment options should be provided for service users, families and mental health professionals. Further research into effective service-wide strategies that explore with families how their engagement can be positively fostered in mental health services is warranted.

ABSTRACT

Introduction Mental health service policy stipulates that family carers be involved in care planning. Aim To identify families' experiences of care planning involvement in adult mental health services. Method An integrative review where electronic databases and grey literature were searched for papers published between 01 January 2005 and 10 February 2016. Results Fifteen papers met the inclusion criteria. Thematic analysis generated three themes: (1) families' experience of collaboration, (2) families' perceptions of professionals and (3) families' impressions of the care planning process. Collaborative decision-making is not regularly experienced by families with an 'us' and 'them' divide, perpetuated by a lack of communication, confidentiality constraints and a claim of 'insider knowledge' of service users. When involved, families perceive care planning to be uncoordinated and that their lived experiences are not always appreciated. Discussion Families need to be valued, empowered and engaged in care planning and the partnership distance be addressed. Accommodating the views of family, service user and professionals is preferable but not always possible. Our findings suggest that the key element for professionals is to value all 'insider knowledge' where possible. Implications for Practice Services should develop written information on confidentiality for families and facilitate open communication concerning their involvement in care planning.

Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.

Benign subcutaneous emphysema: A case report with bite

INTRODUCTION

Subcutaneous emphysema is the presence of air/gas within the subcutaneous tissue plane. Though there are numerous causative factors, benign subcutaneous emphysema is rare.

CASE REPORT

We report a very rare case of benign subcutaneous emphysema following an insect bite on the forearm of a 48-year old man. The puncture area was erythematous and the emphysema extended to the whole arm, axilla and superior mediastinum. Despite, conservative management, the patient had residual discomfort and erythema around the puncture site. Surgical debridement resulted in resolution of symptoms.

DISCUSSION

Subcutaneous emphysema affecting an isolated limb is extremely rare. It is vital to differentiate it from life-threatening soft-tissue infections secondary to a gas-forming organism. Immunodeficiency states are key factors in the development and the outcomes of patients with subcutaneous emphysema. Medical management successfully resolves symptoms in the majority of cases. However, surgical debridement of the puncture site and surrounding fibrotic tissue has been advocated for those with persistent symptoms.

CONCLUSION

This case highlights a rare cause of benign subcutaneous emphysema, highlighting key issues surrounding its management for a successful outcome.

Burns in young children: a retrospective matched cohort study of health and developmental outcomes

BACKGROUND

Unintentional injuries are a major cause of death and disability in childhood. Most burns are unintentional, the majority occurring in pre-school children. Little is known about the outcomes of young children following burns. The purpose of this study was to examine the presenting features of burned children and compare their health and developmental outcomes with controls.

METHODS

Children under 3 years admitted to the Welsh Regional Burns Centre between September 1994 and August 1997 were studied up to their sixth birthday (final data collection 2003) to ascertain the nature, course and cause of their burn. One hundred and forty-five burned children were matched with 145 controls. Their physical, psychosocial and educational health status was compared. Retrospective data were gathered from hospital notes, social services, emergency department databases, child health surveillance records and schools.

RESULTS

Burns peaked at age 13-18 months were typically sustained by scalding, drink spillage and contact with hot objects. They occurred most frequently at mealtimes and 89.7% were judged to be unintentional. There was a high rate of non-attendance for follow-up - 24%. The families of children admitted with burns were more likely to have moved home than those of controls (P = 0.001). By age 6 significantly more cases were admitted to hospital with an unrelated condition (P = 0.018). There were no differences between the cases and controls in immunization status, development, school attendance and educational progress up to the age of 6 years (P > 0.05).

CONCLUSIONS

We found important findings in relation to unintentional injury prevention and also noted markers that may indicate inequalities in health service utilization between cases and controls. There were no major differences between developmental and educational outcomes in the two groups.

Baseline predictors of response to treatment with darbepoetin-alpha (DA) in anemic patients with low-risk myelodysplastic syndrome (MDS)

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Background: Patients (pts) with MDS often develop anemia, resulting in fatigue and an increased requirement for transfusions. The erythropoiesis-stimulating agent (ESA) DA can raise hemoglobin (Hb) levels in low-risk MDS pts. Previous analyses suggest that baseline (BL) endogenous erythropoietin (eEPO) levels and French-American-British (FAB) disease category are predictors of response to ESAs. Methods: This was a phase 2, open-label, 52-week (wk) study of DA administered 500 mcg every 3 wks (Q3W) to anemic (Hb=11g/dL), low- or intermediate-risk MDS pts. Pts received 500 mcg DA Q2W if they did not respond by wk 7. The last DA dose was at wk 52; end of study was wk 53 or 55 for pts receiving DA Q2W or Q3W, respectively. The primary endpoint was % pts with an erythroid response (International Working Group criteria) by wk 13. Other endpoints included change from BL in Hb and FACT-F score. Exploratory analyses examined the incidence of erythroid responses adjusted by FAB category (refractory anemia [RA], RA with ringed sideroblasts [RARS], or RA with excess blasts [RAEB]). Results: Final 53/55 wk data will be presented. Results were stratified by whether pts received an ESA before enrollment (ESA-naive [ESA-N] vs ESA-treated [ESA-T]). ESA-T pts are a heterogeneous group and their data are difficult to interpret; thus, predictors of response will be presented for ESA-N pts only. Of 144 ESA-N pts, 56% had RA, 37% had RARS, and 7% had RAEB. Most ESA-N pts achieved the target Hb and had a major erythroid response ( Table ). Pts with RA were more likely to achieve a major erythroid response than pts with RARS or RAEB. For ESA-T pts, demographics and type/length of ESA treatment will be presented. Of all pts, serious adverse events (SAEs) were reported in 62 (30%) pts and treatment-related SAEs in 2 (1%) pts. Conclusions: FAB category may affect response to DA in MDS pts. Additional data will be presented on the effect of BL eEPO, transfusion needs, and previous ESA treatment on response and duration of response.

[Table: see text]

Tranfusion independence assessed using three alternative dosing schedules of azacitidine in patients with myelodysplastic syndromes

6574

Background: The dosing schedule of azacitidine (75 mg/m2/day subcutaneous [SC] × 7 days, every 28 days) decreased transfusion requirements in myelodysplastic syndrome (MDS) patients in a CALGB trial by Silverman et al (JCO 2002;20:2429). Our study assessed effects on transfusion requirements in MDS patients receiving 3 alternative azacitidine dosing regimens not requiring weekend injections. Methods: This phase II, multicenter study enrolled MDS patients with any FAB subtype, life expectancy ≥7 months, and ECOG performance grade of 0–3. RA/RARS patients had to have ≥1 of the following: hemoglobin <110 g/L with transfusion need, platelet counts <100 × 109/L, or ANC <1.5 × 109/L. Patients were randomized to 1 of 3 SC regimens: AZA 5–2-2 (75 mg/m2/day × 5 days, followed by 2 days no treatment, followed by 75 mg/m2/day × 2 days), AZA 5–2-5 (50 mg/m2/day × 5 days, followed by 2 days no treatment, followed by 50 mg/m2/day × 5 days), or a 3rd regimen added later by protocol amendment: AZA 5 (75 mg/m2/day × 5 days). After 6 cycles, patients meeting International Working Group MDS response/improvement criteria (Blood 2000;96: 3671) of ≥ stable disease could continue in study for 12 more cycles. Results: In all, 75 patients (median age, 74.5 years; 61% male) are currently enrolled with 49 evaluable (completed ≥ 2 treatment cycles). To date, 12, 9, and 1 patient(s) have received ≥6 cycles of AZA 5–2-2, AZA 5–2-5, or AZA 5, respectively. RA + RARS, defined by FAB (60%) or WHO (47%), are the most common MDS subtypes. Of 24 patients, RBC transfusion dependent at baseline, 13 (54%) became independent ( Table ). Only 2 patients were platelet transfusion dependent at baseline; both became independent. After a median followup of 24 weeks, median duration of transfusion independence has not been reached. Conclusions: Treatment with azacitidine yields transfusion independence rates of 40%-60%. These preliminary results are similar across the 3 alternative doses and consistent with previous azacitidine data.

[Table: see text]

No significant financial relationships to disclose.

Darbepoetin alfa for treating anemia in low-risk myelodysplastic syndrome patients: Interim results after 27/28 weeks

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Background: Patients (pts) with myelodysplastic syndrome (MDS) disorders often develop anemia, resulting in increased transfusions and fatigue. Using the erythropoiesis-stimulating agent (ESA) epoetin alfa to treat anemia in low-risk MDS pts results in an average response rate of 30% (40% when used with G-CSF). Pilot studies suggest that 150 or 300 mcg/week (wk) darbepoetin alfa (DA) can raise hemoglobin (Hb) levels in anemic MDS pts. Methods: This fully enrolled (n = 209), phase 2, single-arm, 52-wk ongoing study is examining DA 500 mcg every 3 weeks (Q3W) for treating anemic pts (Hb ≤ 11 g/dL) with low- or intermediate-risk MDS (IPSS definition). The study’s primary endpoint is the proportion of pts achieving an erythroid response by 13 wks. Other endpoints include the proportion of pts achieving an erythroid response by 27/28 wks and change in both Hb levels and FACT-F scores. Results are stratified by whether pts received ESA therapy before enrollment: ESA-naïve (ESA-N) vs ESA-treated (ESA-T). Results: Previous interim data suggested that low-risk MDS pts can achieve a major erythroid response after 13 wks of DA 500 mcg Q3W. This is the first reported summary of results from a planned interim analysis after 27/28 wks of treatment (n = 129). Of 84 ESA-N pts, 51% were men, 86% were white, and the average (SD) age was 74.1 (9.7) years; the 45 ESA-T pts had similar demographics. During 27/28 wks of treatment, a majority of pts achieved a major erythroid response. ESA-N pts had a mean (SD) 1.2 (1.4) g/dL rise in Hb levels from BL and a clinically significant increase in FACT-F score from BL ( Table ). Of the 129 pts analyzed after 27/28 wks, 83% reported an adverse event (AE) and none reported serious treatment-related AEs or thrombotic events (of 189 pts analyzed after 13 wks, 1 pt reported a serious treatment-related AE). Conclusions: These interim results suggest that DA 500 mcg Q3W is well tolerated and can raise Hb levels in anemic, low-risk MDS pts. Final 27/28-wk data from all enrolled pts (n = 209) will be shown.

[Table: see text]

[Table: see text]

Darbepoetin alfa for treating anemia in patients with low-risk myelodysplastic syndromes: Exploratory analysis of baseline predictors of response

6579

Background: Patients (pts) with myelodysplastic syndromes (MDS) often develop anemia, resulting in fatigue and increased transfusions. The erythropoiesis-stimulating agents (ESAs) epoetin alfa and darbepoetin alfa (DA) can raise hemoglobin (Hb) levels in low-risk MDS pts. Baseline (BL) endogenous erythropoietin (eEPO) levels, transfusion history, and FAB sub-type can be predictive factors of response to ESAs (Hellström-Lindberg et al., 2003). Methods: This is an ongoing, fully enrolled (n = 209), phase 2, single-arm, 52-week (wk) study of DA 500 mcg every three weeks (Q3W) for treating anemia (Hb ≤ 11 g/dL) in low- or intermediate-risk MDS pts. A planned interim analysis was done after 13 wks (n = 189). The primary endpoint is the proportion of pts with an erythroid response by 13 wks. Other endpoints include change in Hb levels and in FACT-F score from BL. Results are stratified by whether pts received an ESA before enrollment: ESA-naïve (ESA-N) pts vs ESA-treated (ESA-T) pts. Exploratory analyses of the percentage of pts with an erythroid response adjusted by BL eEPO or FAB category were done. Results: Of 130 ESA-N pts, 52% were women, 86% were white, 58% had refractory anemia (RA), 34% had RA with ringed sideroblasts (RARS), 8% had RA with excess blasts (RAEB), and the mean (SD) age was 74.8 (10.1) years. The 59 ESA-T pts had similar demographics. A majority of ESA-N pts had an erythroid response, achieved a target Hb of 11 g/dL, and had a clinically significant rise in FACT-F score; ESA-N pts with lower BL eEPO levels were more likely to have a major erythroid response ( Table ). A major erythroid response was seen in 50% of pts with RA (n = 111), in 30% of pts with RARS (n = 64), and in 23% of pts with RAEB (n = 13). Of all 189 pts, 78% had an adverse event (AE), 1 had a serious treatment-related AE (hypertension), and none had thrombotic events. Conclusions: These interim results suggest that FAB sub-type and BL eEPO may affect response. Final 13-wk data from all enrolled pts (n = 209) will be shown.

[Table: see text]

[Table: see text]

Microdialysis sampling and the clinical determination of topical dermal bioequivalence

Our objective was to determine whether the degree of variability associated with dermal microdialysis allows its practical application to determinations of bioequivalence of topically applied agents with a reasonable number of subjects. A statistical review of literature data was conducted to estimate the variances associated with subject-to-subject variability and the probe-to-probe variability within the subjects. In order to successfully utilise dermal microdialysis to establish bioequivalence of topically applied agents, particular care must be applied to study design. Due to the inherent variability between subjects, to maintain subject numbers at reasonable levels, each subject should act as their own control, thus removing the element of subject-to-subject variability from calculations of sample sizes. It is also recommended that measurements are made in duplicate in each subject to reduce the element of variability further. It is then possible to demonstrate, within 80-125% confidence limits and a subject population of approximately 20, that two formulations are bioequivalent.

The DNA sequence quality machine at IFOM: a simple Web-based tool for quantitative assessment of sequencing reactions

DNA sequence quality is a factor of paramount importance in the world of modern genetic and genomics. Both the sequencing of Human Genome in the "post-draft" era [NHGRI Standard for quality of Human Genomic Sequences, Rev. 7 July (2002) where http://www.nhgri.nih.gov/Grant_info/Funding/ Statements/RFA/quality_standard.html is the HTTP address] and recent "high-throughput" approaches to genetic investigation such as SAGE [Velculescu, V.E., Zhang, L., Vogelstein, B. et al. (1995) "Serial analysis of gene expression", Science 270, 484-487] need a reliable, standardized measure of the quality of a sequencing reaction. The increasing importance of SNP studies also requires a stronger quality control on sequencing reactions by the final user. We propose here a simple, web-based tool for integrated sequence quality evaluation, high quality region quantitative value calculation and chromatogram display. This software is aimed at the small to medium DNA sequence laboratory or to the single researcher, interested in getting a quantitative measure of the sequence quality, browsing the chromatogram and checking the quality values base by base. The program is freely available from the IFOM bioinformatics web Server at http://bio.ifom-firc.it/Phred20/index.html.

Botulism as a cause of respiratory failure in injecting drug users

BACKGROUND

Wound botulism occurs as a consequence of inoculation of Clostridium botulinum spores into a wound.

AIM

To describe such a case of wound botulism.

RESULTS

A 23-year-old drug-injecting user presented with bulbar symptoms and progressive signs over a three-day period. The diagnosis of botulism was suspected and was treated with large doses of penicillin and botulinum antitoxin. The diagnosis was confirmed by the presence of serum botulinum toxin A.

CONCLUSION

Physicians should be aware of the association of botulism in injecting drug users, particularly in Ireland.

A combination vaccine confers full protection against co-infections with influenza, herpes simplex and respiratory syncytial viruses

Combined/composite vaccines should be useful in reducing the number of vaccinations and provide more flexibility in confronting biological warfare scenarios. We tested the effectiveness of a composite genetic vaccine designed from previously known protective antigens directed against influenza A virus (INF-A), herpes simplex virus type-1 (HSV-1) and respiratory syncytial virus (RSV) in a mouse-based challenge. Immunizing mice with a pool of four plasmids; INF-A haemagglutinin (HA), INF-A nucleoprotein (NP), HSV-1 glycoprotein D (gD) and RSV glycoprotein F, against the three pathogens provided full protection when mice were challenged with each pathogen. Remarkably, mice challenged with all three pathogens at once were also fully protected, even when a bacterial pathogen, Mycoplasma pulmonis, was included in the challenge. If these results are extendable to other combinations of vaccines in other hosts, it would support the development of gene vaccines as multi-component, combination vaccines.

Aerosol gene transfer with inducible nitric oxide synthase reduces hypoxic pulmonary hypertension and pulmonary vascular remodeling in rats

BACKGROUND

Nitric oxide (NO) is a potent vasodilator with an important role in the regulation of pulmonary vascular tone. The effects of NO synthase (NOS) gene transfer on pulmonary vascular remodeling associated with hypoxic pulmonary hypertension are unknown.

METHODS AND RESULTS

We aerosolized 3 x 10(9) pfu of an adenoviral vector containing inducible NOS gene (AdNOS2), constitutive NOS3 gene (AdNOS3), or no transgene (AdRR5) into rat lungs. Exhaled NO levels, monitored with chemiluminescence, were higher in AdNOS2-infected rats than in AdNOS3- and AdRR5-infected rats (at 3 days, 33+/-6 ppb, n=9, versus 17+/-4, n=9, and 6+/-2 ppb, n=3, P:<0.05 for both). Exposure to FIO(2) 0.10 for 7 days increased pulmonary artery pressure from 19+/-4 mm Hg (baseline) to 27+/-1 and 26+/-2 mm Hg in AdNOS3- and AdRR5-infected rats, respectively, but only to 21+/-1 mm Hg in AdNOS2-infected animals (P:<0.05). After 7 days of hypoxia, total pulmonary resistance in AdRR5- and AdNOS3-infected rats was significantly higher than in AdNOS2-infected animals (0.41+/-0.05 and 0.39+/-0.07 versus 0.35+/-0. 03 mm Hg. mL(-)(1). min(-)(1), respectively, P:<0.05). Right ventricular hypertrophy was reduced in AdNOS2-infected rats [right ventricular/(left ventricular+septal) weight, 0.19+/-0.10 versus 0. 28+/-0.10 and 0.32+/-0.10 in AdRR5- and AdNOS3-infected rats, respectively, P:<0.05]. The percentage of muscularized precapillary pulmonary resistance vessels was also significantly decreased (18+/-4% versus 25+/-8% and 30+/-5% in AdRR5- and AdNOS3-infected rats, P:<0.05).

CONCLUSIONS

Aerosol NOS2 gene transfer increases pulmonary NO production and significantly reduces hypoxic pulmonary hypertension and pulmonary vascular remodeling. Aerosol NOS2 gene transfer may be a promising strategy to target pulmonary vascular disorders.

Growth factor-independent proliferation of erythroid cells infected with Friend spleen focus-forming virus is protein kinase C dependent but does not require Ras-GTP

Interaction of erythropoietin (Epo) with its cell surface receptor activates signal transduction pathways which result in the proliferation and differentiation of erythroid cells. Infection of erythroid cells with the Friend spleen focus-forming virus (SFFV) leads to the interaction of the viral envelope glycoprotein with the Epo receptor and renders these cells Epo independent. We previously reported that SFFV induces Epo independence by constitutively activating components of several Epo signal transduction pathways, including the Jak-Stat and the Raf-1/mitogen-activated protein kinase (MAPK) pathways. To further evaluate the mechanism by which SFFV activates the Raf-1/MAPK pathway, we investigated the effects of SFFV on upstream components of this pathway, and our results indicate that SFFV activates Shc and Grb2 and that this leads to Ras activation. While studies with a dominant-negative Ras indicated that Ras was required for Epo-induced proliferation of normal erythroid cells, the Epo-independent growth of SFFV-infected cells can still occur in the absence of Ras, although at reduced levels. In contrast, protein kinase C (PKC) was shown to be required for the Epo-independent proliferation of SFFV-infected cells. Further studies indicated that PKC, which is thought to be involved in the activation of both Raf-1 and MAPK, was required only for the activation of MAPK, not Raf-1, in SFFV-infected cells. Our results indicate that Ras and PKC define two distinct signals converging on MAPK in both Epo-stimulated and SFFV-infected erythroid cells and that activation of only PKC is sufficient for the Epo-independent proliferation of SFFV-infected cells.

Approximations for modal coupling in scattered fields from orifices

Previous investigations have used Hankel transforms to establish the velocity potentials of the wave fields resulting from arbitrary angle plane wave impingement on a circular orifice in a rigid, thick wall. The scattered field from the orifice is examined, in particular the modal contributions to the amplitude of its velocity potential. For each m,n mode the amplitude is dependent upon the amplitude of the in-orifice waves and a driving term unique to each m,n mode. In establishing the amplitudes of the in-orifice waves, the effects of modal coupling are also considered. In this work these two components of the scattered wave amplitude are investigated on a modal basis and approximations given for coupling effects. These approximations are then used to calculate the scattered field and the results compared with conventional solutions that use full modal coupling.

Efficacy of antiretroviral agents against murine replication-competent retrovirus infection in human cells

Retroviral vectors for gene therapy are designed to minimize the occurrence of replication-competent retrovirus (RCR); nonetheless, it is possible that a vector-derived RCR could establish an infection in a patient. Since the efficacy of antiretroviral agents can be impacted by interactions between virus, host cell, and drug, five commonly used antiretroviral drugs were evaluated for their abilities to inhibit the replication of a murine leukemia virus (MLV)-derived RCR in human cells. The results obtained indicate that the combination of nucleoside analogs zidovudine and dideoxyinosine with the protease inhibitor indinavir effectively inhibits MLV-derived RCR replication in three human cell lines. In addition, MLV-derived RCR was found to be inherently resistant to the nucleoside analogs lamivudine and stavudine, suggesting that mutations conferring resistance to nucleoside analogs in human immunodeficiency virus type 1 have the same effect even in an alternative viral backbone.

In vitro analysis of transformation potential associated with retroviral vector insertions

While replication-defective retroviral vectors provide excellent vehicles for the long-term expression of therapeutic genes, they also harbor the potential to induce undesired genetic changes by random insertions into the host genome. The rate of insertional mutagenesis for retroviral vectors has been determined in several different assay systems; however, the rate at which such events induce cellular transformation has not been directly determined. Such measurements are critical to determining the actual risk of carcinogenesis resulting from retroviral gene therapy. In this study, the ability of a replication-defective retroviral vector, GlnBgSvNa, to induce cellular transformation in the BALB/c-3T3 in vitro transformation assay was assessed. The transformation frequency observed in vector-transduced BALB/c-3T3 cells, which contained one to six copies of integrated provirus, was not significantly different from that of untreated control cells. The finding that GlnBgSvNa was nontransforming in this assay indicates that the rate of transformation induced by retroviral insertions is less than the spontaneous rate of cellular transformation by BALB/c-3T3 cells, or less than 1.1 x 10(-5). These results are the first to define an upper limit for the rate of transformation induced by retroviral vectors.

Ten-year survival of Down syndrome births

OBJECTIVE

To determine the survival status of children with Down syndrome (DS), and to document factors influencing survival.

DESIGN

Follow-up study of cases identified from the Dublin European Register of Congenital Anomalies and Twins (EUROCAT) Register. Follow-up was attempted for each case until death or 1992 or until the date last known to be alive.

SETTING

Eastern Health Board, Dublin.

SUBJECTS

In all, 389 DS children, born between 1 January 1980 and 31 December 1989 were followed up.

RESULTS

Survival rates of 88% at one year and 82% at 10 years were found. There was a non-significant improvement in survival between the cohort born in 1980-1984 and that born in 1985-1989. Congenital heart defects reduced survival to 72% and complete atrio-ventricular canal defects (CAVD) had the poorest prognosis (58% survival at 10 years). Cases with CAVD showed a trend towards improved survival when surgically treated. Maternal age mother's county of residence, sex of infant, season of birth and presence of additional non-cardiac congenital anomalies had no impact on survival.

CONCLUSIONS

Four out of five DS children now survive at least 10 years. Adequate educational and health service provision needs to be made for them, especially those with congenital heart defects. The need for studies which compare survival and quality of life in DS children with CAVD who undergo cardiac surgery versus those who do not, taking account of various selection factors, is identified.

Expression of human cholesterol 7alpha-hydroxylase in atherosclerosis-susceptible mice via adenovirus infection

Adenovirus is a vector for the delivery of genes mainly to the liver. Short-term (approximately 3 days) studies using adenovirus transfection have provided valuable insights into how genes can complement normal and pathological phenotypes. When atherosclerosis-susceptible C57BL/6 mice were infected with an adenovirus vector containing the human 7alpha-hydroxylate cDNA (AV17h1) and fed on a chow diet, human 7alpha-hydroxylase mRNA and enzyme activity doubled compared with that in mice infected with an adenovirus vector (AV1Null) alone. In AV17h1-infected mice fed on a high fat cholic acid (HFCA) diet, mRNA expression and activity of both the endogenous and adenovirus (human) 7alpha-hydroxylase were repressed. AV17h1-infected mice fed on a HFCA diet and killed at mid-light had increased 7alpha-hydroxylase activity and mRNA compared with mice killed at mid-dark. Since expression of AV17h1 is driven by a constitutive Rous sarcoma virus promoter, the repression of human 7alpha-hydroxylase by the HFCA diet was unexpected. In spite of this post-transcriptional repression by the HFCA diet, AV17h1-infected mice expressed the human 7alpha-hydroxylase mRNA, causing its enzyme activity to be 3-fold greater than in AV1Null-infected mice. In AV17h1-infected mice, the 7alpha-hydroxylase enzyme activity varied as a linear function of human mRNA abundance. In conclusion, the accumulation of apolipoprotein B-containing lipoproteins in plasma of C57BL/6 mice fed on the HFCA diet was not reduced by longer-term (2 weeks) 7alpha-hydroxylase expression, probably because of its diminished expression caused by the diet and hepatic inflammation from the adenovirus infection. These results may suggest that adenovirus is effective in promoting longer-term (2 weeks) expression of 7alpha-hydroxylase.