Self-report and device-based physical activity measures and adherence to physical activity recommendations: a cross-sectional survey among people with inflammatory joint disease in four European countries

OBJECTIVES

Self-monitoring of physical activity (PA) has the potential to contribute to successful behaviour change in PA interventions in different populations, including people with inflammatory joint diseases (IJDs). The objectives of this study were to describe the use and knowledge of self-report-based and device-based PA measures in people with IJDs in four European countries, and to explore if the use of such devices, sociodemographic or disease-related variables were associated with adherence to the recommendations of at least 150 min of moderate to vigorous PA per week.

SETTING

Cross-sectional survey, performed in 2015-2016.

PARTICIPANTS

People with IJDs in Belgium, Denmark, Ireland and Sweden.

PRIMARY AND SECONDARY OUTCOME MEASURES

Use of self-report and device-based PA measures, receipt of instructions how to use PA measures, confidence in using them, adherence to PA recommendations and associated factors for adherence to PA recommendations.

RESULTS

Of the 1305 respondents answering questions on PA measures, 600 (46%) reported use of any kind of self-report or device-based measures to self-monitor PA. Between country differences of 34%-58% was observed. Six per cent and four per cent received instructions from health professionals on how to use simple and complex devices, respectively. Independent associated factors of fulfilment of recommendations of PA were living in Ireland (OR=84.89, p<0.001) and Sweden (OR=1.68, p=0.017) compared with living in Denmark, not perceiving activity limitations in moderate activities (OR=1.92, p<0.001) and using a device to measure PA (OR=1.56, p<0.001). Those living in Belgium (OR=0.21, p<0.001) were less likely to fulfil recommendations of PA.

CONCLUSIONS

Almost half of the participants with IJDs used self-report-based or deviced-based PA measures, although few used wearable devices regularly. The results indicate that participants meeting public PA health guidelines were engaged in self-monitoring of PA.

'I learnt so much about being active': experiences of people with rheumatoid arthritis on the impact of a physiotherapist-led intervention to encourage physical activity

INTRODUCTION

Physical activity (PA) is an important component in improving the health of people with rheumatoid arthritis (RA). A Physiotherapist-led Intervention to Promote PA in people with RA (PIPPRA) was undertaken using the Behaviour Change (BC) Wheel. A qualitative study was conducted post intervention involving participants and healthcare professionals who participated in a pilot RCT.

METHODS

Face-to-face semi-structured interviews were conducted with the schedule exploring: experience and views of the intervention; experience and suitability of outcome measures used; and perceptions of BC and PA. Thematic analysis was used as an analytical approach. The COREQ checklist provided guidance throughout.

RESULTS

Fourteen participants and eight healthcare staff participated. Three main themes were generated from participants: (1) positive experience of intervention - 'I found it very knowledgeable to help me get stronger'; (2) improvement in self-management - '&hellip; motivate me maybe to go back to doing a little bit more exercise'; and (3) negative impact of COVID-19 - 'I don't think doing it online again would be really good at all'. Two main themes were generated from healthcare professionals: (1) positive learning experience of delivery - 'Really made me realise the importance of discussing physical activity with patients'; and (2) positive approach to recruitment - 'Very professional team showing the importance of having a study member on site'.

DISCUSSION

Participants had a positive experience of being involved in a BC intervention in order to improve their PA and found it acceptable as an intervention. Healthcare professionals also had a positive experience, in particular the importance of recommending PA in empowering patients.

Feasibility of a physiotherapist-led behaviour change intervention to improve physical activity in people with rheumatoid arthritis

INTRODUCTION

Physical activity (PA) interventions incorporating behaviour change (BC) theory are needed to improve PA levels in people with rheumatoid arthritis. A pilot feasibility study of a Physiotherapist-led Intervention to Promote PA in Rheumatoid Arthritis (PIPPRA) was undertaken to obtain estimates for recruitment rate, participant retention and protocol adherence.

METHODS

Participants were recruited at University Hospital (UH) rheumatology clinics and randomly assigned to control group (physical activity information leaflet) or intervention group (four BC physiotherapy sessions in 8 weeks). Inclusion criteria were diagnosis of RA (ACR/EULAR 2010 classification criteria), aged 18+ years and classified as insufficiently physically active. Ethical approval was obtained from the UH research ethics committee. Participants were assessed at baseline (T0), 8 weeks (T1) and 24 weeks (T2). Descriptive statistics and t-tests were used to analyse the data with SPSS v22.

RESULTS

320 participants were approached about the study with n=183 (57%) eligible to participate and n=58 (55%) consented to participate (recruitment rate: 6.4 per month; refusal rate 59%). Due to the impact of COVID-19 on the study, n=25 (43%) participants completed the study (n=11 (44%) intervention and n=14 (56%) control). Of the 25, n=23 (92%) were female, mean age was 60 years (s.d. 11.5). Intervention group participants completed 100% of BC sessions 1 and 2, 88% completed session 3 and 81% completed session 4.

DISCUSSION

The intervention to promote physical activity was feasible and safe and provides a framework for larger intervention studies. Based on these findings, a fully powered trial is recommended.

Real-world treatment sequencing and survival in previously treated advanced renal cell carcinoma patients receiving nivolumab monotherapy: a UK retrospective cohort study

Background

The CheckMate 025 trial established nivolumab monotherapy as one of the standards of care in previously treated advanced or metastatic renal cell carcinoma (aRCC). However, supporting real-world data is lacking. This study investigated characteristics, treatment sequences and clinical outcomes of patients who received nivolumab monotherapy for previously treated aRCC in the UK.

Methods

This was a retrospective cohort study of aRCC patients treated with nivolumab at second line or later (2L +) at 4 UK oncology centres. Eligible patients commenced nivolumab (index date) between 01 March 2016 and 30 June 2018 (index period). Study data were extracted from medical records using an electronic case report form. Data cut-off (end of follow-up) was 31 May 2019.

Results

In total, 151 patients were included with median follow-up of 15.2 months. Mean age was 66.9 years, male preponderance (72.2%), and mostly Eastern Cooperative Oncology Group performance status grade 0–1 (71.5%). Amongst 112 patients with a known International Metastatic RCC Database Consortium score, distribution between favourable, intermediate, and poor risk categories was 20.5%, 53.6%, and 25.9% respectively.

The majority of patients (n = 109; 72.2%) received nivolumab at 2L, and these patients had a median overall survival (OS) of 23.0 months [95% confidence interval: 17.2, not reached]. All patients who received nivolumab at 2L had received TKIs at 1L. Amongst the 42 patients (27.8%) who received nivolumab in third line or later (3L +) the median OS was 12.4 months [95% CI: 8.8, 23.2]. The most common reasons for nivolumab discontinuation were disease progression (2L: 61.2%; 3L: 68.8%) and adverse events (2L: 34.7%; 3L: 28.1%).

Conclusion

This study provides real-world evidence on the characteristics, treatment sequences, and outcomes of aRCC patients who received 2L + nivolumab monotherapy in the UK. Nivolumab-specific survival outcomes were similar to those achieved in the CheckMate 025 trial.

Assessment of Different Methods for Pediatric Meningitis Dosing Clinical Decision Support

Background: Indication-specific medication dosing support is needed to improve pediatric dosing support. Objective: To compare the sensitivity and positive predictive value (PPV) of different meningitis dosing alert triggers and dosing error rates between antimicrobials with and without meningitis order sentences. Methods: We retrospectively analyzed 4-months of pediatric orders for antimicrobials with meningitis-specific dosing. At the time of the order, it was determined if the antimicrobial was for meningitis management, if a cerebrospinal fluid (CSF) culture was ordered, and if a natural language processing (NLP) system could detect “meningitis” in clinical notes. Results: Of 1383 orders, 243 were for the management of meningitis. A CSF culture or NLP combination trigger searching the electronic health record since admission yielded the greatest sensitivity for detecting meningitis management (67.5%, P < 0.01 vs others), but dosing error detection was similar if the trigger only searched 48 hours preceding the order (68.8% vs 62.5%, P = 0.125). Using a CSF culture alone and a 48-hour time frame had a higher PPV versus a combination with a 48-hour time frame (97.1% vs 80.9%, P < 0.001), and both triggers had a higher PPV than others ( P < 0.001). Antimicrobials with meningitis order sentences had fewer dosing errors (19.8% vs 43.2%, P < 0.01). Conclusion and Relevance: A meningitis dosing alert triggered by a combination of a CSF culture or NLP system and a 48-hour triggering time frame could provide reasonable sensitivity and PPV for meningitis dosing errors. Order sentences with indication-specific recommendations may provide additional dosing support, but additional studies are needed.

A survey of physiotherapists' current management and the promotion of physical activity, in people with rheumatoid arthritis

Purpose: Establishing physiotherapists' management of people with rheumatoid arthritis, in addition to their promotion of physical activity, is important to ascertain if there are educational needs in this area. Materials and methods: Physiotherapists from three Irish Chartered Physiotherapy clinical interest groups (N = 457) were invited to participate in a cross-sectional online questionnaire hosted on SurveyMonkey^(R)™. Results: One hundred and sixty-eight (168/457; 37%) responded. Exercise prescription and education were the most frequent treatments, with 84% always/regularly providing same. Physical activity is a component of treatment with 52% always/regularly advising. In addition, 69% agree that physical activity is attainable, 68% safe, and 67% an important goal. However, 62% never recommend the appropriate guidelines, while 14% define physical activity according to frequently used definitions. There was a statistically significant association between longer years qualified and more years working with people with RA, when using guidelines to guide physical activity and exercise prescription. Low-intensity exercises were prescribed by however, 67% never provide high-intensity. Conclusions: Current practice is in line with guidelines in which, exercise therapy and education are considered as the mainstay. Promotion of physical activity is strong; however, two-thirds never recommend the appropriate guidelines, and only a minority defined physical activity correctly. The majority never prescribe high-intensity exercise. There is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis. Implications for rehabilitation Exercise therapy and education are considered as the mainstay in the physiotherapy management of people with rheumatoid arthritis. Those physiotherapists' who are qualified longer and have more experience working with people with rheumatoid arthritis use the relevant physical activity guidelines. Overall there is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis.

Open release versus radiofrequency microtenotomy in the treatment of lateral epicondylitis: a prospective randomized controlled trial

BACKGROUND

Optimal surgical treatment of lateral epicondylitis remains uncertain. Recently, radiofrequency microtenotomy (RFMT) has been proposed as a suitable treatment. We compared RFMT with standard open release (OR) in this prospective randomized controlled trial.

METHODS

In total, 41 patients with symptoms for at least 6 months were randomized into two groups: 23 patients had RFMT and 18 had OR. Two patients from RFMT withdrew. Each patient underwent Numerical Rating Scale (NRS) pain score, grip strength and Disabilities of the Arm, Shoulder and Hand (DASH) scores pre-operatively and at 6 weeks. Pain and DASH scores were repeated at 6 months and 12 months.

RESULTS

NRS pain scores improved by 4.8 points for RFMT and by 3.9 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year. Grip strength improved by 31% in the RFMT group compared to 38% in OR. There was no significant difference between the initial and 6 weeks scores or between treatments. At 1 year, DASH was 39.8 points for RFMT and 24.4 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year.

CONCLUSIONS

Both groups showed significant improvements and similar benefit to the patient. The results of the present study do not show any benefit of RFMT over the standard OR. As a result of the extra expense of RFMT, we therefore recommend that OR is offered as the standard surgical management.

Abstract B163: Identification and preclinical characterisation of VER-250840, a potent, selective Chk1 inhibitor with in vivo oral single-agent antitumor activity

On sustaining damage to their DNA, cells employ a sophisticated mechanism of detection and repair, termed the DNA damage response (DDR). As a critical component of the DDR and G2/M checkpoint, Chk1 kinase represents an attractive target for cancer therapy. We have utilized a structure-based drug design approach to identify and develop VER-250840, a novel, orally active inhibitor of the checkpoint kinase, Chk1. VER-250840 exhibited sub-nM potency against Chk1 kinase with exquisite selectivity over an extensive and diverse panel of kinases. In vitro, VER-250840 inhibited Chk1 autophosphorylation with an IC50 of 1.0 nM and increased the number of S-phase tumor cells staining positive for pan-nuclear γH2AX with an EC50 of 7 - 27 nM. Accumulated genomic DNA damage by Chk1 inhibition led to irreversible cell cycle arrest, inhibition of tumor cell proliferation, increased replication stress, and cell death in both 2D culture and multicellular tumor spheroids. In an in vivo A2058 tumor xenograft PD study, VER-250840 demonstrated rapid and sustained inhibition of Chk1 auto-phosphorylation within 30 minutes of oral administration. Doses of 10 mg/kg and higher PO resulted in greater than 90% inhibition of tumor pChk1 (S296) over 24 hours. In SKOV3 in vivo models, VER-250840 inhibited Chk1 auto-phosphorylation, modulated other biomarkers of replication stress and DNA damage, and exhibited moderate antitumor activity with minimal toxicity when administered orally on a 21-day once-daily schedule. Work is ongoing to further optimize in vivo efficacy. In conclusion, VER-250840 demonstrates potent and selective activity as a monotherapy both in vitro and in vivo. From these findings, further evaluation and optimization of this novel kinase inhibitor is justly merited.

Citation Format: Joanne Wayne, Stephen Stokes, Nicolas Foloppe, Helen Browne, Teresa Brooks, Karen Benwell, Lisa Baker, Zoe Daniels, Andrea Fiumana, Christopher Graham, Alba Macias, Daniel Maddox, Sean McKenna, Christopher Northfield, Stuart Ray, Heather Simmonite, Emma Stefaniak, Paul Webb, Mike Wood, Andrew Massey. Identification and preclinical characterisation of VER-250840, a potent, selective Chk1 inhibitor with in vivo oral single-agent antitumor activity [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B163.

Sleep and physical activity: a survey of people with inflammatory arthritis and their engagement by health professionals in rheumatology in Ireland

PURPOSE

Sleep is important in maintaining the body's circadian rhythm and in maintaining health. Aim was to investigate sleep and physical activity among people who have inflammatory arthritis and their engagement with Health Professionals.

MATERIALS AND METHODS

Members from a national charitable organisation for patients with arthritis and a national rheumatology health professionals society were invited to participate in separate cross-sectional surveys hosted on SurveyMonkey^(R)TM.

RESULTS

Ninety people responded and report an average of 5.7 (SD 1.46) hours sleep per night. A majority (61%) report their sleep quality as bad, with 31% taking medications at least once a week to help sleep. There was a statistically significant association between longer years with symptoms, taking medication at least once a week and limited in their activities, when rating their sleep quality as bad. Twenty eight (65%) health professional's responded with 53% discussing sleep with their patients.

CONCLUSIONS

People with inflammatory arthritis report low sleep with those having symptoms longer, taking medications regularly and having limitations with their activities, reporting poorer sleep quality. Only half of health professionals discuss sleep. More research is needed in investigating poor sleep quality, disturbances, and physical activity in order to promote health and well-being in this population. Implications for Rehabilitation People with inflammatory arthritis fall far below the National Sleep Foundations' "sleep needs spectrum", which is concerning as those who have reduced levels of sleep have been associated with decreased quality of life and physical function. Due to the importance of receiving sufficient sleep, there is a need to develop education and training for health professionals in the importance of engaging their patients in their sleep quality and disturbances. The effects of physical activity interventions on poor sleep need to be examined to show if it is a positive non-pharmacological treatment approach for the management of poor sleep in patients with inflammatory arthritis.

Does exercise impact on sleep for people who have rheumatoid arthritis? A systematic review

To systematically search for the availability of evidence for exercise impacting on sleep for people who have rheumatoid arthritis. Two reviewers independently searched seven electronic databases, identified and extracted relevant studies by applying eligibility criteria. Sources of bias were assessed independently by two reviewers using the Cochrane bias assessment tool for randomized controlled trials (RCTs) and Newcastle-Ottawa Quality Assessment Scale for non-RCTs. Data were synthesized using a level of evidence approach. Meta-analyses were deemed to be inappropriate due to the heterogeneity of study designs, measurement tools and interventions. Five studies were included: one RCT; two pilot RCTs and two samples of convenience. A total of 262 people with RA were included. Interventions used were difficult to assess due to the heterogeneity of study designs and the inclusion of two using different types of yoga as an intervention. Different sleep outcome measures were used thus, it was not feasible to pool results. Studies had a high risk of bias. This review could find no consistent or conclusive evidence on whether exercise impacts on sleep in people who have rheumatoid arthritis, therefore no firm conclusions can be made. However, there is some indication that exercise may have positive benefits on sleep in people who have rheumatoid arthritis. Further studies with improved study designs, using subjective and objective measures, are needed.

Application of Off-Rate Screening in the Identification of Novel Pan-Isoform Inhibitors of Pyruvate Dehydrogenase Kinase

Libraries of nonpurified resorcinol amide derivatives were screened by surface plasmon resonance (SPR) to determine the binding dissociation constant (off-rate, k_d) for compounds binding to the pyruvate dehydrogenase kinase (PDHK) enzyme. Parallel off-rate measurements against HSP90 and application of structure-based drug design enabled rapid hit to lead progression in a program to identify pan-isoform ATP-competitive inhibitors of PDHK. Lead optimization identified selective sub-100-nM inhibitors of the enzyme which significantly reduced phosphorylation of the E1α subunit in the PC3 cancer cell line in vitro.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study

AIM

To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.

METHODS

A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.

RESULTS

Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort.

CONCLUSIONS

Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

An Analysis of the Association of Gastroenteric Lesions with Chronic Wasting Syndrome of Marmosets

Retrospective pathology data from necropsies of 162 marmosets, Saguinus oedipus, were studied to determine the nature of chronic wasting syndrome, a poorly defined entity associated with a high mortality rate in many marmoset colonies. Paraffin sections of the gastroenteric organs of 116 of these marmosets were re-examined in detail; lesions were identified, quantitated, and analyzed with a method of multiple chi-square testing for possible associations between findings. Five distinct disease entities were identified: prosthenorchosis, amebiasis, paramyxovirus disease, sepsis, and chronic colitis. Lesions of several of these often occurred in the same monkey, and all but the first were associated with cachexia. Lesions of chronic colitis were crypt abscesses, mononuclear and polymorphonuclear infiltration of the lamina propria, epithelial cell atypia, karyorrhexis, and lymphoid hyperplasia. The cause of chronic colitis was not identified, nor was any explanation found for weight loss and increased susceptibility to disease.

Design Activity Framework for Visualization Design

An important aspect in visualization design is the connection between what a designer does and the decisions the designer makes. Existing design process models, however, do not explicitly link back to models for visualization design decisions. We bridge this gap by introducing the design activity framework, a process model that explicitly connects to the nested model, a well-known visualization design decision model. The framework includes four overlapping activities that characterize the design process, with each activity explicating outcomes related to the nested model. Additionally, we describe and characterize a list of exemplar methods and how they overlap among these activities. The design activity framework is the result of reflective discussions from a collaboration on a visualization redesign project, the details of which we describe to ground the framework in a real-world design process. Lastly, from this redesign project we provide several research outcomes in the domain of cybersecurity, including an extended data abstraction and rich opportunities for future visualization research.

Pre-requisites for optimum centering of a tibiotalocalcaneal arthrodesis nail

BACKGROUND

Purpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths.

METHODS

We conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs.

RESULTS

Angles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails. Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p=0.01).

CONCLUSIONS

Both nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.

Profiling of sputum inflammatory mediators in asthma and chronic obstructive pulmonary disease

Background

Asthma and chronic obstructive pulmonary disease (COPD) display features of overlap in airway physiology and airway inflammation. Whether inflammatory phenotypes in airway disease describe similar mediator expression is unknown.

Objectives

To explore the relationship of airway inflammation and cytokine and chemokine expression in asthma and COPD.

Methods

Subjects with asthma and COPD (n = 54 and n = 49) were studied. Clinical characteristics and sputum were collected at entry into the study. A 2-step sputum processing method was performed for supernatant and cytospin preparation. Meso Scale Discovery and Luminex platforms were used to measure cytokines, chemokines and matrix metalloproteinase levels.

Results

Analytes sensitive to dithiothreitol (DTT) that had increased recovery in the 2-step sputum process were IL-1β, 4, 5, 10, 13, IFN-γ, TNFRI, GM-CSF, CCL2, 3, 4, 5, 13 and 17. There was a differential expression in IL-8, TNFRI and TNFRII between asthma and COPD [mean fold difference (95% CI): IL-8, 2.6 (1.3–5.4), p = 0.01; TNFRI, 2.1 (1.3–5.4), p = 0.03; TNFRII, 2.6 (1.2–5.6), p = 0.02]. In neutrophilic and eosinophilic airway inflammation, TNFα, TNFRI, TNFRII, IL-6, IL-8 and IL-5 could differentiate between these phenotypes. However, these phenotypes were unrelated to the diagnosis of asthma or COPD.

Conclusion

Recovery of sputum mediators sensitive to DTT can be improved using the described sputum processing technique. Within airway inflammatory sub-phenotypes there is a differential pattern of mediator expression that is independent of disease. Whether these inflammatory phenotypes in asthma and COPD confer distinct pathogeneses, therapeutic responses and clinical phenotypes needs to be further evaluated.

Physician assessment of disease activity in JIA subtypes. Analysis of data extracted from electronic medical records

OBJECTIVE

Although electronic medical records (EMRs) have facilitated care for children with juvenile idiopathic arthritis (JIA), analyses of treatment outcomes have required paper based or manually re-entered data. We have started EMR discrete data entry for JIA patient visits, including joint examination and global assessment, by physician and patient. In this preliminary study, we extracted data from the EMR to Xenobase™ (TransMed Systems, Inc., Cupertino, CA), an application permitting cohort analyses of the relationship between global assessment to joint examination and subtype.

METHODS

During clinic visits, data were entered into discrete fields in ambulatory visit forms in the EMR (EpicCare™, Epic Systems, Verona, WI). Data were extracted using Clarity Reports, then de-identified and uploaded for analyses to Xenobase™. Parameters included joint examination, ILAR diagnostic classification, physician global assessment, patient global assessment, and patient pain score. Data for a single visit for each of 160 patients over a 2 month period, beginning March, 2010, were analyzed.

RESULTS

In systemic JIA patients, strong correlations for physician global assessment were found with pain score, joint count and patient assessment. In contrast, physician assessment for patients with persistent oligoarticular and rheumatoid factor negative patients showed strong correlation with joint counts, but only moderate correlation with pain scores and patient global assessment. Conversely, for enthesitis patients, physician assessment correlated strongly with pain scores, and moderately with joint count and patient global assessment. Rheumatoid factor positive patients, the smallest group studied, showed moderate correlation for all three measures. Patient global assessment for systemic patients showed strong correlations with pain scores and joint count, similar to data for physician assessment. For polyarticular and enthesitis patients, correlation of patient global assessment with pain scores was strong. Moderate correlations were found between patient global assessment and joint count in oligoarticular and polyarticular patients.

CONCLUSION

Data extraction from the EMR is feasible and useful to evaluate JIA patients for indicators of treatment responsiveness. In this pilot study, we found correlates for physician global assessment of arthritis differed, according to disease subtype. Further data extraction and analyses will determine if these findings can be confirmed, and will assess other outcome measures, compare longitudinal responses to treatment, and export extracted data to multi-center databases.

Public Health and Primary Care

Why are the goals of public health and primary care less politically popular and financially supported than those of curative medicine? A major part of the answer to this question lies in the fact that humans often worry wrongly by assessing risk poorly. This reality is a significant obstacle to the adequate promotion of and investment in public health, primary care, and prevention. Also, public health’s tendency to infringe on personal privacy—as well as to call for difficult behavioral change—often sparks intense controversy and interest group opposition that discourage broader political support. Finally, in contrast to curative medicine, both the cost-benefit structure of public health (costs now, benefits later) and the way in which the profession operates make it largely invisible to and, thus, underappreciated by the general public. When curative medicine works well, most everybody notices. When public health and primary care work well, virtually nobody notices.

The impact of project closure on HIV incidence and mortality in a cohort of couples in Lusaka, Zambia

The objective of this study was to assess the impact of temporary closure of an HIV research clinic on the health of study participants. Primary data were collected quarterly from couples enrolled in research studies at an established HIV study site. There were 632 participating couples enrolled when the project closed, 475 of whom returned when it re-opened six months later. HIV sero-incidence, mortality rates and risk-taking behaviours were compared before and during the closure. Perceived impact of the closure was measured in returning participants. Demographic data collected at the last pre-closure study visit were used to look at the differences between returning and non-returning study participants. Serologic data from those who returned were compared pre- and post-closure to examine changes in HIV incidence. Mortality rates were estimated from reported deaths, and were compared pre- and during project closure. Perceptions of the impact of the closure among returning participants were examined through an interviewer administered questionnaire. It was found that couples who returned were not demographically different from couples who did not return. Most participants reported no problems with finding alternate sources of condoms and the incidence of HIV did not change significantly during the closure. Eighty-four percent respondents reported that the closure had a negative impact on them, 87% of whom rated loss of medical care as the main impact. The mortality rate among HIV-positive participants doubled from 6.7/100 person years to 12.4/100 person years during the closure (p=0.01). Results indicate that couples voluntary counselling and testing (CVCT) established durable risk-reduction behaviours that persisted during project closure. ThIn ae loss of healthcare was perceived as the most negative impact on participants, reflected in increased mortality rates. Research projects should make transition plans and budget for mechanisms to reduce the negative impact on participants of project closures.

Pre-eclampsia is associated with airway hyperresponsiveness

Several large retrospective cohort studies demonstrate that pre-eclampsia is common in asthmatics. Whether airway hyperresponsiveness (AHR), a hallmark of asthma, is associated with pre-eclampsia is unknown. We measured AHR, using a methacholine challenge, and atopy in 19 women 3-60 months postpartum following pre-eclamptic or normotensive pregnancies. The geometric mean (95% CI) concentration of methacholine required to produce a >20% fall in the forced expiratory volume in 1 second (PC20 FEV1) was 8.9 (2.2-36) mg/ml in pre-eclamptics versus 72 (32-131) mg/ml in controls (P = 0.01) and 9 (1.9-40) mg/ml in atopic pre-eclamptics without asthma versus 54 (17-174) mg/ml (P = 0.038) in matched controls. Therefore, AHR was increased in women who have had pre-eclampsia. This association and its possible mechanisms warrant further investigation.

Squamous cell carcinoma arising in a dermoid cyst of the ovary: a case series

OBJECTIVE

Malignant transformation in a dermoid cyst of the ovary is a rare complication, occurring in only 1-2% of cases, with squamous cell carcinoma being the most common type. Preoperative diagnosis is difficult because of the lack of specific symptoms and signs to suggest malignancy. Because of the small numbers of women involved, our knowledge of this rare tumour type is limited. This study aims to further characterise the population of women affected, the disease itself and the most appropriate management strategy.

DESIGN

We identified 14 women with this diagnosis between 1989 and 2006. This is a descriptive study, looking at the patient characteristics, mode of presentation and the role of tumour markers and radiological imaging in diagnosis. We also examined the stage and pathological features of the tumour at presentation and the subsequent course of the disease. We have also described our experiences using surgery, chemotherapy and radiotherapy in the management of these women.

RESULTS

We found that these tumours present at an age older than that of mature teratomas and that there are no reliable diagnostic tools or prognostic indicators. The behaviour of these tumours is unpredictable, and the role of chemotherapy and radiotherapy remains unclear. We suggest that repeated surgical resection of disease at the time of relapse could give a very durable response in selected women.

Identification, synthesis, and biological evaluation of novel pyrazoles as low molecular weight luteinizing hormone receptor agonists

In the course of a high throughput screening, a series of pyrazole compounds were identified with luteinizing hormone receptor (LH-R) agonist activity. A focused pyrazole library was produced by solid-phase synthesis and key pyrazole regioisomers were obtained selectively in solution. Evaluation of those compounds in a cAMP assay in CHO cells transfected with h-LH receptor allowed us to propose a structure-activity relationship model for this series and led to the identification of the first low molecular weight molecule with in vitro activity in a Leydig cells assay (ED(50)=1.31 microM) and in vivo in a model of testosterone induction in rats (significant effect at 32 mpk ip).

Eosinophilic airway inflammation and exacerbations of COPD: a randomised controlled trial

Evidence suggests that eosinophilic airway inflammation is important in the pathogenesis of severe chronic obstructive pulmonary disease (COPD) exacerbations. The present authors tested the hypothesis that a management strategy that aims to reduce sputum eosinophil counts is associated with a reduction in exacerbations of COPD. A total of 82 patients with COPD were randomised into two groups. One group was treated according to traditional guidelines (British Thoracic Society (BTS) group) and the other (sputum group) was treated with the additional aim of minimising eosinophilic airway inflammation, assessed using the induced sputum eosinophil count. The primary outcome was exacerbations, which were categorised as mild, moderate or severe. The frequency of severe exacerbations per patient per year was 0.5 and 0.2 in the BTS and sputum groups, respectively (mean reduction 62%). The majority of this benefit was confined to patients with eosinophilic airway inflammation. There was no difference in the frequency of mild and moderate exacerbations. The average daily dose of inhaled or oral corticosteroids during the trial did not differ between the groups. Out of 42 patients in the sputum group, 17 required regular oral corticosteroids to minimise eosinophilic airway inflammation. A management strategy that aims to minimise eosinophilic airway inflammation, as well as symptoms, is associated with a reduction in severe exacerbations of chronic obstructive pulmonary disease.

Biological properties of a novel follicle-stimulating hormone/human chorionic gonadotropin chimeric gonadotropin

A chimeric recombinant human gonadotropin, termed C3, demonstrates both follitropic and lutropic bioactivities. The alpha-subunit construct for C3 is comprised of the recombinant wild-type human glycoprotein hormone alpha-subunit. The beta-subunit DNA construct for C3 encodes residues 1-145 from human chorionic gonadotropin (hCG)-beta with the exceptions that FSH beta amino acid 88 (D) is substituted for hCG beta amino acid 94 (R) and FSH beta amino acids 95-108 (TVRGLGPSYCSFGE) are substituted for hCG beta amino acids 101-114 (GGPKDHPLTCDDPR). C3 is a potent FSH and LH agonist able to bind and to signal through FSH and LH receptors in vitro. In in vivo bioassays optimized to quantify each type of activity, C3 was found to have lutropin and follitropin potencies at levels similar to those of recombinant human LH and recombinant human FSH, respectively. In immature rats, C3 was sufficient to support the maturation of normal ovarian follicles. Moreover, a significant portion of follicles matured by C3 ruptured in response to an ovulatory hCG stimulus and gave rise to morphologically normal oocytes. Furthermore, a low dose of C3 promoted weight gain in the rodent uterus, suggesting it also supported preparation for implantation without histological evidence of excessive luteinization of the ovary. In summary, the biological properties of C3 indicate that its chimeric nature has resulted in a fully functional, dual-acting human gonadotropin.

Local gene therapy of solid tumors with GM-CSF and B7-1 eradicates both treated and distal tumors

Gene therapy-induced expression of immunostimulatory molecules at tumor cell level may evoke antitumor immune mechanisms by recruiting and enhancing viability of antigen-processing cells and specific tumoricidal lymphocytes. The antitumor efficacy of a plasmid, coding for granulocyte-macrophage colony-stimulating factor (GM-CSF) and the B7-1 costimulatory immune molecule, delivered into growing solid tumors by electroporation was investigated. Murine fibrosarcomas (JBS) growing in Balb/C mice (<or=100 mm3) were transfected with GM-CSF/B7-1-expressing plasmid. Complete tumor regression occurred in greater than 60% of treated animals. This response was systemic, durable and tumor specific, with all responding animals resistant to repeat tumor challenge. Using a liver metastatic model, effective cure of distal metastases was achieved following treatment of the primary subcutaneous tumor. This treatment strategy could be applicable in the clinical setting for effective elimination of both primary tumors and associated metastatic disease.

Comparison of asthma treatment given in addition to inhaled corticosteroids on airway inflammation and responsiveness

There is increasing evidence that the assessment of eosinophilic airway inflammation using induced sputum and measurement of airway hyperresponsiveness provides additional, clinically important information concerning asthma control. The aim of this study was to directly compare the effects of different treatments on these markers in patients with asthma and persistent symptoms, despite the use of low-dose inhaled corticosteroids. A double-blind four-way crossover study was performed, which compared a 1-month treatment with budesonide 400 mug b.i.d., additional formoterol, additional montelukast and placebo in 49 patients with uncontrolled asthma despite budesonide 100 mug b.i.d., with each treatment separated by a 4-week washout period. The change in sputum eosinophil count with formoterol (2.4 to 3.8% change, 0.6-fold reduction, 95% confidence interval (CI) 0.5-0.9) differed significantly from placebo (2.8 to 2.5% change, 1.1-fold reduction, 95% CI 0.7-1.6) and high-dose budesonide (2.7 to 1.6% change, 1.6-fold reduction, 95% CI 1.2-2.2). The effects of montelukast did not differ from placebo. The changes in methacholine airway responsiveness were small and did not differ between treatments. High-dose budesonide had the broadest range of beneficial effects on other outcomes, including symptom scores, morning peak expiratory flow and forced expiratory volume in one second. In conclusion, treatment given in addition to low-dose inhaled corticosteroids results in modest benefits. Formoterol and high-dose budesonide have contrasting effects on eosinophilic airway inflammation.

Purification and properties of the ubiquitin-conjugating enzymes Cdc34 and Ubc13.Mms2

A prerequisite for structure/function studies on the ubiquitin-conjugating enzymes (Ubc) Cdc34 and Ubc13.Mms2 has been the ability to express and purify recombinant derivatives of each. This chapter describes the methods used in the expression and purification of these proteins from Escherichia coli, including variations of these protocols used to generate (35)S, (15)N, (13)C/(15)N, and seleno-L-methionine derivatives. Assays used to measure the Ub thiolester and Ub conjugation activities of these Ubcs are also described.

Distinct regulation of Ubc13 functions by the two ubiquitin-conjugating enzyme variants Mms2 and Uev1A

Ubc13, a ubiquitin-conjugating enzyme (Ubc), requires the presence of a Ubc variant (Uev) for polyubiquitination. Uevs, although resembling Ubc in sequence and structure, lack the active site cysteine residue and are catalytically inactive. The yeast Uev (Mms2) incites noncanonical Lys63-linked polyubiquitination by Ubc13, whereas the increased diversity of Uevs in higher eukaryotes suggests an unexpected complication in ubiquitination. In this study, we demonstrate that divergent activities of mammalian Ubc13 rely on its pairing with either of two Uevs, Uev1A or Mms2. Structurally, we demonstrate that Mms2 and Uev1A differentially modulate the length of Ubc13-mediated Lys63-linked polyubiquitin chains. Functionally, we describe that Ubc13-Mms2 is required for DNA damage repair but not nuclear factor kappaB (NF-kappaB) activation, whereas Ubc13-Uev1A is involved in NF-kappaB activation but not DNA repair. Our finding suggests a novel regulatory mechanism in which different Uevs direct Ubcs to diverse cellular processes through physical interaction and alternative polyubiquitination.

Observational study of the natural history of eosinophilic bronchitis

BACKGROUND

Eosinophilic bronchitis is an important cause of chronic cough. Treatment with inhaled corticosteroids is associated with a short-term improvement in cough and reduced sputum eosinophil count but the long-term outcome is uncertain.

OBJECTIVE

To determine the long-term outcome in patients diagnosed with and treated for eosinophilic bronchitis.

METHODS

We have performed a longitudinal study of symptoms, eosinophilic airway inflammation, spirometry and airway hyper-responsiveness in all patients diagnosed with eosinophilic bronchitis over 7 years.

RESULTS

We identified 52 patients with eosinophilic bronchitis and longitudinal data of greater than 1 year (mean 3.1 years) was available in 32 patients, all of whom were treated with inhaled steroids. Three (9%) patients developed symptoms consistent with asthma and a methacholine PC20<8 mg/mL on one or more occasion. Five (16%) patients developed fixed airflow obstruction defined by a persistent post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity<70%. One (3%) patient had complete resolution of symptoms and eosinophilic airway inflammation off treatment. The remaining patients had ongoing eosinophilic airway inflammation and/or continuing symptoms. Multiple linear regression identified smoking, female gender and area under the curve of sputum eosinophil count over time as the most important predictors of decline in FEV1.

CONCLUSIONS

The most common outcome in eosinophilic bronchitis is continuing disease and complete resolution is rare. Asthma and fixed airflow obstruction developed in relatively few patients. The most important factors associated with a more rapid decline in FEV1 were female gender, smoking and prolonged eosinophilic airway inflammation.

Sputum eosinophilia in idiopathic pulmonary fibrosis

OBJECTIVES AND DESIGN

Cough is a common symptom in idiopathic pulmonary fibrosis that is difficult to treat and has a major impact on quality of life. We tested the hypothesis that the cough and increased cough reflex sensitivity seen in patients with idiopathic pulmonary fibrosis may be due to airway inflammation in a prospective, cross-sectional study.

SUBJECTS AND METHODS

We measured the induced sputum inflammatory cell profile and cell-free supernatant inflammatory mediator concentrations in 15 patients with idiopathic pulmonary fibrosis, 17 healthy controls and 15 patients with chronic obstructive pulmonary disease.

RESULTS

Both the geometric mean sputum differential eosinophil cell count and median eosinophilic-cationic-protein concentration were significantly higher in patients with idiopathic pulmonary fibrosis than controls (2.1% vs 0.3%; p <0.001 and 1.1 mg/ml versus 0.2 mg/ml; p=0.03 respectively). There were no significant differences in sputum eosinophil counts and eosinophilic-cationic-protein concentrations between patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. Sputum leukotriene-B4 concentrations were significantly lower in patients with idiopathic pulmonary fibrosis (p=0.03) and chronic obstructive pulmonary disease (p=0.008) compared to controls.

CONCLUSIONS

Idiopathic pulmonary fibrosis is characterised by the presence of active eosinophilic airway inflammation raising the possibility that airway inflammation may contribute to symptoms such as cough.

Sputum eosinophilia and the short term response to inhaled mometasone in chronic obstructive pulmonary disease

BACKGROUND

An association between the sputum eosinophil count and the response to a 2 week course of prednisolone has previously been reported in patients with chronic obstructive pulmonary disease (COPD). Whether the response to inhaled corticosteroids is related to the presence of eosinophilic inflammation is unclear.

METHODS

A randomised, double blind, crossover trial of placebo and mometasone furoate (800 microg/day), each given for 6 weeks with a 4 week washout period, was performed in subjects with COPD treated with bronchodilator therapy only. Spirometric tests, symptom scores, chronic respiratory disease questionnaire (CRQ), and induced sputum were performed before and after each treatment phase.

RESULTS

Ninety five patients were recruited of which 60 were randomised. Overall there were no treatment associated changes in forced expiratory volume in 1 second (FEV(1)), total CRQ, or sputum characteristics. After stratification into tertiles by baseline eosinophil count, the net improvement in post-bronchodilator FEV(1) increased with mometasone compared with placebo progressively from the least to the most eosinophilic tertile. The mean change in post-bronchodilator FEV(1) with mometasone compared with placebo in the highest tertile was 0.11 l (95% CI 0.03 to 0.19). This improvement was not associated with a fall in the sputum eosinophil count.

CONCLUSIONS

An increased sputum eosinophil count is related to an improvement in post-bronchodilator FEV(1) following treatment with inhaled mometasone in COPD, but the improvement is not associated with a reduction in the sputum eosinophil count.

Airway function and markers of airway inflammation in patients with treated hypothyroidism

BACKGROUND

There is increasing evidence of an association between organ specific autoimmune diseases, particularly autoimmune thyroid disease and respiratory morbidity. A study was undertaken to determine whether patients with autoimmune thyroid disease have objective evidence of airway inflammation and dysfunction.

METHODS

Twenty six non-smoking women with treated hypothyroidism and 19 non-smoking controls completed a symptom questionnaire and underwent full lung function tests, capsaicin cough reflex sensitivity measurement, methacholine challenge test, and sputum induction over two visits.

RESULTS

Symptoms of cough (p = 0.01), dyspnoea (p = 0.01), sputum production (p = 0.004), and wheeze (p = 0.04) were reported more commonly in patients than controls. Patients with hypothyroidism had heightened cough reflex sensitivity compared with controls (geometric mean concentration of capsaicin causing five coughs: 40 v 108 mmol/l; mean difference 1.4 doubling doses; 95% confidence interval of difference 0.4 to 2.5; p = 0.008) and a significantly higher proportion of patients had airway hyperresponsiveness (methacholine provocative concentration (PC(20)) <8 mg/ml: 38% v 0%; p = 0.016). Patients with hypothyroidism also had a significantly higher induced sputum total neutrophil cell count (p = 0.01), total lymphocyte count (p = 0.02), and sputum supernatant interleukin-8 concentrations (p = 0.048).

CONCLUSION

Patients with treated hypothyroidism report more respiratory symptoms and have objective evidence of airway dysfunction and inflammation.