Prognosis of glioblastoma patients improves significantly over time interrogating historical controls

BACKGROUND

Glioblastoma (GBM) is the most common devastating primary brain cancer in adults. In our clinical practice, median overall survival (mOS) of GBM patients seems increasing over time.

METHODS

To address this observation, we have retrospectively analyzed the prognosis of 722 newly diagnosed GBM patients, aged below 70, in good clinical conditions (i.e. Karnofsky Performance Status -KPS- above 70%) and treated in our department according to the standard of care (SOC) between 2005 and 2018. Patients were divided into two groups according to the year of diagnosis (group 1: from 2005 to 2012; group 2: from 2013 to 2018).

RESULTS

Characteristics of patients and tumors of both groups were very similar regarding confounding factors (age, KPS, MGMT promoter methylation status and treatments). Follow-up time was fixed at 24 months to ensure comparable survival times between both groups. Group 1 patients had a mOS of 19 months ([17.3-21.3]) while mOS of group 2 patients was not reached. The recent period of diagnosis was significantly associated with a longer mOS in univariate analysis (HR=0.64, 95% CI [0.51 - 0.81]), p < 0.001). Multivariate Cox analysis showed that the period of diagnosis remained significantly prognostic after adjustment on confounding factors (adjusted Hazard Ratio (aHR) 0.49, 95% CI [0.36-0.67], p < 0.001).

CONCLUSION

This increase of mOS over time in newly diagnosed GBM patients could be explained by better management of potentially associated non-neurological diseases, optimization of validated SOC, better management of treatments side effects, supportive care and participation in clinical trials.

Hashimoto's thyroiditis and renal transplant rejection

PURPOSE

Hashimoto's thyroiditis (HT) is a common autoimmune thyroid disorder that can disrupt thyroid function and homeostasis. As HT results from a dysregulated immune system, we hypothesized that these patients might be more susceptible to transplant failure; however, literature on this association is limited. The purpose of this study is to examine the association of HT with the risk of renal transplant failure.

METHODS

We utilized the United States Renal Database System dataset collected from 2005 to 2014 and compared the time from first renal transplant to transplant failure in end-stage renal disease (ESRD) patients with a HT diagnosis to ESRD patients without a HT diagnosis that underwent renal transplant.

RESULTS

A total of 144 ESRD patients had International Classification of Disease-9 claim codes for HT prior to renal transplant, amongst a total cohort of 90,301 renal transplant patients aged 18-100 and meeting criteria. Patients with HT were significantly more likely to be female, white, and to have a diagnosis of cytomegalovirus compared to patients without. ESRD patients with a HT diagnosis that underwent renal transplant had a significantly increased risk of renal transplant failure compared to those ESRD renal transplant patients without an HT diagnosis. There was a significantly increased adjusted hazard ratio for graft failure in patients with a HT diagnosis compared to those without.

CONCLUSION

Thyroid health and HT may play a significant role in the development of the increased risk of renal transplant failure observed in this study. Additional studies are needed to investigate the underlying mechanisms for this association.

Psychological interventions for individuals with Ehlers-Danlos syndrome and hypermobility spectrum disorder: a scoping review

PURPOSE

To identify the nature and extent of the evidence on psychological interventions among individuals with Ehlers-Danlos Syndrome (EDS) and Hypermobility Spectrum Disorder (HSD).

MATERIALS AND METHODS

Eligible studies reported on psychological interventions for individuals of all ages with EDS and/or HSD. All studies published in English were included, with no restrictions to publication year or status. MEDLINE, CINAHL, EMBASE, and PsycINFO were searched. Two reviewers independently screened studies and abstracted data.

RESULTS

This scoping review included 10 studies reporting on EDS, HSD, or both. Only cohort studies and case studies were identified. Four studies investigated Cognitive Behavioural Therapy (CBT), one investigated Dialectical Behavioural Therapy (DBT), two investigated psychoeducation, two investigated Intensive Interdisciplinary Pain Treatment (IIPT), and one investigated Acceptance Commitment Therapy (ACT). Interventions targeted pain management, self-destructive behaviours, and related psychological issues (e.g., depression/anxiety). Sample sizes were small (n < 50) for most studies and interventions were generally poorly described.

CONCLUSIONS

There is a critical need for high-quality research surrounding psychological interventions for individuals with EDS/HSD. Psychological interventions for these individuals are understudied and existing studies lack validity. Researchers should investigate psychological interventions for individuals with all types of EDS/HSD with high-quality studies to validate findings from the existing studies.

Salivary cortisol levels and appraisals of daily hassles across dimensions of the tripartite model of anxiety and depression in emerging adults

The objective of this study was to investigate how cortisol levels and appraisals of daily hassles differ across tripartite dimensions of depression and anxiety in emerging adults. Data collected from a sample of undergraduate students at a large Midwestern university was used to investigate these aims. This included salivary cortisol data collected over four days, scores on a measure of the tripartite model of anxiety and depression, and scores on a measure of daily hassles administered everyday for two weeks. Generalized estimating equations and multilevel modeling techniques were used to analyze data. Elevated cortisol levels during the awakening period and the evening period, lower total levels across the day, steeper diurnal slopes, and elevated levels of negative affect and physiological hyperarousal predicted experiences of daily hassles. Tripartite dimensions were unrelated to cortisol indices. The present study demonstrates the utility of modeling multiple cortisol indices and provides evidence of differential associations between physiological and phenomenological indices of stress.

Human pegivirus identified in severe myelitis and optic neuritis in immunocompromised patients: A pathogenic role for a forgotten virus?

The role of Human pegivirus (HPgV) in patients with encephalitis has been recently questioned. We present cases of 4 patients with similar clinical, biological, and radiological characteristics, including a past history of transplantation with long-term immunosuppression and a progressive course of severe and predominantly myelitis, associated in 3 cases with optic neuropathy causing blindness. Extensive workup was negative but analysis of the CSF by use of pan-microorganism DNA- and RNA-based shotgun metagenomics was positive for HPgV. This case series further supports the hypothesis of HPgV CNS infection and highlights the utility of metagenomic next-generation sequencing of CSF in immunocompromised patients.

OS07.1.A A threshold of mitotic activity and post-surgery residual volume are independant prognostic factors in astrocytoma IDH-mutant

Background

The distinction between grade 2 and 3 is instrumental to choose between observational follow-up and adjuvant treatment in resected astrocytoma IDH-mutant. However, criteria of grade 2 versus 3 have not been updated since the WHO 2007 classification. There is no consensus on the method of evaluation of the mitotic activity or a cut-off of mitoses separating grade 2 and grade 3 tumors. The objectives were to evaluate the maximal mitotic activity on a series of resected astrocytoma IDH-mutant and assess its prognostic impact on survival.

Material and Methods

Maximal mitotic activity on consecutive high power fields corresponding to 3 mm2 was examined in 118 lower-grade astrocytoma IDH-mutant. The prognostic value for time-to-treatment (TTT) and overall survival (OS) of mitotic activity and other putative prognostic factors (including age, performance status, pre-surgical tumor volume, plurilobar involvement, post-surgical residual tumor volume, midline involvement) was assessed in tumors with (i) ATRX loss, and (ii) without CDKN2A homozygous deletion, lesional enhancement, histological necrosis nor microvascular proliferation.

Results

Among the 75 (64%) of tumors which had gone through observational follow-up after resection, the maximal mitotic activity, the post-surgical residual volume and the plurilobar involvement were independent prognostic factors of TTT (p &lt; 0.0001). A threshold of mitotic activity for grade 2 was fitted on TTT and OS prognosis. Using this threshold, patients with “grade 2 tumors” had a median TTT of 55 months versus 19 months for “grade 3” (p = 0.0057) and a median OS of 102 months versus 73 months respectively (p = 0.001). Residual volume &lt; 1 cm3 was associated with longer OS (113 months versus 88 months, p = 0.0021).

Conclusion

Mitotic activity and post-surgical residual volume can be combined to evaluate prognosis in resected astrocytoma IDH-mutant and could select the best candidates for observational follow-up.

Delayed Diagnosis of Congenital Hypoparathyroidism in a Kindred of Three Patients With Autosomal Dominant Deafness

Background: Congenital hypoparathyroidism can be related to autosomal dominant mutations or deletions in GATA-binding protein 3 gene on chromosome 10^1,2. Affected patients present with a triad of hypoparathyroidism, renal dysplasia and neurosensorial deafness. We hereby present the case of a patient with the rare Barakat syndrome, also known as HDR syndrome. Clinical Case: A 11-year-old girl, diagnosed with deafness at birth, was brought to medical attention because of menorrhagia requiring blood transfusions two months after menarche. A pelvic ultrasound demonstrated a septate uterus as well as right multicystic dysplastic kidney with solitary left kidney and ovary. As her maternal grandmother, mother and older sister suffered from congenital deafness and her mother also had a kidney cyst, the patient was referred to genetics to identify a unifying cause of the autosomal dominant pattern of deafness and urogenital anomalies. Chromosome microarray analysis revealed a copy number change on chromosome 10p14 of 1925 kb predicted to result in the deletion of a single protein coding gene, GATA3. Embryonically, GATA3 is involved in the development of the inner ear, kidneys and parathyroid glands. The patient was lost to follow up so that a serum calcium was drawn three years later, revealing low ionized calcium of 1.06 mmol/L (N 1.16–1.29), low corrected total calcium of 2.11 mmol/L (N 2.30–2.62) along with PTH of 1.1 pmol/L (N 2.0–9.4), PO4 of 1.73 mmol/L (N 1.03–1.78) and creatinine of 64 umol/L (N 50–71). She was started on calcium carbonate 1000 mg TID and calcitriol 0.5 mcg BID and genetic analysis of the mother and sister revealed the same mutation compatible with Barakat syndrome. Compliance has been difficult, and when the patient transitioned to adult endocrinology three years later, she was on alfacalcidiol 2 mcg daily along with calcium carbonate 1500 mg daily and her labs were still suboptimal with a total corrected calcium of 1.82 mmol/L (N 2.22–2.54) and ionized calcium 0.98 mmol/L (N 1.16–1.29). Renal function determines the prognosis, and reassuringly her creatinine remains normal. Upon further questioning of the mother, she recalls that the patient had to be intubated for respiratory failure as a newborn, she had delayed milestones and also had seizure like activity during her infancy and early childhood. She had brought these symptoms to her family physician’s attention however no further investigations were completed and serum calcium was not checked.

Conclusion: Early recognition of hypocalcemia symptoms is critical in identifying patients with congenital hypoparathyroidism, even more so when associated with other features that are part of complex familial syndrome such as Barakat syndrome.

1. Barakat, AJ. Barakat syndrome revisited. Am J of Med Genet A. 2018, Jun; 176(6):1341–13482. Barakat, AY. Familial nephrosis, nerve deafness and hypoparathyroidism. J Pediatri. 1977;9(1):61

MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital

Background

Glycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020.

Methods:

The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention.

Results:

Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked.

Conclusions:

Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention.

References

(1)

Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773.

(2)

Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53.

(3)

Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.

Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department

BACKGROUND

In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment.

METHODS

During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors.

RESULTS

During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants.

CONCLUSION

Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

The Recommendation and Use of Extracorporeal Membrane Oxygenation (ECMO) in Cases Reported to the California Poison Control System

INTRODUCTION

Antidotes are available to treat some specific poisonings; however, the mainstay of treatment for the poisoned patient remains supportive care. Extracorporeal membrane oxygenation (ECMO) is one of the most aggressive supportive measures available to manage poisoned patients.

OBJECTIVE

To characterize the recommendation and use of ECMO in cases reported to the California Poison Control System (CPCS).

METHODS

This retrospective chart review queried the CPCS database from 1997 to 2016 for cases containing the American Association of Poison Control Centers (AAPCC) code for ECMO, and "ECMO" and "ECLS" free-text searches. The collected data included year, age, gender, substances involved, route of exposure, clinical effects, treatments, and medical outcome.

RESULTS

A total of 94 cases discussed ECMO as a supportive option with 16 cases utilizing ECMO. Cases where ECMO was discussed rose from one case in 1997 to 13 cases in 2016. Of the 94 cases where ECMO was discussed, 38 cases (40%) involved toxicity from a cardiovascular agent(s) and 33 cases (35%) involved exposure to hydrocarbons. Of the 16 cases where ECMO was performed, 13 (81%) involved males. The median age was 17 years (range 1 month-54 years). Ten cases (63%) involve patients under the age of 18. In this series, 13 of 16 ECMO-supported patients survived (81%).

CONCLUSIONS

ECMO is being recommended more often for treatment of acute poisoning cases by the CPCS. All caregivers involved in the treatment of poisoning should gain a working knowledge of the potentially lifesaving technology of ECMO, its indications for use, adverse effects, and drug or poison interactions.

Effect of chronic liraglutide therapy and its withdrawal on time to postchallenge peak glucose in type 2 diabetes

Delayed timing of peak serum glucose following an oral glucose challenge can predict declining β-cell function and worsening glucose tolerance over time. Accordingly, postchallenge peak glucose is typically delayed in patients with type 2 diabetes (T2DM). However, little is known about the capacity of antidiabetic medications to reverse this delay. Thus, we sought to evaluate the effect of the glucagon-like peptide-1 agonist liraglutide on time to peak glucose in early T2DM. In this secondary analysis of a double-blind placebo-controlled trial, 51 patients with T2DM of 2.6 ± 1.9 yr duration were randomized to daily subcutaneous liraglutide or placebo injection for 48 wk, with oral glucose tolerance test (OGTT) performed every 12 wk while on therapy and after a 2-wk washout. On each OGTT, time to peak glucose was determined from venous glucose measurements at 0, 10, 20, 30, 60, 90, and 120 min. At randomization, most patients in both arms exhibited peak glucose at 90 min postchallenge. By 12 wk, 65.4% of the liraglutide arm had shifted to an earlier peak (vs. 36% on placebo; P = 0.19), with little change thereafter at 24, 36, and 48 wk. After the 2-wk washout, however, 57.7% of those who had been on liraglutide reverted to a later peak (vs. 4.5% on placebo; P < 0.001). This shift was associated with declining β-cell function ( P = 0.001), resulting in higher 2-h blood glucose at washout in the liraglutide arm compared with placebo ( P = 0.001). Thus, although liraglutide possibly might improve the delay in peak glucose, its cessation yielded a worsening thereof and higher glycemia. The mechanisms underlying these observations and their clinical implications warrant further investigation.

Efficacy of glucagon-like peptide-1 receptor agonists compared to dipeptidyl peptidase-4 inhibitors for the management of type 2 diabetes: A meta-analysis of randomized clinical trials

AIMS

Glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors are both incretin-based therapies for type 2 diabetes (T2DM) but have distinct efficacy and side effect profiles. We thus performed a systematic review and meta-analysis to compare the effects of GLP-1 agonists to DPP-4 inhibitors on glycaemic control, weight and incidence of adverse events in adults with T2DM. We also sought to determine whether there was any additional effect in switching from DPP-4 inhibitor to GLP-1 agonist.

MATERIALS AND METHODS

We systematically searched PubMed, Embase and ClinicalTrials.gov for (1) randomized controlled trials (RCTs) comparing any GLP-1 agonist to any DPP-4 inhibitor and (2) interventional studies where a DPP-4 inhibitor was switched to a GLP-1 agonist. We assessed pooled data using random-effects model (CRD42017057115).

RESULTS

The pooled analysis of 13 RCTs (n = 4330) showed that, compared to DPP-4 inhibitors, GLP-1 agonists yielded a greater mean reduction in glycated haemoglobin (HbA1c) of -0.41% (95% CI -0.53 to -0.30) and in weight of -2.15 kg (-3.04 to -1.27). GLP-1 agonists were associated with greater likelihood of gastrointestinal side effects with no increased risk of hypoglycaemia. In 5 interventional studies (n = 433), switching from DPP-4 inhibitor to GLP-1 agonist yielded further mean reduction in HbA1c of -0.69% (-1.03 to -0.35) and in weight of -2.25 kg (-3.12 to -1.38).

CONCLUSIONS

GLP-1 agonists yield greater reduction in HbA1c and weight as compared to DPP-4 inhibitors, with increased incidence of gastrointestinal symptoms but not hypoglycaemia. Replacing a DPP-4 inhibitor with GLP-1 agonist provides additional benefits in glycaemic control and weight loss.

Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia

An undersupply of generalists doctors in rural communities globally led to widening participation (WP) initiatives to increase the proportion of rural origin medical students. In 2002 the Australian Government mandated that 25% of commencing Australian medical students be of rural origin. Meeting this target has largely been achieved through reduced standards of entry for rural relative to urban applicants. This initiative is based on the assumption that rural origin students will succeed during training, and return to practice in rural locations. One aim of this study was to determine the relationships between student geographical origin (rural or urban), selection scores, and future practice intentions of medical students at course entry and course exit. Two multicentre databases containing selection and future practice preferences (location and specialisation) were combined (5862), representing 54% of undergraduate medical students commencing from 2006 to 2013 across nine Australian medical schools. A second aim was to determine course performance of rural origin students selected on lower scores than their urban peers. Selection and course performance data for rural (461) and urban (1431) origin students commencing 2006-2014 from one medical school was used. For Aim 1, a third (33.7%) of rural origin students indicated a preference for future rural practice at course exit, and even fewer (6.7%) urban origin students made this preference. Results from logistic regression analyses showed significant independent predictors were rural origin (OR 4.0), lower Australian Tertiary Admissions Rank (ATAR) (OR 2.1), or lower Undergraduate Medical and Health Sciences Admissions Test Section 3 (non-verbal reasoning) (OR 1.3). Less than a fifth (17.6%) of rural origin students indicated a preference for future generalist practice at course exit. Significant predictors were female gender (OR 1.7) or lower ATAR (OR 1.2), but not rural origin. Fewer (10.5%) urban origin students indicated a preference for generalist practice at course exit. For Aim 2, results of Mann-Whitney U tests confirmed that slightly reducing selection scores does not result in increased failure, or meaningfully impaired performance during training relative to urban origin students. Our multicentre analysis supports success of the rural origin WP pathway to increase rural student participation in medical training. However, our findings confirm that current selection initiatives are insufficient to address the continuing problem of doctor maldistribution in Australia. We argue for further reform to current medical student selection, which remains largely determined by academic meritocracy. Our findings have relevance to the selection of students into health professions globally.

A modified portfolio diet complements medical management to reduce cardiovascular risk factors in diabetic patients with coronary artery disease

BACKGROUND & AIMS

Secondary prevention can improve outcomes in high risk patients. This study investigated the magnitude of cardiovascular risk reduction associated with consumption of a modified portfolio diet in parallel with medical management.

DESIGN

30 patients with type II diabetes, 6 weeks post bypass surgery received dietary counseling on a Modified Portfolio Diet (MPD) (low fat, 8 g/1000 kcal viscous fibres, 17 g/1000 kcal soy protein and 22 g/1000 kcal almonds). Lipid profiles, endothelial function and markers of glycemic control, oxidative stress and inflammation were measured at baseline and following two and four weeks of intervention. Seven patients with no diet therapy served as time controls.

RESULTS

Consumption of the MPD resulted in a 19% relative reduction in LDL (1.9 ± 0.8 vs 1.6 ± 0.6 mmol/L, p < 0.001) with no change in HDL cholesterol. Homocysteine levels dropped significantly (10.1 ± 2.7 vs 7.9 ± 4 μmol/L, p = 0.006) over the study period. Flow mediated dilatation increased significantly in treated patients (3.8 ± 3.8% to 6.5 ± 3.6%, p = 0.004) while remaining constant in controls (p = 0.6). Endothelial progenitor cells numbers (CD34+, CD 133+ and UEA-1+) increased significantly following MPD consumption (p < 0.02) with no difference in migratory capacity. In contrast, time controls showed no significant changes.

CONCLUSION

Dietary intervention in medically managed, high risk patients resulted in important reductions in risk factors. Clinical Trials registry number NCT00462436.

What do Canadian uro-oncologists believe patients should know about androgen deprivation therapy?

Introduction

Patients prescribed luteinizing hormone-releasing hormone agonists for androgen deprivation therapy (ADT) have significant misconceptions about treatment side effects and how to manage them. We surveyed a subset of Canadian physicians about what they think is important information to tell patients starting on ADT to determine the degree to which there is consensus of opinion.

Method

A questionnaire about ADT side effects and management strategies was distributed to physicians–urologists, radiation oncologists, and medical oncologists – actively practicing within cancer and urology centers in the Canadian provinces of British Columbia, Alberta, Ontario, and the Maritime Provinces.

Result

A total of 75 physicians filled out the survey. Physicians agreed that osteoporosis, erectile dysfunction, hot flashes, loss of libido, and loss of muscle mass were drug responses that were essential or important to warn patients about. However, for six commonly reported side effects (i.e. depression, diabetes, elevated cholesterol, anemia, delayed or absent orgasm, and genital shrinkage), physicians showed great variance, with less than 60% agreeing on whether to discuss these topics or not.

Conclusion

There is little consensus among physicians regarding what to tell patients when prescribing this treatment. The lack of agreement among physicians may partially explain the lack of awareness of ADT side effects by patients and partners. The current findings may help guide strategies for the design, evaluation, and implementation of educational interventions for both physicians and patients that will better prepare patients to recognize, adapt to, and overcome ADT side effects.

Luteinizing hormone--releasing hormone agonists: a quick reference for prevalence rates of potential adverse effects

Men with prostate cancer (PCa) frequently undergo androgen deprivation therapy (ADT), typically in the form of a depot injection of luteinizing hormone-releasing hormone agonists (LHRHa). LHRHa are associated with many adverse effects (eg, hot flashes, sexual dysfunction, loss of muscle mass, osteopenia, metabolic syndrome), which drastically impact patient quality of life. This literature review, which includes a comprehensive table documenting prevalence rates, provides a quick reference for health care professionals involved in the care of men undergoing ADT with LHRHa. Primary sources were acquired from PubMed using the search terms "androgen deprivation therapy" and each potentially adverse effect (eg, "androgen deprivation therapy and hot flashes"). Commonly cited review articles were also examined for citations of original studies containing prevalence rates. More than 270 articles were reviewed. In contrast to many existing reviews, rates are cited exclusively from original sources. The prevalence rates, obtained from original sources, suggest that more than half of documented adverse effects are experienced by as many as 40% or more of patients. A critique of the literature is also provided. Although there is a vast literature of both original and review articles on specific adverse effects of LHRHa, the quality of research on prevalence rates for some adverse effects is subpar. Many review articles contain inaccuracies and do not cite original sources. The table of prevalence rates will serve as a quick reference for health care providers when counseling patients and will aid in the development of evidence-based patient education materials.

Nitric oxide release is not required to decrease the ulcerogenic profile of nonsteroidal anti-inflammatory drugs

The objective of this work was to evaluate the biological properties of a new series of nitric oxide-releasing nonsteroidal anti-inflammatory drugs (NO-NSAIDs) possessing a tyrosol linker between the NSAID and the NO-releasing moiety (PROLI/NO); however, initial screening of ester intermediates without the PROLI/NO group showed the required (desirable) efficacy/safety ratio, which questioned the need for NO in the design. In this regard, NSAID ester intermediates were potent and selective COX-2 inhibitors in vitro, showed equipotent anti-inflammatory activity compared to the corresponding parent NSAID, but showed a markedly reduced gastric toxicity when administered orally. These results provide complementary evidence to challenge the currently accepted notion that hybrid NO-NSAIDs exert their cytoprotective effects by releasing NO. Results obtained in this work constitute a good body of evidence to initiate a debate about the future replacement of NSAID prodrugs for unprotected NSAIDs (possessing a free carboxylic acid group) currently in clinical use.

Vietnamese community screening for hepatitis B virus and hepatitis C virus

Asian Americans represent an important cohort at high risk for viral hepatitis. To determine the prevalence of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection and HBV vaccination in a Vietnamese community, a total of 322 Vietnamese subjects from a local doctor's office and annual Vietnamese Health Fair were included in this study. Demographic and clinical data were collected. 2.2% of the screened cohort tested positive for anti-HCV and 9.3% tested positive for HBsAg. Unlike HBV-positive subjects, HCV-positive subjects had significantly higher liver enzymes (P = 0.0045 and P = 0.0332, respectively). The HBV-positive group was more likely to report jaundice (P = 0.0138) and a family history of HBV (P = 0.0115) compared to HBV-negative subjects. Forty-eight patients (15.5%) reported a family history of liver disease (HBV, HCV, HCC, cirrhosis, other). Of this 48, 68.8% reported no personal history of HBV vaccination and 77.1% reported no family history of vaccination for HBV. Among the 183 subjects without a family history of liver disease, 156 (85.2%) reported no personal history of vaccination and 168 (91.8%) reported no family history of vaccination. HBV vaccination rates in those reporting a family history of liver disease were significantly higher (P =0.020). There was a high prevalence of HBV infection in this community screening. Nevertheless, the rate for HBV vaccination was low. The low prevalence of abnormal liver enzymes in HBV-positive subjects emphasizes the need for screening to be triggered by risk factors and not by abnormal liver enzymes.

Novel APC-cleavage sites in FVa provide insights into mechanisms of action of APC and its cofactor protein S

BACKGROUND

Activated protein C (APC) inhibits factor Va (FVa) by cleaving at Arg306, Arg506 and Arg679. Protein S serves as cofactor, in particular for the Arg306 site, and a protein S-mediated relocation of the active site of APC closer to the membrane has been proposed as a mechanism. Recently, it was demonstrated that FVa, which was mutated at all three APC-cleavage sites (FVa-306Q/506Q/679Q), could still be cleaved by APC. These sites were close to Arg306 and Arg506 but not further defined.

OBJECTIVE

To identify and characterize the additional APC-cleavage sites in FVa.

METHODS

The cDNA for FV-306Q/506Q/679Q was used as a template to create FV variants with one or more possible cleavage sites being mutated. The FV variants were expressed and their sensitivity for APC characterized functionally and with Western blotting.

RESULTS

The additional APC-cleavage sites were located at Lys309, Arg313, Arg316, Arg317 and Arg505. FVa-306Q/309Q/313Q/316Q/317Q/505Q/506Q/679Q (denoted 8M-FVa) was APC resistant. To investigate individual sites, they were mutated back using 8M-FV as a template. The kinetics of APC-degradation of these variants demonstrated that protein S was equally efficient in enhancing the APC effect for all the novel sites.

CONCLUSIONS

Multiple APC-cleavage sites close to Arg306 and a single site close to Arg506 were identified. Protein S was equally efficient as APC cofactor for all novel sites. The stimulation by protein S of the Arg505 cleavage argues against a specific protein S-mediated stimulation of cleavage at Arg306 due to relocation of the APC active site closer to the membrane.

Does donating blood for the first time during a national emergency create a better commitment to donating again?

BACKGROUND AND OBJECTIVES

Emergency situations often elicit a generous response from the public. This occurred after attacks on the US on September 11, 2001 when many new blood donors lined up to donate. This study was performed to compare return rates for first time donors (FTD) after September 11th, 2001 to FTD during a comparable period in 2000.

MATERIALS AND METHODS

A total of 3315 allogeneic whole blood donations from FTD at a regional blood centre were collected between September 11th and 30th, 2001. Subsequent donations by the FTD before March 31, 2002 were reviewed. This (test) group was compared to 1279 FTD (control group) donating during the same time period in September 2000 and to their return rate in the subsequent 6 months.

RESULTS

Following September 11, 2001, 1087/3315 (32.8%) FTD returned by March 31, 2002. This return rate was similar to the control group [427/1279 (33.4%)]. The deferral rate during the donor screening process for the control group was significantly higher than the deferral rate for the September 11-30, 2001 group (P < 0.01). The odds of an individual FTD returning increased with age, and the chance of a female donor returning was 1.13 times higher than a male (P = 0.06). There was a carryover effect after September 11, 2001 too.

CONCLUSION

A national emergency, September 11, 2001, inspired people to donate blood for the first time. However, the proportion of return donations amongst them was not increased. Females and males in certain age groups were more likely to become repeat donors due to the residual effect of September 11, 2001. Additional efforts are needed to retain eligible FTD in donor pools.

The stimulus-dependent co-localization of serum- and glucocorticoid-regulated protein kinase (Sgk) and Erk/MAPK in mammary tumor cells involves the mutual interaction with the importin-alpha nuclear import protein

In Con8 rat mammary epithelial tumor cells, indirect immunofluorescence revealed that Sgk (serum- and glucocorticoid-regulated kinase) and Erk/MAPK (extracellular signal-regulated protein kinase/mitogen activated protein kinase) co-localized to the nucleus in serum-treated cells and to the cytoplasmic compartment in cells treated with the synthetic glucocorticoid dexamethasone. Moreover, the subcellular distribution of the importin-alpha nuclear transport protein was similarly regulated in a signal-dependent manner. In vitro GST-pull down assays revealed the direct interaction of importin-alpha with either Sgk or Erk/MAPK, while RNA interference knockdown of importin-alpha expression disrupted the localization of both Sgk and Erk into the nucleus of serum-treated cells. Wild type or kinase dead forms of Sgk co-immunoprecipitated with Erk/MAPK from either serum- or dexamethasone-treated mammary tumor cells, suggesting the existence of a protein complex containing both kinases. In serum-treated cells, nucleus residing Sgk and Erk/MAPK were both hyperphosphorylated, indicative of their active states, whereas, in dexamethasone-treated cells Erk/MAPK, but not Sgk, was in its inactive hypophosphorylated state. Treatment with a MEK inhibitor, which inactivates Erk/MAPK, caused the relocalization of both Sgk and ERK to the cytoplasm. We therefore propose that the signal-dependent co-localization of Sgk and Erk/MAPK mediated by importin-alpha represents a new pathway of signal integration between steroid and serum/growth factor-regulated pathways.

Catalase overexpression attenuates angiotensinogen expression and apoptosis in diabetic mice

Increased generation of reactive oxygen species (ROS) leads to oxidative stress in diabetes. Catalase is a highly conserved heme-containing protein that reduces hydrogen peroxide to water and oxygen and is an important factor decreasing cellular injury owing to oxidative stress. Hyperglycemic conditions increase oxidative stress and angiotensinogen gene expression. Angiotensinogen conversion to angiotensin II leads to a furtherance in oxidative stress through increased generation of reactive oxygen species. In this study, we utilized mice transgenically overexpressing rat catalase in a kidney-specific manner to determine the impact on ROS, angiotensinogen and apoptotic gene expression in proximal tubule cells of diabetic animals. Proximal tubules isolated from wild-type and transgenic animals without or with streptozotocin-induced diabetes were incubated in low glucose media in the absence or presence of angiotensin II or in a high-glucose media. Our results show that the overexpression of catalase prevents the stimulation of ROS and angiotensinogen mRNA in tubules owing to elevated glucose or angiotensin II in vitro. Additionally, overexpression of catalase attenuated ROS generation, angiotensinogen and proapoptotic gene expression and apoptosis in the kidneys of diabetic mice in vivo. Our studies point to an important role of ROS in the pathophysiology of diabetic nephropathy.