Coordinated ARP2/3 and glycolytic activities regulate the morphological and functional fitness of human CD8+ T cells

Actin cytoskeleton remodeling sustains the ability of cytotoxic T cells to search for target cells and eliminate them. We here investigated the relationship between energetic status, actin remodeling, and functional fitness in human CD8+ effector T cells. Cell spreading during migration or immunological synapse assembly mirrored cytotoxic activity. Morphological and functional fitness were boosted by interleukin-2 (IL-2), which also stimulated the transcription of glycolytic enzymes, actin isoforms, and actin-related protein (ARP)2/3 complex subunits. This molecular program scaled with F-actin content and cell spreading. Inhibiting glycolysis impaired F-actin remodeling at the lamellipodium, chemokine-driven motility, and adhesion, while mitochondrial oxidative phosphorylation blockade impacted cell elongation during confined migration. The severe morphological and functional defects of ARPC1B-deficient T cells were only partially corrected by IL-2, emphasizing ARP2/3-mediated actin polymerization as a crucial energy state integrator. The study therefore underscores the tight coordination between metabolic and actin remodeling programs to sustain the cytotoxic activity of CD8+ T cells.

Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial

BACKGROUND

Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID.

METHODS

We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194.

FINDINGS

Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo.

INTERPRETATION

Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe.

FUNDING

Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.

Metformin reduces SARS-CoV-2 in a Phase 3 Randomized Placebo Controlled Clinical Trial

Current antiviral treatment options for SARS-CoV-2 infections are not available globally, cannot be used with many medications, and are limited to virus-specific targets.1-3 Biophysical modeling of SARS-CoV-2 replication predicted that protein translation is an especially attractive target for antiviral therapy.4 Literature review identified metformin, widely known as a treatment for diabetes, as a potential suppressor of protein translation via targeting of the host mTor pathway.5 In vitro, metformin has antiviral activity against RNA viruses including SARS-CoV-2.6,7 In the COVID-OUT phase 3, randomized, placebo-controlled trial of outpatient treatment of COVID-19, metformin had a 42% reduction in ER visits/hospitalizations/death through 14 days; a 58% reduction in hospitalizations/death through 28 days, and a 42% reduction in Long COVID through 10 months.8,9 Here we show viral load analysis of specimens collected in the COVID-OUT trial that the mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95%CI, -1.05 to -0.06, p=0.027) while there was no virologic effect for ivermectin or fluvoxamine vs placebo. The metformin effect was consistent across subgroups and with emerging data.10,11 Our results demonstrate, consistent with model predictions, that a safe, widely available,12 well-tolerated, and inexpensive oral medication, metformin, can be repurposed to significantly reduce SARS-CoV-2 viral load.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers

BACKGROUND

Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited.

OBJECTIVE

To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering.

DESIGN

and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020.

MAIN MEASURES

Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates.

KEY RESULTS

Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered.

CONCLUSIONS

In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review

The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.

Using group testing in a two-phase epidemiologic design to identify the effects of a large number of antibody reactions on disease risk

BACKGROUND

The role of immunological responses to exposed bacteria on disease incidence is increasingly under investigation. With many bacterial species, and many potential antibody reactions to a particular species, the large number of assays required for this type of discovery can make it prohibitively expensive. We propose a two-phase group testing design to more efficiently screen numerous antibody effects in a case-control setting.

METHODS

Phase 1 uses group testing to select antibodies that are differentially expressed between cases and controls. The selected antibodies go on to Phase 2 individual testing.

RESULTS

We evaluate the two-phase group testing design through simulations and example data and find that it substantially reduces the number of assays required relative to standard case-control and group testing designs, while maintaining similar statistical properties.

CONCLUSION

The proposed two-phase group testing design can dramatically reduce the number of assays required, while providing comparable results to a case-control design.

0619 To Rely or No to Rely: Understanding the Demographics and Polysomnographic Features of False Negative Home Sleep Apnea Testing

Introduction

The current gold standard for a definitive diagnosis of OSA is an in-center Polysomnography (PSG). Home Sleep Apnea Testing(HSAT) has become an important tool in identifying high-risk populations. One of the limitations of the study is the lack of Electroencephalographic (EEG) data. This prevents the inclusion of Respiratory Effort Related Arousals (RERAs). We attempted to identify the patients whose HSAT showed an REI of less than 5 but are at risk for having sleep apnea based on the presence of airflow and thoraco-abdominal fluctuations.

Methods

Patients in this study were those that underwent HSAT from September 2016 till June of 2019. The studies reviewed and interpreted by board certified Sleep Specialists. Studies were done using nox-T3 sleep monitor and Nomad portable Home Sleep Testing type III devices-Both are type 3 Portable Monitors. Only those patients whose REI in their HSAT less than 5 were included in this study. All these patients had multiple airflow fluctuations in their HSAT that raised the suspicion for the presence of RERAs. None of these patients had significant hypoxemia in the HSAT.Airflow fluctuations were defined by the presence of fluctuations in the signal in the airflow channel along with increasing thoracoabdominal channels. Those patients with REI of less than 5 and without airflow fluctuations were excluded from the study.

Results

A total of 178 patients were recommended to undergo an in-center polysomnogram. Of those, 92 patients completed their polysomnogram with 59 patients ending up with a diagnosis of sleep apnea while 33 did not suggesting a false negative rate of 64.13%. Of those who were positive, 39 were females while 20 were males. Both groups did not differ significantly. Females had a median BMI of 32.9(28.19 for males), a median ESS of 11(8 in males) and a median RDI of 14.8(13.25).

Conclusion

Our study shows that both Home Sleep apnea testing can have a high proportion of false-negative results in patients exhibiting thoraco-abdominal and airflow fluctuations. The interpreting physicians should understand the limitations of the HSAT and should have a low threshold to recommend an in-center polysomnogram.

Support

None.

White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear.

MATERIALS AND METHODS

In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0-2) and moderate-to-severe (van Swieten score, 3-4) white matter disease using logistic regression: 90-day mRS 3-6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery.

RESULTS

Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58-79 years). A van Swieten score of 3-4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3-6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34-5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3-4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56-2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93-4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed.

CONCLUSIONS

Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.

Light wine consumption is associated with a lower odd for cardiovascular disease in chronic kidney disease

AIMS

To examine the association between wine consumption and the prevalence of chronic kidney disease (CKD) and cardiovascular disease (CVD).

DATA SYNTHESIS

We performed a cross-sectional logistic regression analysis of National Health and Nutrition Examination Survey (NHANES) in participants 21 years of age or older from 2003 to 2006 in a large representative study of the U.S.

POPULATION

Wine consumption was categorized as none (0 glass per day), light (<1 glass per day), or moderate (≥1 glasses per day). Prevalent CKD was defined as a urine albumin/creatinine ratio (UACR) ≥30 mg/g or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m². CVD was defined as history of CVD including angina, myocardial infarction, or stroke. Only 27 (0.5%) individuals reported moderate wine consumption, whereas 57.5% and 42% reported abstinence and light wine consumption, respectively. Light wine consumption was associated with a lower prevalence of CKD as opposed to abstinence in unadjusted analysis. After adjusting for demographics and CVD risk factors light wine consumption was associated with lower prevalence of CKD defined as UACR ≥30 mg/g but not with low eGFR. Furthermore, light wine consumption was associated with significantly lower rates of CVD in the general population and in subjects with CKD. The adjusted odd of CVD for those with light wine consumption was 0.72 (CI 0.52-0.99, p = 0.046) for the subjects with CKD.

CONCLUSION

These data suggest that light wine consumption (compared to abstinence) is associated with lower prevalence of CKD and a lower odd of CVD in those with CKD in the U.S.

Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Ilioprofunda Endobypass Can Successfully Treat a Post-Operative Femoral Pseudo-Aneurysm

INTRODUCTION

A 75-year-old male patient with significant cardiopulmonary comorbidity presented with a 70-mm left femoral pseudoaneurysm 6 years after aortobifemoral bypass (and prior femoral endarterectomy).

REPORT

As the left superficial femoral artery was occluded, an ilioprofunda endobypass was undertaken following extraperitoneal exposure of the left limb of the bypass graft with subsequent deployment of four Viabahn endoprostheses via the left limb into the proximal left deep femoral artery with successful exclusion of the pseudoaneurysm. The endografts remain patent at 6 months with regression noted in the pseudoaneurysm itself.

DISCUSSION

Post-operative femoral pseudoaneurysm following anastomotic dehiscence has traditionally been treated by open surgical repair. Re-re-do open femoral vascular surgery has a high complication rate. Scarring and potential graft infection may necessitate ligation of involved arteries and extra-anatomic bypasses with an attendant risk of limb loss. Although the common femoral artery is conventionally contraindicated for endograft deployment because of the perceived high risk of stent fracture in a highly mobile zone, an endobypass can avoid the potential complications of open revision groin surgery in an unfit, high-risk patient.

Impact of weight cycling on risk of morbidity and mortality

Unintentional weight gain is commonly observed in adult humans, often provoking intentional weight loss attempts followed by unintentional weight regain. This episodic variation in body weight over a period of time has been referred to as 'weight cycling'. Over the last two decades, weight cycling has been associated with a number of morbid health conditions and increased mortality. This article provides a comprehensive evaluation of recent weight-cycling evidence, looks to understand design differences between studies and study outcomes, assesses the need for further research on particular health outcomes, and proposes alternative methodologies that will bridge the needs and capabilities of research. Searches were conducted per PRISMA guidelines. Articles on weight cycling in the literature were initially identified using search strings in PubMed. Eligibility assessment of the remaining articles was performed independently by three reviewers to identify publications that presented direct evidence. Twenty human studies (in addition to seven animal studies) were selected and retained; 12 accounted for the intentionality of weight loss. Although weight regain following successful weight loss remains one of the most challenging aspects of body-weight regulation, evidence for an adverse effect of weight cycling appears sparse, if it exists at all.

Obesity and mortality: are the risks declining? Evidence from multiple prospective studies in the United States

We evaluated whether the obesity-associated years of life lost (YLL) have decreased over calendar time. We implemented a meta-analysis including only studies with two or more serial body mass index (BMI) assessments at different calendar years. For each BMI category (normal weight: BMI 18.5 to <25 [reference]; overweight: BMI 25 to <30; grade 1 obesity: BMI 30 to <35; and grade 2-3 obesity: BMI ≥ 35), we estimated the YLL change between 1970 and 1990. Because of low sample sizes for African-American, results are reported on Caucasian. Among men aged ≤60 years YLL for grade 1 obesity increased by 0.72 years (P < 0.001) and by 1.02 years (P = 0.01) for grade 2-3 obesity. For men aged >60, YLL for grade 1 obesity decreased by 1.02 years (P < 0.001) and increased by 0.63 years for grade 2-3 obesity (P = 0.63). Among women aged ≤60, YLL for grade 1 obesity decreased by 4.21 years (P < 0.001) and by 4.97 years (P < 0.001) for grade 2-3 obesity. In women aged >60, YLL for grade 1 obesity decreased by 3.98 years (P < 0.001) and by 2.64 years (P = 0.001) for grade 2-3 obesity. Grade 1 obesity's association with decreased longevity has reduced for older Caucasian men. For Caucasian women, there is evidence of a decline in the obesity YLL association across all ages.

MiR-93 enhances angiogenesis and metastasis by targeting LATS2

Here we report that miR-93, a miRNA in the miR-106B~25 cluster, a paralog of the miR-17-92 cluster, was significantly upregulated in human breast carcinoma tissues. We stably expressed miR-93 in the MT-1 human breast carcinoma cell line and found that tumors formed by the miR-93 cells contained more blood vessels than those formed by the control cells. Co-culture experiments indicated that the MT-1 cells displayed a high activity of adhesion with endothelial cells and could form larger and more tube-like structures with endothelial cells. Lung metastasis assays were performed in a mouse metastatic model, and it was found that expression of miR-93 promoted tumor cell metastasis to lung tissue. In cell culture, expression of miR-93 enhanced cell survival and invasion. We examined the potential target that mediated miR-93's effects and found that the large tumor suppressor, homology 2 (LATS2) was a target of miR-93. Higher levels of LATS2 were associated with cell death in the tumor mass. Silencing LATS2 expression promoted cell survival, tube formation and invasion, while ectopic expression of LATS2 decreased cell survival and invasion. These findings demonstrated that miR-93 promoted tumor angiogenesis and metastasis by suppressing LATS2 expression. Our results suggest that the inhibition of miR-93 function may be a feasible approach to repress tumor metastasis.

The utility of cytodiagnostic urinalysis as a tool to diagnose kidney allograft dysfunction in the era lymphocyte-depleting induction therapy

Cytodiagnostic urinalysis (CDU) has been used to evaluate causes of kidney allograft dysfunction, such as an acute rejection episode (ARE), calcineurin inhibitor (CNI) toxicity, or polyoma virus infection. We examined the concordance between CDU and allograft biopsy in patients with allograft dysfunction. Between 2002 and 2006, 201 patients had CDU performed within 7 days of a biopsy. The cohort was black (73%) with, male preponderance (59.2%), and an overall mean age of 48±13 years with 46% having received a deceased donor kidney. The induction regimen consisted of either antithymocyte globulin or alemtuzumab. CDU results that demonstrated 5 to 10 lymphocytes per high-power field (HPF) and >20 lymphocytes/HPF had 2.5 increased odds of predicting acute rejection (AR) on biopsy (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.12-5.79; P=.025). In the era of antithymocyte globulin induction, a CDU result demonstrating>5 lymphocytes/HPF had a 4.3 increased odds of predicting AR (CI 1.76-10.50; P=.001). This association was lost with alemtuzumab induction. A positive CDU result for calcineurin inhibitor (CNI) toxicity did not predict CNI nephrotoxcity on biopsy, but a positive CDU for polyoma virus infection predicted polyoma virus nephropathy (OR 22.18; CI: 4.41-111.63; P<.001). In conclusion, CDU is an adjunctive diagnostic tool for kidney transplantation.

Development and roll out of the JETS e-portfolio: a web based electronic portfolio for endoscopists

The JAG Endoscopy Training System (JETS) e-portfolio was designed to provide an electronic log of endoscopic experience, improve the effectiveness of training, streamline the JAG certification process and support the quality assurance of trainers, units and regional training programmes. It was piloted in 2008 with an 82.6% uptake in trainees offered the system. The system was released in the UK in September 2009. Steady adoption across the UK demonstrates the service finds it a valuable tool. In time it will be the only vehicle through which a trainee can achieve certification through JAG to practise independently.

Abstract P1-15-08: Comparison of Core Needle Biopsy and Surgical Specimens To Investigate the Percentage of Pre-Operative Ductal Carcinoma In Situ Diagnosis Who Were Found To Have Invasive Breast Cancer after Surgery at University Hospitals of Leicester (UHL)

Introduction:

Ductal carcinoma in situ (DCIS) accounts for 25% of all breast cancer diagnosis. This study was carried out to investigate the percentage of patients at UHL who are diagnosed to have DCIS on core needle biopsy but found to have invasive cancer from the surgical specimen. In addition, we analysed how many of these patient went on to have further surgery for removal of residual invasive cancer and axillary staging.

Method:

Data of all patients who presented between 2008 and 2010 was retrospectively analysed. Clinical presentation, histology pre-and post-procedure, cancer grade, treatment methods, axillary node involvement and calcification were recorded.

Results:

A total of 177 patients with DCIS were recorded. The mean age was 61.1 years (range 31 — 102). The most common site of cancer was upper outer quadrant (28.2%). Majority of patients were identified through the screening programme (67.2%) as opposed to symptomatic presentation (32.8%). The most common procedure was Wide Local Excision (59.3%) followed by Mastectomy (31.7%). 9% of patients who had positive histology did not have any surgery. Post-procedure histology proved that the mean size of DCIS was 25.4mm and 62.7% was high grade. Most patients had no axillary node involvement and no malignant calcification (91.5% and 74.6% respectively).

In 54 of 177 (30.5%) patients who were histopathologically diagnosed as DCIS by core needle biopsy, final diagnosis was changed to invasive carcinoma in surgical specimens The mean size of the invasive tumour in these patients was 13.4 mm and majority of the patients had grade 2 invasion (46.2%). Out of these 54 patients with new invasion, core biopsy results showed 31 patients (57.4%) had high grade DCIS, 10 patients (18.5%) had intermediate grade DCIS, 5 patients (9.2%) had low grade DCIS and 8 patients (14.8%) had unknown DCIS grade. Nineteen out of 54 patients (35.2%) went on to have further surgery after invasion was detected.

Conclusion:

The most common site was upper outer quadrant and majority of patients have been identified through the screening programme. Wide local excision was the most common surgical intervention. Our study showed almost 1/3 patients who were originally diagnosed with DCIS were found to have invasion post surgery at UHL and majority had high grade DCIS on core needle biopsy. This value is in keeping with the findings from previous studies[1]. However, only a small percentage of these patients went on to have further surgery.

[1] Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only. Dillon MF, McDermott EW, Quinn CM, O'Doherty A, O'Higgins N, Hill AD. Department of Surgery, St Vincent's University Hospital, Dublin, Ireland. J Surg Oncol. 2006 Jun 1;93(7):559- 63.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-15-08.

Use of self-reported height and weight biases the body mass index-mortality association

Background

Many large-scale epidemiologic data sources used to evaluate the body mass index (BMI: kg/m²) mortality association have relied on BMI derived from self-reported height and weight. Although measured BMI (BMI_M) and self-reported BMI (BMI_SR) correlate highly, self-reports are systematically biased.

Objective

To rigorously examine how self-reporting bias influences the association between BMI and mortality rate.

Subjects

Samples representing the US non-institutionalized civilian population.

Design and Methods

National Health and Nutrition Examination Survey data (NHANES II: 1976-80; NHANES III: 1988-94) contain BMI_M and BMI_SR. We applied Cox regression to estimate mortality hazard ratios (HRs) for BMI_M and BMI_SR categories, respectively, and compared results. We similarly analyzed subgroups of ostensibly healthy never-smokers.

Results

Misclassification by BMI_SR among the underweight and obesity ranged from 30–40% despite high correlations between BMI_M and BMI_SR (r>0.9). The reporting bias was moderately correlated with BMI_M (r>0.35), but not BMI_SR (r<0.15). Analyses using BMI_SR failed to detect six of eight significant mortality HRs detected by BMI_M. Significantly biased HRs were detected in the NHANES II full dataset (χ² = 12.49; p = 0.01) and healthy subgroup (χ² = 9.93; p = 0.04), but not in the NHANES III full dataset (χ² = 5.63; p = 0.23) or healthy subgroup (χ² = 1.52; p = 0.82).

Conclusions

BMI_SR should not be treated as interchangeable with BMI_M in BMI-mortality analyses. Bias and inconsistency introduced by using BMI_SR in place of BMI_M in BMI-mortality estimation and hypothesis tests may account for important discrepancies in published findings.

Combined epidural and general anesthesia for paediatric renal transplantation-a single center experience

BACKGROUND

Appropriate anesthesia for pediatric renal transplantation requires stable intraoperative hemodynamics, optimal perfusion of the newly transplanted kidney and good analgesia during recovery. The aim of this study was to assess the preliminary application, success and safety of combined epidural and general anesthesia in pediatric renal transplantation in a small cohort.

METHODS

We retrospectively reviewed the anesthesia records of 46 consecutive pediatric patients who received renal transplantation under combined epidural and general anesthesia from January 2003-2007.

RESULTS

The mean patient age and weight were 13.2 +/- 2.4 years and 25.7 +/- 5.46 kg, respectively. The infused crystalloids, 20% albumin and red blood cell concentrates were 120 +/- 2 mL/kg to achieve a CVP of 13 to 15 mm Hg. Brisk diuresis was observed in all patients. Epidural tramadol (2 mg/kg) provided good postoperative analgesia in 89% patients. 15% patients developed radiological evidence of pulmonary edema, only one required mechanical ventilation for hypoxemia. Minor adverse effects were nausea and vomiting (17.5%) and convulsions (8.5%). No perioperative mortality or major morbidity was recorded.

CONCLUSION

Epidural anesthesia is a useful adjunct to general anesthesia due to stable intraoperative haemodynamics and good postoperative analgesia.

A Non-randomised Controlled Trial of the Clinical and Cost Effectiveness of a Supervised Exercise Programme for Claudication

OBJECTIVES

The main aims of treatment in patients with intermittent claudication (IC) are to improve the clinical indicators of lower limb ischaemia and patients' quality of life (QoL). The aims of this study were assess the clinical and cost effectiveness of a supervised exercise programme (SEP) in patients with IC.

DESIGN

Non-randomised, controlled trial.

SETTING

University teaching hospital.

PATIENTS AND METHODS

Two groups of patients with IC were studied. Seventy patients were sequentially recruited before and after the establishment of a Supervised Exercise Programme at our unit. Thirty-seven patients (median age 69 years, 26 men) received conservative medical therapy (CMT) and 33 patients (median age 67 years, 22 men) received CMT plus a 3 month SEP of graduated physical exercise for sixty minutes, three times each week. Patients were assessed prior to and at 6 months following treatment. At each assessment patient reported walking distances (PRWD), treadmill claudication and maximal distances (ICD and MWD), ankle brachial pressure indices (ABPI) pre & post exercise and patient reported QoL using the SF36 questionnaire were assessed.

RESULTS

Prior to intervention the two groups were well matched. Following treatment, CMT patients demonstrated no significant change in PRWD or ICD but did record a small but significant improvement in MWD. CMT was also associated with a negative effect size in the SF36 index and in 7 of the 8 SF36 QoL domains, effect size >-0.5 for the domains of Physical Function and Emotional Role. SEP patients demonstrated significant improvement in PRWD, ICD and MWD. SEP was associated with a positive effect size in the SF36 index and in 2 SF36 QoL domains but a negative effect size in a further 2 domains. However, all QoL effect sizes following SEP were < +/-0.5. Intergroup differences in effect sizes were >0.5 for the SF36 domains of Physical Function, Physical Role, Emotion Role and SF36 index. SEP resulted in a 0.027 quality adjusted life year (QALY) gain over CMT in the first year post-treatment thus the cost/QALY gained of SEP is pound1780 at 1 year.

CONCLUSIONS

Compared to CMT, SEP increases walking distances, improves QoL and is a highly cost-effective treatment for IC.

Outer membrane c-type cytochromes required for Fe(III) and Mn(IV) oxide reduction in Geobacter sulfurreducens

The potential role of outer membrane proteins in electron transfer to insoluble Fe(III) oxides by Geobacter sulfurreducens was investigated because this organism is closely related to the Fe(III) oxide-reducing organisms that are predominant in many Fe(III)-reducing environments. Two of the most abundant proteins that were easily sheared from the outer surfaces of intact cells were c-type cytochromes. One, designated OmcS, has a molecular mass of ca. 50 kDa and is predicted to be an outer membrane hexaheme c-type cytochrome. Transcripts for omcS could be detected during growth on Fe(III) oxide, but not on soluble Fe(III) citrate. The omcS mRNA consisted primarily of a monocistronic transcript, and to a lesser extent, a longer transcript that also contained the downstream gene omcT, which is predicted to encode a second hexaheme outer membrane cytochrome with 62.6% amino acid sequence identity to OmcS. The other abundant c-type cytochrome sheared from the outer surface of G. sulfurreducens, designated OmcE, has a molecular mass of ca. 30 kDa and is predicted to be an outer membrane tetraheme c-type cytochrome. When either omcS or omcE was deleted, G. sulfurreducens could no longer reduce Fe(III) oxide but could still reduce soluble electron acceptors, including Fe(III) citrate. The mutants could reduce Fe(III) in Fe(III) oxide medium only if the Fe(III) chelator, nitrilotriacetic acid, or the electron shuttle, anthraquinone 2,6-disulfonate, was added. Expressing omcS or omcE in trans restored the capacity for Fe(III) oxide reduction. OmcT was not detected among the sheared proteins, and genetic studies indicated that G. sulfurreducens could not reduce Fe(III) oxide when omcT was expressed but OmcS was absent. In contrast, Fe(III) oxide was reduced when omcS was expressed in the absence of OmcT. These results suggest that OmcS and OmcE are involved in electron transfer to Fe(III) oxides in G. sulfurreducens. They also emphasize the importance of evaluating mechanisms for Fe(III) reduction with environmentally relevant Fe(III) oxide, rather than the more commonly utilized Fe(III) citrate, because additional electron transfer components are required for Fe(III) oxide reduction that are not required for Fe(III) citrate reduction.

Assessing the Validity and Responsiveness of Disease-specific Quality of Life Instruments in Intermittent Claudication

PURPOSE

To recommend a suitable disease-specific quality of life (QOL) instrument for use in intermittent claudication (IC) based on validity and responsiveness.

METHODS

Seventy claudicants completed two generic (SF36 and EUROQOL) and three disease-specific (CLAUS, VASCUQOL and SIP(IC)) QOL instruments prior to and 6 months after treatment (angioplasty or conservative therapy). Ankle brachial pressure indices and treadmill walking distances were measured at each assessment and International Society of Cardiovascular Surgery (ISCVS) recommended outcome measures were used to stratify the results. Construct and convergent-divergent validity was assessed for the three disease-specific QOL instruments. Responsiveness was assessed using effect sizes (effect size >0.5 is clinically significant).

RESULTS

All clinical indicators improved significantly following treatment. All five domains of CLAUS, the VASCUQOL and SIP(IC) showed highly significant spearman correlation with intermittent claudication distance (ICD) and maximum walking distance (MWD) (0.267-0.697, p=0.01), suggesting good construct validity. There was greater correlation between like domains of CLAUS and SF36 than non-like domains suggesting good convergent-divergent validity. Pain domain of CLAUS and VASCUQOL could detect mild clinical improvement significantly (effect sizes 0.55 and 0.67). Pain and everyday life domain of CLAUS and the VASCUQOL could detect moderate clinical improvement significantly (effect sizes 0.7, 0.74 and 0.56, respectively).

CONCLUSION

The three disease-specific QOL instruments (CLAUS, VASCUQOL, SIP(IC)) showed a high degree of construct and convergent-divergent validity. Amongst the three disease-specific QOL instruments, the VASCUQOL was most responsive and we would recommend its use in clinical practice.

A comparative study of aortic wall stress using finite element analysis for ruptured and non-ruptured abdominal aortic aneurysms

BACKGROUND

The decision to repair an asymptomatic abdominal aortic aneurysm (AAA) is currently based on diameter (> or =5.5 cm) alone. However, aneurysms less than 5.5 cm do rupture while some reach greater than 5.5 cm without rupturing. Hence the need to predict the risk of rupture on an individual patient basis is important. This study aims to calculate and compare wall stress in ruptured and non-ruptured AAA.

METHODS

The 3D geometries of AAA were derived from CT scans of 27 patients (12 ruptured and 15 non-ruptured). AAA geometry, systolic blood pressure and literature derived material properties, were utilised to calculate wall stress for individual AAA using finite element analysis.

RESULTS

Peak wall stress was significantly higher in the ruptured AAA (mean 1.02 MPa) than the non-ruptured AAA (mean 0.62 MPa). In patients with an identifiable site of rupture on CT scan, the area of peak wall stress correlated with rupture site.

CONCLUSIONS

Peak wall stress can be calculated from routinely performed CT scans and may be a better predictor of risk of rupture than AAA diameter on an individual patient basis.

The Value of Abdominal Examination in the Diagnosis of Abdominal Aortic Aneurysm

BACKGROUND

There is considerable variability in the reported value of clinical examination in the diagnosis of abdominal aortic aneurysms (AAA). This study aims to assess accuracy of abdominal examination by a doctor, a nurse and the patient in the diagnosis of AAA and whether this accuracy is related to the size of the aneurysm and/or the BMI of the patient.

METHODS

164 patients, 138 men and 26 women, median age 71 years, consented to participate in this prospective, single blind, controlled study. Thirty-nine patients attending for carotid duplex were used as controls. Abdominal examination was performed by a doctor and a nurse. Patients then performed self-examination.

RESULTS

Examination by a doctor, a nurse and the patient were similar in accuracy in diagnosing/excluding AAA which was directly related to AAA size and patient BMI. The Negative Predicted Value of abdominal examination exceeds 0.9 with AAA diameters > or =4 cm and the Positive Predictive Value exceeds 0.8 with AAA diameters > or =5 cm.

CONCLUSIONS

Abdominal examination by a doctor, a nurse and the patient is of value in the exclusion and diagnosis of significant AAA. It should be promoted and may represent a useful adjunct to population screening with ultrasound.

Disease-specific quality of life assessment in intermittent claudication: review

OBJECTIVES

intermittent claudication (IC) is a common condition that has a major impact on the patients' quality of life (QoL). Generic QoL instruments often lack sensitivity to detect small but clinically significant variation in QoL. Disease-specific instruments may overcome this problem. This study aims to review various disease-specific QoL instruments available for use in IC and make recommendations for clinical utilization based on validity, reliability and responsiveness.

METHODS

a detailed literature search and extensive bibliography review of all papers relating to disease-specific QoL and IC.

RESULTS

several disease-specific QoL instruments are available for use in patients with IC. The most notable of these are the Claudication Scale (CLAU-S), Sickness Impact Profile - Intermittent Claudication (SIP(IC)) and the VascuQoL. The Walking Impairment Questionnaire (WIQ) is an objective measure of the patient's walking ability and not a QoL instrument.

CONCLUSION

many of the questionnaires are new and have undergone only a limited validation process. More work is required in this field before any one disease-specific QoL instrument can be recommended for use in patients with IC.

Indications for pelvic sonography-Do patients and doctors agree?

PURPOSE

Often, it seems that the patient history provided by the referring clinician on the sonography requisition form differs from that given by the patient during the sonographic examination. Because such a discrepancy in the history may delay the scan and disrupt the daily work flow while the referring clinician is contacted for clarification, we sought to document the incidence and cause of such discrepancies at our institution.

METHODS

During a 3-month period, all outpatients who were referred for a pelvic sonographic examination were asked to indicate their understanding of why the examination had been requested. The health care providers' reasons for requesting sonography were recorded using a computer order entry system. Each pair of responses (health care provider and patient) were classified as either concordant or discordant. Patient and physician characteristics were fit into a logistic regression model with concordance of history as the outcome variable.

RESULTS

One hundred fifty-six (90%) of the 173 patients enrolled in our study indicated that their health care provider had discussed with them the reason for ordering the sonographic examination. The histories provided by the patient and health care provider were concordant in 134 (77%) of 173 cases. The histories provided by the patient and health care provider were more likely to be concordant if the patient's insurance was a managed care plan or if the patient had a college or graduate level education, had been cared for by the same health care provider for more than 2 years, or had been seen by a female health care provider. Concordance of history was not associated with a higher incidence of abnormal sonographic findings.

CONCLUSIONS

It appears that health care providers, despite increased demands on their time, adequately discuss with their patients the reasons for ordering a pelvic sonographic examination. However, our study suggests that health care providers may need to spend additional time with patients whose education is limited and that male physicians may need to pay particular attention to their communication with female patients.

Central nervous system abnormalities assessed with prenatal magnetic resonance imaging

OBJECTIVE

To determine the frequency at which magnetic resonance imaging (MRI) provides additional information in fetuses with suspected central nervous system (CNS) abnormalities on ultrasound.

METHODS

Between May 1, 1996, and March 26, 1999, 83 women with 90 fetuses (including seven sets of live twins) had 91 ultrasonographic and MRI examinations of the fetal CNS. Eight women were studied twice, one for two different indications. If referrals came from outside our institution, a confirmatory sonogram was obtained. Indications for examination were ventriculomegaly (n = 25), suspected neural tube defect (n = 16), arachnoid cyst (n = 12), large cisterna magna (n = 11), and miscellaneous indications (n = 20).

RESULTS

Magnetic resonance imaging findings led to changed diagnoses in 26 (40%) of 66 fetuses with abnormal confirmatory sonograms. Magnetic resonance imaging findings not found by ultrasound included partial or complete agenesis of the corpus callosum (n = 11), porencephaly (n = 6), hemorrhage (n = 5), tethered cord (n = 3), cortical gyral abnormality (n = 2), cortical cleft (n = 2), midbrain abnormality (n = 2), and partial or complete agenesis of the septi pellucidi (n = 3), as well as holoprosencephaly, cerebellar hypoplasia, subependymal and cortical tubers, vascular malformation, and vermian cysts (one case each). Abnormalities better delineated by MRI than ultrasound included three cephaloceles, a dural arteriovenous malformation, one distal sacral neural tube defect, and the mass effect of three arachnoid cysts. That information was used to alter patient counseling and at times management.

CONCLUSION

When a CNS anomaly is detected by sonography or suspected on ultrasound, MRI findings might lead to altered diagnosis and patient counseling.

A national survey of board-certified emergency physicians: quality of care and practice structure issues

The opinions and experiences of board-certified emergency physicians regarding employment structure and finances, professional society policies, and quality of patient care have never been formally studied. A survey questionnaire was sent to a random sample of 1,050 emergency physicians certified by the American Board of Emergency Medicine. The survey contained 29 multiple choice questions. Of the 1,050, 465 (44.3%) of the surveys were returned. Respondents averaged 13.5 years of emergency medicine practice, 83% were members of the American College of Emergency Physicians, and 44% were emergency medicine residency trained. Seventy-five percent felt they had been financially exploited by the emergency department contract holder and 49% considered leaving their employer because of unfair business practices. Fifteen percent have been terminated without due process/peer review, and 11% have been forced to leave a position, move, or pay compensation because of noncompete clauses. The majority reported encountering instances of substandard emergency medical care, most commonly in settings with multihospital contract company coverage. The majority also believe their specialty societies should address issues of employment structure and quality of patient care standards.