Rapid Prototyping of Thermoplastic Microfluidic 3D Cell Culture Devices by Creating Regional Hydrophilicity Discrepancy

Microfluidic 3D cell culture devices that enable the recapitulation of key aspects of organ structures and functions in vivo represent a promising preclinical platform to improve translational success during drug discovery. Essential to these engineered devices is the spatial patterning of cells from different tissue types within a confined microenvironment. Traditional fabrication strategies lack the scalability, cost-effectiveness, and rapid prototyping capabilities required for industrial applications, especially for processes involving thermoplastic materials. Here, an approach to pattern fluid guides inside microchannels is introduced by establishing differential hydrophilicity using pressure-sensitive adhesives as masks and a subsequent selective coating with a biocompatible polymer. Optimal coating conditions are identified using polyvinylpyrrolidone, which resulted in rapid and consistent hydrogel flow in both the open-chip prototype and the fully bonded device containing additional features for medium perfusion. The suitability of the device for dynamic 3D cell culture is tested by growing human hepatocytes in the device under controlled fluid flow for a 14-day period. Additionally, the study demonstrated the potential of using the device for pharmaceutical high-throughput screening applications, such as predicting drug-induced liver injury. The approach offers a facile strategy of rapid prototyping thermoplastic microfluidic organ chips with varying geometries, microstructures, and substrate materials.

"What we talk about is creating a probability": Exploring the interaction between the anticipation and decision-making processes of professional bowlers and batters in Twenty20 cricket

Expert performers in time constrained sports use a range of information sources to facilitate anticipatory and decision-making processes. However, research has often focused on responders such as batters, goalkeepers, defenders, and returners of serve, and failed to capture the complex interaction between opponents, where responders can also manipulate probabilities in their favour. This investigation aimed to explore the interaction between top order batters and fast or medium paced bowlers in cricket and the information they use to inform their anticipatory and decision-making skills in Twenty20 competition. Eleven professional cricketers were interviewed (8 batters and 3 bowlers) using semi-structured questions and scenarios from Twenty20 matches. An inductive and deductive thematic analysis was conducted using the overarching themes of Situation Awareness (SA) and Option Awareness (OA). Within SA, the sub-themes identified related to information sources used by bowlers and batters (i.e., stable contextual information, dynamic contextual information, kinematic information). Within OA, the sub-themes identified highlighted how cricketers use these information sources to understand the options available and the likelihood of success associated with each option (e.g., risk and reward, personal strengths). A sub-theme of 'responder manipulation' was also identified within OA to provide insight into how batters and bowlers interact in a cat-and-mouse like manner to generate options that manipulate one another throughout the competition. A schematic has been developed based on the study findings to illustrate the complex interaction between the anticipation and decision-making processes of professional top order batters and fast or medium paced bowlers in Twenty20 cricket.

An Unusual Extramedullary Presentation of an NPM1-Mutated Acute Myeloid Leukemia (AML) in a Young Adult

Introduction/Objective

Pleural effusion presentation of AML, particularly without leukemic disease, has been rarely described in the literature. This case serves to investigate the value of an identified NPM1 mutation.

Methods/Case Report

A 25-year-old male with Down syndrome presented with dyspnea. Computerized tomography scan identified a moderate pleural effusion and pelvic lytic bone lesions. A complete blood count was normal. Pleural fluid cytologic evaluation showed a spectrum of immature myeloid precursors, and flow cytometry identified a 23% CD117 positive myeloblast population expressing CD33, CD13, and dim CD45 but lacking CD34 and HLA-DR. Fluorescence in-situ hybridization testing was negative for a PML-RARA fusion. Given the phenotype, molecular testing was initiated and confirmed an NPM1 mutation. Testing revealed additional pathogenic variants in DNMT3A and IDH1 with no FLT3 mutations. Peripheral blood smear and bone marrow evaluations yielded no clear leukemic involvement, and cytogenetics from bone marrow showed 47,XY,+21c[20]. The significance of this myeloid infiltrate was initially not entirely clear with no established leukemic involvement or tumor-forming mass as required for the World Health Organization diagnosis of myeloid sarcoma. However, the finding of the NPM1 mutation lent high confidence for a diagnosis of an extramedullary presentation of acute myeloid leukemia, though the lytic bone lesions were not biopsied to possibly demonstrate a myeloid sarcoma.

Results (if a Case Study enter NA)

N/A.

Conclusion

The identified NPM1 mutation was instrumental in diagnosing an unusual presentation of AML where material was limited. Subsequent to this presentation the patient developed more overt leukemic disease at an outside institution, additionally supporting this diagnosis.

Structured expert elicitation to inform long-term survival extrapolations using alternative parametric distributions: a case study of CAR T therapy for relapsed/ refractory multiple myeloma

Background

Our aim was to extend traditional parametric models used to extrapolate survival in cost-effectiveness analyses (CEAs) by integrating individual-level patient data (IPD) from a clinical trial with estimates from experts regarding long-term survival. This was illustrated using a case study evaluating survival of patients with triple-class exposed relapsed/refractory multiple myeloma treated with the chimeric antigen receptor (CAR) T cell therapy idecabtagene vicleucel (ide-cel, bb2121) in KarMMa (a phase 2, single-arm trial).

Methods

The distribution of patients expected to be alive at 3, 5, and 10 years given the observed survival from KarMMa (13.3 months of follow-up) was elicited from 6 experts using the SHeffield ELicitation Framework. Quantities of interest were elicited from each expert individually, which informed the consensus elicitation including all experts. Estimates for each time point were assumed to follow a truncated normal distribution. These distributions were incorporated into survival models, which constrained the expected survival based on standard survival distributions informed by IPD from KarMMa.

Results

Models for ide-cel that combined KarMMa data with expert opinion were more consistent in terms of survival as well as mean survival at 10 years (survival point estimates under different parametric models were 29–33% at 3 years, 5–17% at 5 years, and 0–6% at 10 years) versus models with KarMMa data alone (11–39% at 3 years, 0–25% at 5 years, and 0–11% at 10 years).

Conclusion

This case study demonstrates a transparent approach to integrate IPD from trials with expert opinion using traditional parametric distributions to ensure long-term survival extrapolations are clinically plausible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01745-z.

Dietary Patterns and Risk of a New Carious Lesion Postpartum: A Cohort Study

Dental caries (cavities), one of the most common infectious diseases, is caused by a number of factors. Oral microbes, dietary practices, sociodemographic factors, and dental hygiene all inform caries risk. Assessing the impact of diet is complicated as individuals eat foods in combinations, and the interactions among the foods may alter caries risk. Our study aimed to prospectively assess the association between dietary patterns and caries risk in the postpartum period, a potentially sensitive period for caries development. We analyzed in-person dental assessments and telephone food frequency questionnaires (FFQs) from 879 Caucasian women participating in the Center for Oral Health Research in Appalachia Cohort 2 (COHRA2) that were collected biannually for up to 6 y. One-week recall of food intake frequency was assessed using a Likert scale. We used principal component analysis to summarize the FFQ data; the top 2 components described 15% and 12% of the variance in FFQ data. The first component was characterized by high consumption of fruits and vegetables, while the second component was heavily influenced by desserts and crackers. We used a modified Poisson model to predict the risk of an increase in the number of decayed, missing, and filled teeth in the postpartum period by 1) dietary patterns and 2) individual foods and beverages at the previous study visit, after controlling for other known risk factors, including history of carious lesions. Eating a dietary pattern high in desserts and crackers was associated with a 20% increase in the number of decayed, missing, and filled teeth in the postpartum period (95% confidence interval, 1.03-1.39). However, this effect was attenuated among those who also consumed a dietary pattern high in fruits and vegetables. Dietary patterns should be considered when devising interventions aimed at preventing dental caries.

What is the effectiveness of radiofrequency ablation in the management of patients with spinal metastases? A systematic review and meta-analysis

PURPOSE

Spinal metastases are indicative of progressive cancer which can lead to vertebral body fractures and spinal cord compression. Radiofrequency ablation (RFA) treatment is infrequently used in patients with refractory pain. The aim of this systematic review is to determine the clinical efficacy of RFA, with the scope of using it as front-line management of spinal metastases.

METHODS

Electronic databases were searched (to July 2020) for studies evaluating RFA treatment for spinal metastases in adults. Measured outcomes were pain (primary), disability, health-related quality of life (HRQOL), complications, tumour control and mortality. Study inclusion, data extraction and risk of bias using the ROBIN-I tool were assessed. Meta-analysis was conducted for pooled results with homogeneity, and narrative synthesis was conducted otherwise.

RESULTS

15 studies were included. RFA reduces pain scores at 3-5 weeks [standardised mean difference (SMD 2.24, 95% confidence intervals (CI) 1.55-2.93], 3-4 months (SMD 3.00, 95% CI 1.11-4.90) and 5-6 months (SMD 3.54, 95% CI 1.96-5.11). RFA is effective in reducing disability/improving HRQOL in the short-term but longer-term efficacy remains unclear. 13.2% cases reported local tumour control failure (2.5 months-5 year follow-up) whereas mortality was 23.6% (follow-up of up to 1 year).

CONCLUSION

Low quality evidence has proven RFA to be safe and effective in reducing pain and disability, especially in the short-term. RFA may be routinely implemented in all cases involving refractory pain or radiotherapy-resistant tumours but controlled trials are required to compare the efficacy of RFA to current frontline treatments. PROSPERO protocol registration number: CRD42020202377.

Tumor-Specific Delivery of 5-Fluorouracil-Incorporated Epidermal Growth Factor Receptor-Targeted Aptamers as an Efficient Treatment in Pancreatic Ductal Adenocarcinoma Models

BACKGROUNDS & AIMS

Fluoropyrimidine c (5-fluorouracil [5FU]) increasingly represents the chemotherapeutic backbone for neoadjuvant, adjuvant, and palliative treatment of pancreatic ductal adenocarcinoma (PDAC). Even in combination with other agents, 5FU efficacy remains transient and limited. One explanation for the inadequate response is insufficient and nonspecific delivery of 5FU to the tumor.

METHODS

We designed, generated, and characterized 5FU-incorporated systematic evolution of ligands by exponential enrichment (SELEX)-selected epidermal growth factor receptor (EGFR)-targeted aptamers for tumor-specific delivery of 5FU to PDAC cells and tested their therapeutic efficacy in vitro and in vivo.

RESULTS

5FU-EGFR aptamers reduced proliferation in a concentration-dependent manner in mouse and human pancreatic cancer cell lines. Time-lapsed live imaging showed EGFR-specific uptake of aptamers via clathrin-dependent endocytosis. The 5FU-aptamer treatment was equally effective in 5FU-sensitive and 5FU-refractory PDAC cell lines. Biweekly treatment with 5FU-EGFR aptamers reduced tumor burden in a syngeneic orthotopic transplantation model of PDAC, in an autochthonously growing genetically engineered PDAC model (LSL-KrasG12D/+;LSL-Trp53flox/+;Ptf1a-Cre [KPC]), in an orthotopic cell line-derived xenograft model using human PDAC cells in athymic mice (CDX; Crl:NU-Foxn1nu), and in patient-derived organoids. Tumor growth was significantly attenuated during 5FU-EGFR aptamer treatment in the course of follow-up.

CONCLUSIONS

Tumor-specific targeted delivery of 5FU using EGFR aptamers as the carrier achieved high target specificity; overcame 5FU resistance; and proved to be effective in a syngeneic orthotopic transplantation model, in KPC mice, in a CDX model, and in patient-derived organoids and, therefore, represents a promising backbone for pancreatic cancer chemotherapy in patients. Furthermore, our approach has the potential to target virtually any cancer entity sensitive to 5FU treatment by incorporating 5FU into cancer cell-targeting aptamers as the delivery platform.

Evaluating West Virginia's Emergency Medicine Workforce: A Longitudinal Observational Study

Objective

Although the urban emergency workforce is well studied, rural departments are less understood. This study seeks to further define the landscape of rural healthcare and expand on previous studies of the West Virginia (WV) workforce.

Methods

During the second quarter of 2019, surveys were sent via email to medical directors’ professional IDs as anonymous survey links. Hard copies were also sent to directors at their hospital addresses. Responses were aggregated with hospitals stratified based on annual census and rural classification. Data was interpreted through descriptive analysis.

Results

Surveys were sent to 53 departments with a 55% response rate. Of the responding hospitals, 15 of 29 were identified as rural. The average state-wide annual hospital census was 29,500 visits with board-certified emergency medicine (EM)-trained physicians covering 67% of shifts. Rural departments have a smaller census and less specialized coverage. Full-time physicians are found to have the strongest ties to WV, with 65% attending medical school, residency, or growing up in the state.

Conclusion

Board-certified EM-trained physicians provide some level of coverage in most emergency departments in WV but remain underrepresented in rural locations. This specialized coverage has increased by 20% in the last 15 years. Additionally, a majority of hospitals have access to basic consulting services (surgery and primary care); however, other specialists are rare in rural WV.

Long-term cost-effectiveness of screening for fracture risk in a UK primary care setting: the SCOOP study

Community-based screening and treatment of women aged 70-85 years at high fracture risk reduced fractures; moreover, the screening programme was cost-saving. The results support a case for a screening programme of fracture risk in older women in the UK.

INTRODUCTION

The SCOOP (screening for prevention of fractures in older women) randomized controlled trial investigated whether community-based screening could reduce fractures in women aged 70-85 years. The objective of this study was to estimate the long-term cost-effectiveness of screening for fracture risk in a UK primary care setting compared with usual management, based on the SCOOP study.

METHODS

A health economic Markov model was used to predict the life-time consequences in terms of costs and quality of life of the screening programme compared with the control arm. The model was populated with costs related to drugs, administration and screening intervention derived from the SCOOP study. Fracture risk reduction in the screening arm compared with the usual management arm was derived from SCOOP. Modelled fracture risk corresponded to the risk observed in SCOOP.

RESULTS

Screening of 1000 patients saved 9 hip fractures and 20 non-hip fractures over the remaining lifetime (mean 14 years) compared with usual management. In total, the screening arm saved costs (£286) and gained 0.015 QALYs/patient in comparison with usual management arm.

CONCLUSIONS

This analysis suggests that a screening programme of fracture risk in older women in the UK would gain quality of life and life years, and reduce fracture costs to more than offset the cost of running the programme.

Nonsteroidal Anti-inflammatory Drugs and Cardiovascular Risk in American Football

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with adverse cardiovascular outcomes and reportedly overused in American-style football (ASF). However, assessment of ASF NSAID use in the context of cardiovascular risk has not been performed. We sought to characterize NSAID use patterns and the association with cardiovascular risk in a diverse cohort of high school and collegiate ASF athletes.

METHODS

A total of 226 ASF athletes, 60 endurance athletes, and 63 nonathletic controls were studied pre- and postseason with echocardiography, vascular applanation tonometry, and clinical data assessment. Qualitative NSAID use throughout the season was recorded at postseason.

RESULTS

ASF athletes gained weight (Δ0.86 ± 3.9 kg, P < 0.001), increased systolic blood pressure (SBP, Δ3.1 ± 12 mm Hg, P < 0.001) and pulse wave velocity (Δ0.2 ± 0.6 m·s, P < 0.001), and decreased E' (Δ-1.4 ± 2.8 cm·s, P < 0.001) across one athletic season. Seventy-seven percent (n = 173) of ASF athletes reported that sport-specific NSAID use began in middle school. ASF NSAID use was more frequent with "weekly" (n = 42.19%) and "daily" (n = 32.14%) use compared with endurance athletes (P < 0.001) and controls (P = 0.02). ASF NSAID use increased in parallel with postseason SBP and weights. "Daily" ASF NSAID users demonstrated the highest postseason SBP (137 ± 13 vs 128 ± 13 mm Hg, P = 0.002) and weight (109.0 ± 18.6 vs 95.8 ± 20.5 kg, P = 0.002) compared with "never/rare" users. Adjusting for player position, SBP, pulse wave velocity, and E', increased weight (odds ratio = 1.04, 95% confidence interval = 1.0-1.08, P = 0.037) was associated with more frequent NSAID use.

CONCLUSIONS

Habitual NSAID use commonly begins during adolescence, before full physical maturation, and is associated with cardiovascular risk, particularly increased weight, in ASF athletes. NSAID use frequency should be considered when risk stratifying high-risk ASF athletes.

Screening for high hip fracture risk does not impact on falls risk: a post hoc analysis from the SCOOP study

A reduction in hip fracture incidence following population screening might reflect the effectiveness of anti-osteoporosis therapy, behaviour change to reduce falls, or both. This post hoc analysis demonstrates that identifying high hip fracture risk by FRAX was not associated with any alteration in falls risk.

INTRODUCTION

To investigate whether effectiveness of an osteoporosis screening programme to reduce hip fractures was mediated by modification of falls risk in the screening arm.

METHODS

The SCOOP study recruited 12,483 women aged 70-85 years, individually randomised to a control (n = 6250) or screening (n = 6233) arm; in the latter, osteoporosis treatment was recommended to women at high risk of hip fracture, while the control arm received usual care. Falls were captured by self-reported questionnaire. We determined the influence of baseline risk factors on future falls, and then examined for differences in falls risk between the randomisation groups, particularly in those at high fracture risk.

RESULTS

Women sustaining one or more falls were slightly older at baseline than those remaining falls free during follow-up (mean difference 0.70 years, 95%CI 0.55-0.85, p < 0.001). A higher FRAX 10-year probability of hip fracture was associated with increased likelihood of falling, with fall risk increasing by 1-2% for every 1% increase in hip fracture probability. However, falls risk factors were well balanced between the study arms and, importantly, there was no evidence of a difference in falls occurrence. In particular, there was no evidence of interaction (p = 0.18) between baseline FRAX hip fracture probabilities and falls risk in the two arms, consistent with no impact of screening on falls in women informed to be at high risk of hip fracture.

CONCLUSION

Effectiveness of screening for high FRAX hip fracture probability to reduce hip fracture risk was not mediated by a reduction in falls.

Systematic screening using FRAX® leads to increased use of, and adherence to, anti-osteoporosis medications: an analysis of the UK SCOOP trial

In the large community-based SCOOP trial, systematic fracture risk screening using FRAX^® led to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.

INTRODUCTION

In the SCreening of Older wOmen for Prevention of fracture (SCOOP) trial, we investigated the effect of the screening intervention on subsequent long-term self-reported adherence to anti-osteoporosis medications (AOM).

METHODS

SCOOP was a primary care-based UK multicentre trial of screening for fracture risk. A total of 12,483 women (70-85 years) were randomised to either usual NHS care, or assessment using the FRAX^® tool ± dual-energy X-ray absorptiometry (DXA), with medication recommended for those found to be at high risk of hip fracture. Self-reported AOM use was obtained by postal questionnaires at 6, 12, 24, 36, 48 and 60 months. Analysis was limited to those who initiated AOM during follow-up. Logistic regression was used to explore baseline determinants of adherence (good ≥ 80%; poor < 80%).

RESULTS

The mean (SD) age of participants was 75.6 (4.2) years, with 6233 randomised to screening and 6250 to the control group. Of those participants identified at high fracture risk in the screening group, 38.2% of those on treatment at 6 months were still treated at 60 months, whereas the corresponding figure for the control group was 21.6%. Older age was associated with poorer adherence (OR per year increase in age 0.96 [95% CI 0.93, 0.99], p = 0.01), whereas history of parental hip fracture was associated with greater rate adherence (OR 1.67 [95% CI 1.23, 2.26], p < 0.01).

CONCLUSIONS

Systematic fracture risk screening using FRAX^® leads to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.

Temporal Changes in Cardiovascular Remodeling Associated with Football Participation

PURPOSE

American-style football (ASF) participation rates in the United States are highest among high school (HS) athletes. This study sought to compare the cardiovascular response to HS versus collegiate ASF participation.

METHODS

The ASF participants (HS, n = 61; collegiate, n = 87) were studied at preseason and postseason time points with echocardiography and applanation tonometry. Primary outcome variables included: left ventricular (LV) mass index, LV diastolic function (early relaxation velocity [E']), and arterial stiffness (pulse wave velocity [PWV]).

RESULTS

High school (17.1 ± 0.4 yr) and collegiate ASF participants (18 ± 0.4 yr) experienced similar LV hypertrophy (ΔLV mass HS = 10.5 ± 10 vs collegiate = 11.2 ± 13.6 g·m, P = 0.97). Among HS participants, increases in LV mass were associated with stable diastolic tissue velocities (ΔE' = -0.3 ± 2.9 cm·s, P = 0.40) and vascular function (ΔPWV = -0.1 ± 0.6 m·s, P = 0.13). In contrast, collegiate participants demonstrated a higher burden of concentric LV hypertrophy (21/87, 24% vs 7/61, 11%, P = 0.026) with concomitant reductions in diastolic tissue velocities (ΔE': -2.0 ± 2.7 cm·s, P < 0.001) and increased arterial stiffness (ΔPWV: Δ0.2 ± 0.6 m·s, P = 0.003), changes that were influenced by linemen who had the highest post-season weight (124 ± 10 kg) and systolic blood pressure ([SBP], 138.8 ± 11 mm Hg). In multivariable analyses adjusting for age and ethnicity, body mass was an independent predictor of post-season PWV (β estimate = 0.01, P = 0.04) and E' (β estimate = -0.04, P = 0.05), whereas SBP was an independent predictor of postseason LV mass index (β estimate = 0.18, P = 0.01) and PWV (β estimate = 0.01, P = 0.007).

CONCLUSIONS

The transition from HS to college represents an important physiologic temporal data point after which differential ASF cardiovascular phenotypes manifest. Future work aimed to clarify underlying mechanisms, and the long-term clinical implications of these findings is warranted.

The long-term direct and indirect economic burden among Parkinson's disease caregivers in the United States

BACKGROUND

Parkinson's disease is a progressive, disabling neurodegenerative disorder associated with significant economic burden for patients and caregivers. The objective of this study was to compare the direct and indirect economic burden of Parkinson's patients' caregivers with demographically matched controls in the United States, in the 5 years after first diagnosis of Parkinson's disease.

METHODS

Policyholders (18-64 years old) linked to a Parkinson's disease patient (≥2 diagnoses of Parkinson's disease; first diagnosis is the index date) from January 1, 1998 to March 31, 2014, were selected from a private-insurer claims database and categorized as Parkinson's caregivers. Eligible Parkinson's caregivers were matched 1:5 to policyholders with a non-Parkinson's dependent (controls). Multivariable regression adjusted for baseline characteristics estimated direct costs (all-cause insurer cost [medical and prescription] and comorbidity-related medical costs; patient out-of-pocket costs) and indirect costs (disability and medically related absenteeism costs). Income progression was also compared between cohorts.

RESULTS

A total of 1211 eligible Parkinson's caregivers (mean age, 56 years; 54% female) were matched to 6055 controls. In adjusted analyses, Parkinson's caregivers incurred significantly higher year 1 total all-cause insurer costs ($8999 vs $7117) and medical costs ($7081 vs $5568) (both P < 0.01) and higher prescription costs (range for years 1-5, $2506-2573 vs $1405-$1687) and total out-of-pocket costs ($1259-1585 vs $902-$1192) in years 1-5 (all P < 0.01). Parkinson's caregivers had significantly higher adjusted indirect costs in years 1-3 (range for years 1-3, $2054-$2464 vs $1681-$1857; all P < 0.05) and higher cumulative income loss over 5 years ($5967 vs $2634 by year 5; P for interaction = 0.03).

CONCLUSIONS

Parkinson's caregivers exhibited higher direct and indirect costs and greater income loss compared with matched controls. © 2018 International Parkinson and Movement Disorder Society © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

β-Thromboglobulin in Antecubital Vein Blood - The Influence of Age, Sex and Blood Group

Samples of blood for estimation of beta-thromboglobulin (B. T. G.) in normal subjects have been obtained both from blood donors at the end of their donation and from other volunteers by standard venepuncture. The former was a satisfactory method in males only.

By standard venepuncture females have on average lower values than males and in the pre-menopausal age groups the difference is statistically significant.

Mean values vary little up to 59 years after which they rise slowly but steadily. There is no significant difference in the mean B. T. G. values between the ABO blood groups.

Temporal and external validation of a prediction model for adverse outcomes among inpatients with diabetes

AIM

To temporally and externally validate our previously developed prediction model, which used data from University Hospitals Birmingham to identify inpatients with diabetes at high risk of adverse outcome (mortality or excessive length of stay), in order to demonstrate its applicability to other hospital populations within the UK.

METHODS

Temporal validation was performed using data from University Hospitals Birmingham and external validation was performed using data from both the Heart of England NHS Foundation Trust and Ipswich Hospital. All adult inpatients with diabetes were included. Variables included in the model were age, gender, ethnicity, admission type, intensive therapy unit admission, insulin therapy, albumin, sodium, potassium, haemoglobin, C-reactive protein, estimated GFR and neutrophil count. Adverse outcome was defined as excessive length of stay or death.

RESULTS

Model discrimination in the temporal and external validation datasets was good. In temporal validation using data from University Hospitals Birmingham, the area under the curve was 0.797 (95% CI 0.785-0.810), sensitivity was 70% (95% CI 67-72) and specificity was 75% (95% CI 74-76). In external validation using data from Heart of England NHS Foundation Trust, the area under the curve was 0.758 (95% CI 0.747-0.768), sensitivity was 73% (95% CI 71-74) and specificity was 66% (95% CI 65-67). In external validation using data from Ipswich, the area under the curve was 0.736 (95% CI 0.711-0.761), sensitivity was 63% (95% CI 59-68) and specificity was 69% (95% CI 67-72). These results were similar to those for the internally validated model derived from University Hospitals Birmingham.

CONCLUSIONS

The prediction model to identify patients with diabetes at high risk of developing an adverse event while in hospital performed well in temporal and external validation. The externally validated prediction model is a novel tool that can be used to improve care pathways for inpatients with diabetes. Further research to assess clinical utility is needed.

The association between idiopathic thrombocytopenic purpura and cardiovascular disease: a retrospective cohort study

Essentials We estimated the cardiovascular risk of patients with idiopathic thrombocytopenic purpura (ITP). The risk of cardiovascular disease was 38% higher in ITP patients compared with controls. Among the ITP patients, splenectomy was associated with higher cardiovascular disease. Clinicians should consider cardiovascular risk when managing ITP patients.

SUMMARY

Background Idiopathic thrombocytopenic purpura (ITP) is classically characterized by a transient or persistent decrease of platelet count. Mortality is higher in the ITP population than the general population, with a possible association with increased cardiovascular disease (CVD). Objectives The objective was to assess the strength of the association between ITP and CVD, with a secondary aim to assess the impact of splenectomy on CVD. Methods A population-based retrospective, open cohort study using clinical codes was performed using data from 6591 patients with ITP and 24 275 randomly matched controls (up to 1:4 ratio matched by age, sex, body mass index and smoking status). The main outcome was the risk of CVD, which included ischemic heart disease, stroke, trans-ischemic attack and heart failure. Adjusted incidence rate ratios were calculated using Poisson regression. Results During a median 6-year observation period there was a CVD diagnosis recorded in 392 (5.9%) ITP patients and 1114 (4.5%) control patients. There was an increased risk of developing CVD in the ITP cohort (incidence rate ratio [IRR], 1.38; 95% confidence interval [CI], 1.23-1.55), which remained robust even after a sensitivity analysis only including incident cases of ITP. Findings suggested that patients who had undergone splenectomy were at even further increased risk of developing CVD when compared with the ITP population who had not undergone splenectomy (adjusted IRR, 1.69; 95% CI, 1.22-2.34). Conclusion There is an increased risk of developing CVD in patients with ITP and even further increased risk for those patients with ITP who underwent splenectomy.

Patient Preferences for Device-Aided Treatments Indicated for Advanced Parkinson Disease

BACKGROUND

Effective treatment for advanced Parkinson disease (PD) uncontrolled with oral medication includes device-aided therapies such as deep brain stimulation (DBS) and continuous levodopa-carbidopa infusion to the duodenum via a portable pump.

OBJECTIVE

Our objective was to quantify patient preferences for attributes of these device-aided treatments.

METHODS

We administered a Web-enabled survey to 401 patients in the United States. A discrete-choice experiment (DCE) was used to evaluate patients' willingness to accept tradeoffs among efficacy, tolerability, and convenience of alternative treatments. DCE data were analyzed using random-parameters logit. Best-worst scaling (BWS) was used to elicit the relative importance of device-specific attributes. Conditional logit was used to analyze the BWS data. We tested for differences in preferences among subgroups of patients.

RESULTS

Improving ability to think clearly was twice as important as a 6-hour-per-day improvement in control of movement symptoms. After controlling for efficacy, treatment delivered via portable infusion pump was preferred over DBS, and both devices were preferred to oral therapy with poor symptom control. Patients were most concerned about device attributes relating to risk of stroke, difficulty thinking, and neurosurgery. Avoiding surgery to insert a wire in the brain was more important than avoiding surgery to insert a tube into the small intestine. Some differences in preferences among subgroups were statistically, but not qualitatively, significant.

CONCLUSIONS

This study clarifies the patient perspective in therapeutic choices for advanced PD. These findings may help improve communication between patients and providers and also provide evidence on patient preferences to inform regulatory and access decisions.

Cognitive computing and eScience in health and life science research: artificial intelligence and obesity intervention programs

Objective

To present research models based on artificial intelligence and discuss the concept of cognitive computing and eScience as disruptive factors in health and life science research methodologies.

Methods

The paper identifies big data as a catalyst to innovation and the development of artificial intelligence, presents a framework for computer-supported human problem solving and describes a transformation of research support models. This framework includes traditional computer support; federated cognition using machine learning and cognitive agents to augment human intelligence; and a semi-autonomous/autonomous cognitive model, based on deep machine learning, which supports eScience.

Results

The paper provides a forward view of the impact of artificial intelligence on our human-computer support and research methods in health and life science research.

Conclusions

By augmenting or amplifying human task performance with artificial intelligence, cognitive computing and eScience research models are discussed as novel and innovative systems for developing more effective adaptive obesity intervention programs.

Predicting inpatient hypoglycaemia in hospitalized patients with diabetes: a retrospective analysis of 9584 admissions with diabetes

AIMS

To explore whether a quantitative approach to identifying hospitalized patients with diabetes at risk of hypoglycaemia would be feasible through incorporation of routine biochemical, haematological and prescription data.

METHODS

A retrospective cross-sectional analysis of all diabetic admissions (n=9584) from 1 January 2014 to 31 December 2014 was performed. Hypoglycaemia was defined as a blood glucose level of <4 mmol/l. The prediction model was constructed using multivariable logistic regression, populated by clinically important variables and routine laboratory data.

RESULTS

Using a prespecified variable selection strategy, it was shown that the occurrence of inpatient hypoglycaemia could be predicted by a combined model taking into account background medication (type of insulin, use of sulfonylureas), ethnicity (black and Asian), age (≥75 years), type of admission (emergency) and laboratory measurements (estimated GFR, C-reactive protein, sodium and albumin). Receiver-operating curve analysis showed that the area under the curve was 0.733 (95% CI 0.719 to 0.747). The threshold chosen to maximize both sensitivity and specificity was 0.15. The area under the curve obtained from internal validation did not differ from the primary model [0.731 (95% CI 0.717 to 0.746)].

CONCLUSIONS

The inclusion of routine biochemical data, available at the time of admission, can add prognostic value to demographic and medication history. The predictive performance of the constructed model indicates potential clinical utility for the identification of patients at risk of hypoglycaemia during their inpatient stay.

Long-Term Cardiac Morbidity and Mortality in Patients With Aortic Valve Disease Following Liver Transplantation: A Case Matching Study

INTRODUCTION

This retrospective study examined the role of aortic valve (AV) disease in patients who underwent orthotopic liver transplantation (OLT) to determine the incidence of postoperative cardiac morbidity and mortality when compared with a matched control group without AV disease.

METHODS

Patients were included in the AV group if diagnosed with aortic stenosis (AS) or aortic regurgitation or had received AV replacement prior to OLT. The AV group (n = 53) was matched to a control group (n = 212) with the following preoperative variables: type of organ transplanted, age, gender, race, body mass index, MELD, redo-transplantation, preoperative renal replacement therapy, nonalcoholic steatohepatitis, viral hepatitis, diabetes, and coronary artery disease. A 1:4 ratio was utilized to improve the efficiency and power of the analysis.

RESULTS

No significant difference in survival or posttransplant cardiac complications (acute coronary syndrome, heart failure, or dysrhythmia) was observed between groups. However, statistically significantly more patients-11% (6/53)-required coronary intervention following OLT in the AV group, whereas 3% (7/212) required coronary intervention (χ² = 5.8; P = .0156) in the control group. Following OLT, 9% (5/53) in the AV group required surgical or nonsurgical AV intervention, whereas no valvular events were observed in the control group. Event-free survival in the AV group, with an end point defined as AV intervention (n = 5) and death (n = 10), was 92% (49/53) at 1 year, 83% (44/53) at 3 years, and 72% (38/53) at 5 years.

CONCLUSIONS

Patients with pretransplant AV replacement or AS have significant cardiac complications (myocardial infarction, AV replacement, or cardiac death) in 1 to 3 years post-OLT.

From breathless to failure: symptom onset and diagnostic meaning in patients with heart failure-a qualitative study

OBJECTIVES

To explore 2 key points in the heart failure diagnostic pathway-symptom onset and diagnostic meaning-from the patient perspective.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from a secondary care clinic in central England following referral from primary care.

PARTICIPANTS

Over age 55 years with a recent (<1 year) diagnosis of heart failure confirmed by a cardiologist following initial presentation to primary care.

METHODS

Semistructured interviews were carried out with 16 participants (11 men and 5 women, median age 78.5 years) in their own homes. Data were audio-recorded and transcribed. Participants were asked to describe their diagnostic journey from when they first noticed something wrong up to and including the point of diagnosis. Data were analysed using the framework method.

RESULTS

Participants initially normalised symptoms and only sought medical help when daily activities were affected. Failure to realise that anything was wrong led to a delay in help-seeking. Participants' understanding of the term 'heart failure' was variable and 1 participant did not know he had the condition. The term itself caused great anxiety initially but participants learnt to cope with and accept their diagnosis over time.

CONCLUSIONS

Greater public awareness of symptoms and adequate explanation of 'heart failure' as a diagnostic label, or reconsideration of its use, are potential areas of service improvement.

Abdominal wall ectopic testis torsion mimicking a Spigelian hernia in an adult

We report an unusual case of an ectopic testis identified in a 37-year-old man presenting with acute severe right iliac fossa pain and an irreducible mass. Initially diagnosed as a Spigelian hernia, computed tomography and ultrasonography identified the presence of an ectopic testis in the abdominal wall. Interparietal testicular ectopia is an extremely rare condition. We present and discuss the first case in the literature of an ectopic testis located between the internal and external oblique muscle layers of the anterior abdominal wall in an adult.

Quantifying the relationship between increased disability and health care resource utilization, quality of life, work productivity, health care costs in patients with multiple sclerosis in the US

BACKGROUND

Multiple sclerosis (MS) is a chronic progressive condition affecting the central nervous system. Progression of MS results in increased level of disability and most patients will eventually experience some degree of functional impairment and impaired mobility. Costs and burdens escalate as MS disability increases. However, there is a lack of recent data on the impact of MS disability on the cost and burden among patients in the US.

METHODS

Data for this study were drawn from a real world, cross-sectional survey undertaken between 2013 and 2014. Neurologists completed detailed patient report forms (PRF) for the most recent consulting patients with MS (age >18 years). Patient's perceptions of their diagnosis and health-related quality of life (HRQoL) were collected through a patient self-completion questionnaire (PSC). Regression analysis was used to evaluate the relationship between disability (determined by latest Expanded Disability Status Scale [EDSS] score) and current relapse and health care resource utilization, health care costs, HRQoL and work productivity.

RESULTS

PRF data were collected for 715 patients (335 also completed a PSC). Patients with higher disability scores (EDSS 3-5 and >5 vs <3 points) and current relapse (vs no current relapse) reported significantly greater health resource utilization for physician visits (p < 0.05) and hospitalizations (p < 0.05) in the preceding 12 months. In addition, they had poorer HRQoL (p < 0.05), were significantly more likely to be unemployed (p < 0.05) and to have had to stop working due to MS (p < 0.05). They also incurred significantly higher health care related costs, including costs for physician consultations, hospitalizations and therapy (p < 0.05). The total costs of care were $51,825, $57,889 and $67,116 for EDSS < 3, EDSS 3-5 and EDSS > 5 groups, respectively; $51,692 and $58,648 for non-relapse and relapse groups, respectively.

CONCLUSIONS

For MS patients in the US, health resource utilization and healthcare care costs increase with progression of disability. As the disability worsens, patients also exhibit diminished HRQoL and lower work productivity. There is a need for treatments that slow down or delay disability progression among MS patients.

Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order

BACKGROUND

Advance directives guide healthcare providers to listen to and respect patients' wishes regarding their right to die in circumstances when cardiopulmonary resuscitation is required, and hospitals accredited by The Joint Commission are required to have a do-not-resuscitate (DNR) policy in place. However, when surgery and anesthesia are necessary for the care of the patient with a DNR order, this advance directive can create ethical dilemmas specifically involving patient autonomy and the physician's responsibility to do no harm.

METHODS

This paper discusses the ethical considerations regarding perioperative DNR orders and provides guidance on how to handle situations that may arise in the conduct of perioperative care.

RESULTS

Because of the potential conflicts between ethical care and the restrictions of DNR orders, it is critically important to discuss the medical and ethical issues surrounding this clinical scenario with the patient or surrogate prior to any surgical intervention. However, many anesthesiologists do not adequately address this ethical dilemma prior to the procedure.

CONCLUSION

Practitioners are advised to first consider what is best for the patient and, when in doubt, to communicate with patients or surrogates and with colleagues to arrive at the most appropriate care plan. If irreconcilable conflicts arise, consultation with the institution's bioethics committee, if available, is beneficial to help reach a resolution.

Mortality trends in patients with early rheumatoid arthritis over 20 years: results from the Norfolk Arthritis Register

OBJECTIVE

To examine mortality rates in UK patients with early rheumatoid arthritis (RA) from 1990-2011 and compare with population trends.

METHODS

The Norfolk Arthritis Register (NOAR) recruited adults with ≥2 swollen joints for ≥4 weeks: cohort 1 (1990-1994), cohort 2 (1995-1999), and cohort 3 (2000-2004). At baseline, serum rheumatoid factor and anti-citrullinated protein antibody were measured and the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria were applied. Patients were followed for 7 years, until emigration or death. The UK Office for National Statistics notified the NOAR of the date and cause of deaths, and provided mortality rates for the Norfolk population. All-cause and cardiovascular-specific standardized mortality ratios (SMRs) were calculated. Poisson regression was used to compare mortality rate ratios (MRRs) between cohorts and then, with cubic splines, to model rates by calendar year. Analyses were performed in patients 1) with early inflammatory arthritis, 2) classified as having RA, and 3) autoantibody positive.

RESULTS

A total of 2,517 patients were included, with 1,639 women (65%) and median age 55 years, and 1,419 (56%) fulfilled the 2010 RA criteria. All-cause and cardiovascular-specific SMRs were significantly elevated in the antibody-positive groups. There was no change in mortality rates over time after accounting for changes in the population rates. In RA patients, all-cause MRRs, compared to cohort 1, were 1.13 (95% confidence interval [95% CI] 0.84-1.52) and 1.00 (95% CI 0.70-1.43) in cohorts 2 and 3, respectively.

CONCLUSION

Mortality rates were increased in patients with RA and SMRs were particularly elevated in those who were autoantibody positive. Compared to the general population, mortality rates have not improved over the past 20 years.

Fatigue, psychological and cognitive impairment following transient ischaemic attack and minor stroke: a systematic review

Transient ischaemic attack (TIA) and minor stroke are characterized by short-lasting symptoms; however, anecdotal and empirical evidence suggests that these patients experience ongoing cognitive/psychological impairment for which they are not routinely treated. The aims were (i) to investigate the prevalence and time course of fatigue, anxiety, depression, post-traumatic stress disorder(PTSD) and cognitive impairment following TIA/minor stroke; (ii) to explore the impact on quality of life (QoL), change in emotions and return to work; and (iii) to identify where further research is required and potentially inform an intervention study. A systematic review of MEDLINE, EMBASE, PSYCINFO, CINAHL, the Cochrane libraries and the grey literature between January 1993 and April 2013 was undertaken. Literature was screened and data were extracted by two independent reviewers. Studies were included of adult TIA/minor stroke participants with any of the outcomes of interest: fatigue, anxiety, depression, PTSD, cognitive impairment, QoL, change in emotions and return to work. Random-effects meta-analysis pooled outcomes by measurement tool. Searches identified 5976 records, 289 were assessed for eligibility and 31 studies were included. Results suggest high levels of cognitive impairment and depression post-TIA/minor stroke which decreased over time. However, frequencies varied between studies. Limited information was available on anxiety, PTSD and fatigue. Meta-analysis revealed that the measurement tool administered influenced the prevalence of cognitive impairment: Mini-Mental State Examination 17% [95% confidence interval (CI) 7, 26]; neuropsychological test battery 39% (95% CI 28, 50); Montreal Cognitive Assessment 54% (95% CI 43, 66). There is evidence to suggest that TIA/minor stroke patients may experience residual impairments; however, results should be interpreted with caution because of the few high quality studies. Notwithstanding, it is important to raise awareness of potential subtle but meaningful residual impairments.

Abstract T MP50: Appropriate Stroke Team Activations Through Use of Los Angeles Pre-hospital Stroke Scale (LAPSS)

Background and Purpose: Target Stroke SM aims to reduce the Door to Needle (DTN) times to 60 minutes or less in eligible ischemic stroke patients. They advocate Emergency Medical Service (EMS) pre-notification, a rapid triage protocol,stroke team notification, and a single call activation system 1 . Prior to February 2013 the Stroke Team averaged 92.8 Stroke Team Activations monthly. This volume placed a burden on the Stroke Team and ancillary departments. DeLuca and colleagues noted a possible criticism of Stroke Code in that patients with symptoms mimicking a stroke may overload the stroke personnel 2. We set out to decrease unnecessary stroke team activations without missing an opportunity to treat an eligible patient.

Methods: A retrospective chart review was performed on all Stroke Team Activations between February and July 2012. We identified the volume of cancelled activations, number of patients too late or symptoms too mild, stroke mimics and treatments provided. The Los Angeles Pre-hospital Stroke Scale (LAPSS) was chosen as a screening tool for Medical Command to use with EMS personnel. The Stroke Team Activation time was shortened from 8 to 6 hours from last known well. The Emergency Department physicians had override authority for Activations. The revised Stroke Team Activation Guideline was disseminated in early 2013. To assess the utility of LAPSS as a Stroke Team Activation tool we compared the pre-LAPSS to the post-LAPSS data. A report completed by Medical Command on all requested Stroke Team Activations was also reviewed.

Outcomes: A total of 557 patients were reviewed pre-LAPSS and 426 post-LAPSS. In comparison, the updated Stroke Team Activation Guideline resulted in a decrease of stroke team activations by 23.5%. Average DTN times remained under 60 minutes. A higher percent of patients seen were treated with rtPA (8.6% pre vs. 9.9% post). We have not missed the opportunity to treat an eligible stroke patient.

Conclusion: A higher percentage of patients can be treated with DTN times under 60 minutes without overburdening the Stroke Team when procedures are in place for optimum specificity to identify those patients who would benefit from rapid team activation and stroke intervention.