A Simple Nonviral Method to Generate Human Induced Pluripotent Stem Cells Using SMAR DNA Vectors

Induced pluripotent stem cells (iPSCs) are a powerful tool for biomedical research, but their production presents challenges and safety concerns. Yamanaka and Takahashi revolutionised the field by demonstrating that somatic cells could be reprogrammed into pluripotent cells by overexpressing four key factors for a sufficient time. iPSCs are typically generated using viruses or virus-based methods, which have drawbacks such as vector persistence, risk of insertional mutagenesis, and oncogenesis. The application of less harmful nonviral vectors is limited as conventional plasmids cannot deliver the levels or duration of the factors necessary from a single transfection. Hence, plasmids that are most often used for reprogramming employ the potentially oncogenic Epstein-Barr nuclear antigen 1 (EBNA-1) system to ensure adequate levels and persistence of expression. In this study, we explored the use of nonviral SMAR DNA vectors to reprogram human fibroblasts into iPSCs. We show for the first time that iPSCs can be generated using nonviral plasmids without the use of EBNA-1 and that these DNA vectors can provide sufficient expression to induce pluripotency. We describe an optimised reprogramming protocol using these vectors that can produce high-quality iPSCs with comparable pluripotency and cellular function to those generated with viruses or EBNA-1 vectors.

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

(1) Background: The evidence base for the management of spontaneous viral controllers in pregnancy is lacking. We describe the management outcomes of pregnancies in a series of UK women with spontaneous HIV viral control (<100 copies/mL 2 occasions before or after pregnancy off ART). (2) Methods: A multi-centre, retrospective case series (1999-2021) comparing pre- and post-2012 when guidelines departed from zidovudine-monotherapy (ZDVm) as a first-line option. Demographic, virologic, obstetric and neonatal information were anonymised, collated and analysed in SPSS. (3) Results: A total of 49 live births were recorded in 29 women, 35 pre-2012 and 14 post. HIV infection was more commonly diagnosed in first reported pregnancy pre-2012 (15/35) compared to post (2/14), p = 0.10. Pre-2012 pregnancies were predominantly managed with ZDVm (28/35) with pre-labour caesarean section (PLCS) (24/35). Post-2012 4/14 received ZDVm and 10/14 triple ART, p = 0.002. Post-2012 mode of delivery was varied (5 vaginal, 6 PLCS and 3 emergency CS). No intrapartum ZDV infusions were given post-2012 compared to 11/35 deliveries pre-2012. During pregnancy, HIV was detected (> 50 copies/mL) in 14/49 pregnancies (29%) (median 92, range 51-6084). Neonatal ZDV post-exposure prophylaxis was recorded for 45/49 infants. No transmissions were reported. (4) Conclusion: UK practice has been influenced by the change in guidelines, but this has had little impact on CS rates.

Molecular imaging of experimental atherosclerosis using anti-malondialdehyde-modified low-density lipoprotein humanised antibody fragment targeted nanoparticles

Introduction

Oxidative modification of low-density lipoprotein (LDL), for example by malondialdehyde (MDA) adduction with subsequent uptake by macrophages to form foam cells and later the plaque necrotic core, is a key initiating event in atherogenesis. Accordingly, a larger lipid necrotic core is a key plaque vulnerability factor, predisposing plaques to rupture and subsequent thrombosis and development of an acute coronary syndrome. Thus, MDA-LDL is an attractive focus for the molecular targeting of atherosclerotic plaques.

Purpose

To develop antibody fragment-targeted nanoparticles that can be utilised for both the molecular imaging and therapeutics of vulnerable atherosclerotic plaques.

Methods

LO1 is an IgG3k natural monoclonal murine antibody that reacts with MDA-LDL. Humanised LO1Fab fragments have been engineered to reduce immunogenicity and improve lesion penetration. These humanised LO1Fab fragments were used to functionalise fluorescent poly(lactic-co-glycolic acid) (PLGA) - polyethylene glycol (PEG) nanoparticles. Nanoparticle in vitro function was assessed, prior to fluorescence molecular tomography (FMT) co-registered with micro-CT, four-hours after iv injection in atherosclerotic LDL-receptor−/− mice fed a high-fat diet for 40-weeks.

Results

Humanised LO1Fab fragment conjugated fluorescent PLGA-PEG nanoparticles were formulated with 210nm size and polydispersity index (variability of nanoparticle size around the average) of &lt;0.2. Antibody conjugation efficiency was 30%. In vitro function was confirmed on ELISA versus the blank untargeted nanoparticles with MDA-LDL on solid phase, detecting nanoparticle presence via the conjugated LO1Fab, PEG corona or fluorescence. Fluorescence microscopy on stained aortic root cryosections from atherosclerotic mice confirmed binding to fatty lesions. Construct in vivo in half-life was 90-minutes for both the targeted and untargeted nanoparticles in a two-phase model in LDL-receptor−/− mice, based on fluorescence analysis of serial tail vein blood samples. There was greater uptake in the region-of-interest (heart and aortic arch vessels) in mice injected with LO1Fab-conjugated nanoparticles versus untargeted nanoparticles (mean ± standard deviation) (64.7±22.9 versus 25.2±26.5pmol of Cy5; n=7; p=0.02). Ex vivo analysis fluorescence reflectance imaging and quantitative FMT of the extracted aortae confirmed these findings (1.0±0.3 versus 0.5±0.2pmol of Cy5; n=7; p=0.002; Figure 1).

Conclusions

Humanised antibody Fab fragment fluorescent nanoparticles have been developed that successfully target MDA-LDL and localise to atherosclerotic plaques in murine experimental atherosclerosis. These targeted nanoparticles have the potential to amplify fluorescent signal for imaging and carry a therapeutic cargo for targeted drug delivery direct to atherosclerotic plaques.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Wellcome Trust Clinical Research Fellowship

An observational analysis of trends in rheumatic heart disease incidence and mortality in EU15+ countries over 29 years

Background

Rheumatic heart disease (RHD) is a debilitating sequela of acute rheumatic fever (ARF), caused by Group A streptococcus (GAS) infection. Repeated episodes of ARF results in valvular damage over time. As a preventable disorder which was once common worldwide, RHD has largely been eradicated in affluent nations due to widespread availability of penicillin, improvement in socioeconomic standards and advancements in health and social infrastructures. However, it has been speculated that the global refugee crisis, especially in Europe, might contribute to a resurgence of RHD cases in these regions.

Purpose

This observational study aimed to analyse trends in RHD incidence and mortality rates in European Union 15+ (EU15+) over a 29-year period.

Methods

Data was obtained from the Global Burden of Disease database. Age-standardised mortality and incidence rates for RHD were extracted for the EU15+ countries for the years 1990–2019. Trends were subsequently analysed using Joinpoint regression analysis.

Results

Over the 29-year period, an overall declining trend in RHD incidence and mortality across EU 15+ nations was observed. The United Kingdom demonstrated the largest decrease in RHD incidence amongst females (−54.9%) and Finland amongst males (−55.3%). Both RHD incidence and mortality were higher among females compared to males across EU15+ countries over the observed period. The most recent incidence trends, starting predominantly after 2014, demonstrated a rise in RHD incidence in most countries. For both sexes, increases were seen in Australia, Belgium, Ireland, Italy, Netherlands, Norway, Sweden and USA. For males specifically, increase in RHD incidence was seen in Spain, and Finland, and for females only in Canada and Ireland. The recent increasing RHD incidence rates ranged from +0.4% to + 24.7% for males and +0.6% to +11.4% for females.

Conclusion

Whilst overall there are decreases in incidence and mortality from RHD, we observe more than half of EU15+ countries have increasing incidence trends in RHD in recent years. This increasing trend primarily started after 2014, overlapping with the start of the European migration crisis. Although speculative, disparities in access to healthcare for migrants, amongst other socioeconomic factors, may be potential causes; subsequently, further efforts by governments and public health officials are required to recognise and control the resurgence of RHD in high income nations.

Funding Acknowledgement

Type of funding sources: None.

TH6.3 Establishing a sexually transmitted infection (STI) testing programme in an ambulatory surgical clinic for female patients aged 18–44 years presenting with abdominal pain

Introduction

Young females presenting to hospital with acute abdominal pain (AP) are often discharged without clear diagnoses. Gynaecological causes including chlamydia and gonorrhoea (C&G) are increasing, however STI testing remains underutilised. This study aims to:

1. Establish robust STI testing in an ambulatory surgical clinic (ASC), utilising collaborative pathways between GUM and EGS services.

2. Identify barriers.

Methods

This pilot ran from October to December 2021. GUM-led training for all ASC staff was delivered. All females (18–44yrs) presenting to ASC with AP were offered vulvo-vaginal self-swabs (VVS) and a patient information leaflet. Positive results were referred to GUM for treatment and contact tracing. Following the pilot, a focus group was facilitated to identify barriers and potential improvements.

Results

Twelve eligible patients (mean 28yrs) consented to testing. All results were negative for C&G. Fifteen patients declined (mean 33yrs). The remaining eligible population were not approached. Barriers identified included: nursing staff concerns that offering VVS could make patients feel judged regarding sexual promiscuity; male staff being uncomfortable discussing VVS; concerns regarding other patients overhearing; and a single toilet being inadequate for testing.

Conclusions

The pilot confirmed a robust STI testing programme can be delivered within ASC, which we believe is the first in the country. Strong collaborative working between EGS & GUM teams delivered clear mutually beneficial pathways. However, low numbers of patients undertook testing, accounting for the lack of positive results. Clear barriers were identified which are being addressed prior to delivery of a second pilot period and pathway rollout.

Changing the culture: a qualitative study exploring research capacity in local government

Background

Local government has become a key constituent for addressing health inequalities and influencing the health of individuals and communities in England. Lauded as an effective approach to tackle the multiple determinants of health, there are concerns that generating and utilising research evidence to inform decision-making and action is a challenge. This research was conducted in a local authority situated in the north of England and addressed the research question – ‘What is the capacity to collaborate and deliver research?’. The study explored the assets that exist to foster a stronger research culture, identified barriers and opportunities for developing research capacity, and how a sustainable research system could be developed to impact on local residents’ health and reduce health inequalities.

Methods

This was a qualitative study utilising semi-structured interviews and focus groups. The study used an embedded researcher (ER) who was digitally embedded within the local authority for four months to conduct the data collection. Senior Managers were purposively sampled from across the local authority to take part in interviews. Three focus groups included representation from across the local authority. Framework analysis was conducted to develop the themes which were informed by the Research Capacity Development framework.

Results

Tensions between research led decision making and the political and cultural context of local government were identified as a barrier to developing research which addressed health inequalities. Research was not prioritised through an organisational strategy and was led sporadically by research active employees. A recognition across leaders that a culture shift to an organisation which used research evidence to develop policy and commission services was needed. Building relationships and infrastructure across local government, place-based collaborators and academic institutions was required. The embedded researcher approach is one method of developing these relationships. The study identifies the strengths and assets that are embedded in the organisational make-up and the potential areas for development.

Conclusion

Research leadership is required in local government to create a culture of evidence-based principles and policy. The embedded research model has high utility in gaining depth of information and recognising contextual and local factors which would support research capacity development.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies

Individuals with low socio-economic status (SES) have a more than 25% higher risk of fragility fractures than individuals with high SES. Body mass index and lifestyle appear to mediate the effect of SES on fracture risk. Strategies to prevent fractures should aim to reduce unhealthy behaviours through tackling structural inequalities.

INTRODUCTION

This systematic review and meta-analysis aimed to evaluate the impact of socio-economic status (SES) on fragility fracture risk.

METHODS

Medline, Embase, and CINAHL databases were searched from inception to 28 April 2021 for studies reporting an association between SES and fragility fracture risk among individuals aged ≥50 years. Risk ratios (RR) were combined in meta-analyses using random restricted maximum likelihood models, for individual-based (education, income, occupation, cohabitation) and area-based (Index of Multiple Deprivation, area income) SES measures.

RESULTS

A total of 61 studies from 26 different countries including more than 19 million individuals were included. Individual-based low SES was associated with an increased risk of fragility fracture (RR 1.27 [95% CI 1.12, 1.44]), whilst no clear association was seen when area-based measures were used (RR 1.08 [0.91, 1.30]). The strength of associations was influenced by the type and number of covariates included in statistical models: RR 2.69 [1.60, 4.53] for individual-based studies adjusting for age, sex and BMI, compared with RR 1.06 [0.92, 1.22] when also adjusted for health behaviours (smoking, alcohol, and physical activity). Overall, the quality of the evidence was moderate.

CONCLUSION

Our results show that low SES, measured at the individual level, is a risk factor for fragility fracture. Low BMI and unhealthy behaviours are important mediators of the effect of SES on fracture risk. Strategies to prevent fractures and reduce unhealthy behaviours should aim to tackle structural inequalities in society thereby reducing health inequalities in fragility fracture incidence.

Trends in incidence and mortality from non-rheumatic degenerative mitral valve disease across europe, over the past three decades

Background

Valvular heart disease is common globally; mitral regurgitation is the most common valve pathology in the general population and subsequently the second most frequent indication for valve surgery in Europe. Whilst the European epidemiology of aortic stenosis is well elucidated in the literature, no Europe-wide study has been undertaken to identify trends in incidence and mortality secondary to non-rheumatic degenerative mitral valve disease.

Purpose

Our aim is to describe trends in degenerative mitral valve disease incidence and mortality throughout Europe from 1990 to 2019.

Methods

We performed a temporal analysis of data deposited in the Global Burden of Disease Study Database across the European Union. We extracted age-standardised incidence and age-standardised mortality rates for 20 member states from the database. We graphically inspected the data and performed Joinpoint regression analysis to detect and summarise periods of significant change. These periods were described using estimated annual percentage change (EAPC).

Results

Trends in age-standardised incidence and mortality rates were heterogenous amongst the 20 member states included. A gender disparity in mortality rates favouring males were present in Austria, Belgium, Greece, Hungary and the Netherlands throughout the time period studied. Except for Hungary, this disparity was not reflected in the incidence rates for the aforementioned countries. Incidence rates of degenerative mitral valve disease in 2019 were highest in Italy for both males and females with 90.6 and 140.1 cases per 100,000 respectively. Mortality rates in 2019 were highest in the Netherlands for both males in females with 1.7 and 2.0 cases per 100,000 respectively; this was preceded by a downwards trend in mortality with an EAPC of −7.3% and −8.5% respectively. Other notable inflection points in incidence trends were observed in Italy, with an EAPC of −4.9% females between 1994 to 2004 followed by an EAPC of 0.8% between 2009 to 2019.

Conclusion

No overall trends in non-rheumatic mitral valve disease were observed throughout Europe, but gender disparities and some notable deviations in incidence and mortality rates from the European median were identified. Overall, however, incidence rates remained static in most countries studied despite the ubiquity of colour flow doppler echocardiography. Further analysis of the burden of mitral valve disease can help elucidate this geographical variation.

Funding Acknowledgement

Type of funding sources: None.

Trends in mortality from aortic stenosis in Europe: 2000–2017

Background

Trends in mortality from aortic stenosis across Europe are not well understood, especially given the significant growth in transcatheter aortic valve replacement (TAVR) in the last 10 years.

Purpose

To describe trends in mortality from aortic stenosis in European countries from 2000 to 2017.

Methods

Age-standardised death rates were extracted from the World Health Organisation Mortality Database, using the International Classification of Diseases 10th edition code for non-rheumatic aortic stenosis for those aged &gt;45 years between 2000 and 2017. The UK and countries from the European Union with at least 1,000,000 inhabitants and at least 50% available datapoints over the study period were included: a total of 23 countries. Trends were described using Joinpoint regression analysis.

Results

No reductions in mortality were demonstrated across all countries 2000–2017 (Figure 1). Large increases in mortality were found for Croatia, Poland and Slovakia for both sexes (&gt;300% change). Mortality plateaued in Germany from 2008 in females and 2012 in males, whilst mortality in the Netherlands declined for both sexes from 2007. Mortality differences between the sexes were observed, with greater mortality for males than females across most countries.

Conclusions

Mortality from aortic stenosis has increased across Europe from 2000 to 2017. There are, however, sizable differences in mortality trends between Eastern and Western European countries. Significant plateauing or declining mortality was observed for recent years in countries with greater access to TAVR, whilst increasing trends were observed in countries with the least TAVR use. The need for health resource planning strategies to specifically target AS, particularly given the expected increase with aging populations, is highlighted.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Joinpoint regression analysis for trends in age-standardised death rates from non-rheumatic aortic stenosis for those aged &gt;45 years in Europe from 2000 to 2017. Clear squares indicate males; filled circles indicate females. The lines (dotted for males, solid for females) represent modelled trends based on joinpoint data.

Trends in infective endocarditis mortality in the United Kingdom and EU 15+ countries between 1990–2019: an analysis of the Global Burden of Diseases database

Background

Infective Endocarditis (IE) is a relatively uncommon but lethal condition, with no convincing evidence to date of improving mortality trends (1). The epidemiology of IE is complex, driven by a wide range of constantly evolving factors. While marked international variation has been recently reported (2), temporal trends in mortality over recent decades remain unclear.

Purpose

To describe trends in IE mortality in high income countries over the last 30 years.

Methods

Age-standardised mortality rates (ASMR) for IE, stratified by sex, were extracted from the Global Burden of Disease (GBD) database (3) between 1990 and 2019. The United Kingdom and selected countries with comparable health expenditure (EU15+ countries) were included. Relative changes in ASMR over the observation period were determined and trends were analysed using Joinpoint regression analysis.

Results

Between 1990–2019 ASMR from IE increased for both sexes in all included countries except Finland (−20.1% in males, −15.1% in females) and Austria (−8.98% in males, −22.6% in females). The largest increase in ASMR in males was observed in Greece (+197%), while the largest increase in females was observed in Italy (246%). Joinpoint regression analysis identified multiple significant trends within this observation period (Figure 1; clear squares indicate males, filled circles indicate females and lines represent modelled trends based on joinpoint data). At the end of the observation period the Netherlands had the highest ASMR in both males and females (2.28/100,000 in males and 2.37/100,000 in females), while Finland had the lowest ASMR in both males and females (0.45/100,000 and 0.23/100,000 respectively).

Conclusions

Significant international variation in IE mortality rates were observed. While mortality from IE has generally increased over the last 30 years, recent data suggest this trend may now be plateauing or even reversing in certain countries.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Osteoarthritis: Insights Offered by the Study of Bone Mass Genetics

PURPOSE OF REVIEW

This paper reviews how bone genetics has contributed to our understanding of the pathogenesis of osteoarthritis. As well as identifying specific genetic mechanisms involved in osteoporosis which also contribute to osteoarthritis, we review whether bone mineral density (BMD) plays a causal role in OA development.

RECENT FINDINGS

We examined whether those genetically predisposed to elevated BMD are at increased risk of developing OA, using our high bone mass (HBM) cohort. HBM individuals were found to have a greater prevalence of OA compared with family controls and greater development of radiographic features of OA over 8 years, with predominantly osteophytic OA. Initial Mendelian randomisation analysis provided additional support for a causal effect of increased BMD on increased OA risk. In contrast, more recent investigation estimates this relationship to be bi-directional. However, both these findings could be explained instead by shared biological pathways. Pathways which contribute to BMD appear to play an important role in OA development, likely reflecting shared common mechanisms as opposed to a causal effect of raised BMD on OA. Studies in HBM individuals suggest this reflects an important role of mechanisms involved in bone formation in OA development; however further work is required to establish whether the same applies to more common forms of OA within the general population.

Trends in ischaemic heart disease and cerebrovascular disease mortality in Europe: an observational study from 1990–2017

Background

Cardiovascular disease remains the leading cause of death worldwide. Previously, we identified a growing disparity between Western and Eastern European countries for mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CVD).

Purpose

To describe current trends in mortality from IHD and CVD.

Methods

IHD and CVD age-standardized death rates (ASDR) for European countries between 1990–2017 were extracted from the World Health Organization mortality database using the International Classification of Diseases 9th and 10th Edition codes. Jointpoint regression analysis was used to describe trends over this period.

Results

Between 1990–2017, IHD mortality declined in all included countries except Croatia (+3% in males and +23% in females). Largest mortality improvements were generally seen in Western European countries, including the Netherlands, UK and Sweden, which saw greater than 65% improvements for both sexes. Estonia was a notable exception, which, after the Netherlands, demonstrated the second highest improvement in mortality (−69% in males, −74% in females). Hungary and Greece saw the smallest improvements in IHD mortality (approximately −12% to −27%). Results of jointpoint regression analysis for selected European countries are shown in Figure 1. In 2017 Lithuania had the highest mortality rate in both males and females (279.4/100,000 and 261.3/100,000, respectively) whilst the Netherlands had the lowest mortality in males and females (32.6/100,00 and 15.3/100,000, respectively). This represents an approximately 8.5-fold difference in IHD mortality in males and a 10.5-fold difference in females between these two countries. CVD mortality declined in all included countries between 1990–2017. Estonia saw the greatest improvements in both males and females (−80.8% and −84.9%, respectively), followed by Austria, Portugal and the Czech Republic (over 70% reductions in both sexes). Bulgaria, Romania and Lithuania saw the smallest reductions (approximately −17% to −33%). In 2017, Bulgaria had the highest CVD mortality rate in both males and females (149.9/100,000 and 113.1/100,000, respectively), whilst the lowest mortality rate was observed in Austria (21.8/100,000 and 19.5/100,000 for males and females, respectively). This represents an approximately 7-fold difference in CVD mortality in males and a 6-fold difference in females between these two countries.

Conclusions

IHD and CVD mortality rates continue to decrease for men and women across Europe. While certain Eastern European countries have demonstrated considerable mortality improvements over this observation period, in general the disparity between Eastern and Western Europe persists, with further work required to understand and address these inequalities.

Squares: male. Circles: female

Funding Acknowledgement

Type of funding source: None

Individuals with high bone mass have increased progression of radiographic and clinical features of knee osteoarthritis

OBJECTIVE

High bone mass (HBM) is associated with an increased prevalence of radiographic knee OA (kOA), characterized by osteophytosis. We aimed to determine if progression of radiographic kOA, and its sub-phenotypes, is increased in HBM and whether observed changes are clinically relevant.

DESIGN

A cohort with and without HBM (L1 and/or total hip bone mineral density Z-score≥+3.2) had knee radiographs collected at baseline and 8-year follow-up. Sub-phenotypes were graded using the OARSI atlas. Medial/lateral tibial/femoral osteophyte and medial/lateral joint space narrowing (JSN) grades were summed and Δosteophytes, ΔJSN derived. Pain, function and stiffness were quantified using the WOMAC questionnaire. Associations between HBM status and sub-phenotype progression were determined using multivariable linear/poisson regression, adjusting for age, sex, height, baseline sub-phenotype grade, menopause, education and total body fat mass (TBFM). Generalized estimating equations accounted for individual-level clustering.

RESULTS

169 individuals had repeated radiographs, providing 330 knee images; 63% had HBM, 73% were female, mean (SD) age was 58 (12) years. Whilst HBM was not clearly associated with overall Kellgren-Lawrence measured progression (RR = 1.55 [0.56.4.32]), HBM was positively associated with both Δosteophytes and ΔJSN individually (adjusted mean differences between individuals with and without HBM 0.45 [0.01.0.89] and 0.15 [0.01.0.29], respectively). HBM individuals had higher WOMAC knee pain scores (β = 7.42 [1.17.13.66]), largely explained by adjustment for osteophyte score (58% attenuated) rather than JSN (30% attenuated) or TBFM (16% attenuated). The same pattern was observed for symptomatic stiffness and functional limitation.

CONCLUSIONS

HBM is associated with osteophyte progression, which appears to contribute to increased reported pain, stiffness and functional loss.

Correction to: Lean mass and lower limb muscle function in relation to hip strength, geometry and fracture risk indices in community-dwelling older women

The original version of this article, published on 14 December 2018, unfortunately contained a mistake.

An observational study of initial HIV RNA decay following initiation of combination antiretroviral treatment during pregnancy

Background

In pregnancy, reduction of HIV plasma viral load (pVL) for the prevention of vertical transmission is time-constrained. The study primary objective is to investigate factors associated with faster initial HIV RNA half-life decay when combination antiretroviral treatment (cART) is initiated in pregnancy.

Methods

This was a multicentre, retrospective, observational study, conducted in south England, United Kingdom, between August 2001 and February 2018. Data were extracted from case notes of eligible women initiating cART during the index pregnancy. Anonymised data were collated and analysed centrally. Regression analyses were conducted to determine factors associated with faster HIV RNA half-life decay in the first 14 days after commencing cART (first-phase), and with achieving an undetectable maternal pVL by 36 weeks’ gestation. We then assessed whether HIV- and obstetric- related parameters differed by antiretroviral third agent class and whether the proportions of women with undetectable pVL at 36 weeks’ gestation and at delivery differed by antiretroviral third agent class.

Results

Baseline pVL was the only independent factor associated with faster first-phase HIV RNA half-life decay on commencing cART. Lower pVL on day 14 after starting cART was associated with an increased likelihood of achieving an undetectable pVL by 36 weeks’ gestation. Integrase inhibitor-based cART was associated with a faster first-phase HIV RNA half-life decay on commencing cART. Overall, 73% and 85% of women had an undetectable pVL at 36 weeks’ gestation and at delivery respectively, with no significant difference by antiretroviral third agent class.

Conclusions

Only high baseline pVL independently contributed to a faster rate of first-phase viral half-life decay. pVL at 14 days after initiating cART allows early identification of treatment failure. In the first 14 days after initiating cART in pregnancy, integrase inhibitor-based cART reduced maternal pVL faster than protease inhibitor- and non-nucleoside reverse transcriptase-based cART. While our study findings support INSTI use when initiated in pregnancy especially when initiated at later gestations and in those with higher baseline pVL, other non-INSTI based cART with more data on safety in pregnancy also performed well.

A Roadmap for the Success of Oncolytic Parvovirus-Based Anticancer Therapies

Autonomous rodent protoparvoviruses (PVs) are promising anticancer agents due to their excellent safety profile, natural oncotropism, and oncosuppressive activities. Viral infection can trigger immunogenic cell death, activating the immune system against the tumor. However, the efficacy of this treatment in recent clinical trials is moderate compared with results seen in preclinical work. Various strategies have been employed to improve the anticancer activities of oncolytic PVs, including development of second-generation parvoviruses with enhanced oncolytic and immunostimulatory activities and rational combination of PVs with other therapies. Understanding the cellular factors involved in the PV life cycle is another important area of investigation. Indeed, these studies may lead to the identification of biomarkers that would allow a more personalized use of PV-based therapies. This review focuses on this work and the challenges that still need to be overcome to move PVs forward into clinical practice as an effective therapeutic option for cancer patients.

The surgical treatment of Balanitis Xerotica Obliterans

Background: Balanitis Xerotica Obliterans (BXO) is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary. Conservative surgical procedures (circumcision) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction. This study looked at patients with pathologically proven BXO referred to the Plastic Surgery Unit at James Cook University Hospital between 2005 and 2009. The aim was to look at their management in the past and subsequent management by us. We also looked at whether early referral of progressive and recurrent BXO patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage. Materials and Methods: Data was collected retrospectively and information regarding the exact anatomical location affected, the extent of the disease, the referring specialty and any previous surgical interventions was obtained. Alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed. Results: Of the 23 patients in the study, 43% had previous surgery and 60% of those had undergone two or more procedures. Twenty-one percent of patients had a history of BXO for over five years. Forty-seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease, prior to referral. Early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group. Conclusions: Steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases. Circumcision can be a curative procedure in early disease. Although there is conflicting evidence for treatment of recurring urethral strictures, repeated urethrotomy or urethral dilatation has poor long-term outcome. In patients with recurrent disease and associated complications we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment.

2231HsCRP predicts mortality beyond troponin in 102,337 patients with suspected acute coronary syndrome (CRP-RISK study)

Background

The incremental long-term prognostic value of high-sensitivity C-reactive protein (hsCRP) above troponin in a large real-world cohort of unselected patients presenting with suspected acute coronary syndromes (ACS) is unknown.

Purpose

We hypothesised that a mildly elevated hsCRP is associated with mortality risk in patients with suspected ACS, independent of troponin level.

Methods

We used the National Institute for Health Research Health Informatics Collaborative data of 257,948 patients who had a troponin measured at 5 cardiac centres. We excluded patients with clinically abnormal white cell counts and hsCRP >15 mg/L to try limiting the population to those without overt infections, malignancies or systemic inflammatory conditions that may confound our analyses. Patients were divided into four hsCRP groups (<2, 2–4.9, 5–9.9 and 10–15 mg/L) and the association between hsCRP levels and all-cause mortality assessed.

Results

There were 102,337 patients included in the analysis (hsCRP <2 mg/L (n=38,390), 2–4.9 mg/L (n=27,397), 5–9.9 mg/L (n=26,957) and 10–15 mg/L (n=9,593)). Figure 1A displays cumulative mortality per hsCRP group, revealing increasing mortality with each consecutive group. Figure 1B further stratifies the groups according to dichotomised peak troponin level as positive or negative. This shows the greatest mortality for patients in the highest hsCRP group who also had a positive troponin assay (36.0% at 3 years).

In Cox regression analysis with time-dependent covariates, even mildly raised hsCRP was an independent predictor of mortality over time, after adjusting for age, gender, haemoglobin, white cell count, platelet count, creatinine and troponin positivity. There was a positive and graded relationship between hsCRP level and mortality at baseline, which remained at 3-years (hazard ratio (95% CI) of 1.32 (1.18–1.48) for those with hsCRP 2.0–4.9mg/L, and 1.40 (1.26–1.57), and 2.00 (1.75–2.28) for those with hsCRP 5–9.9 mg/L and 10–15 mg/L, respectively.

We explored whether inclusion of hsCRP could better reclassify the population into at-risk mortality groups. The association with 30-day, 1-year and 3-year mortality was assessed using three different risk models (model 1: age, gender, haemoglobin, creatinine; model 2: model 1 plus troponin (positivity versus negativity); model 3: model 2 plus hsCRP groups. For cumulative mortality at each time point, each successive model was better able to discriminate risk than its precursor (p<0.0001); such that inclusion of troponin and hsCRP gave the most robust risk discrimination. Model 3 achieved an AUROC >0.8 at 30 days, 1-year and 3-year mortality, surpassing the use of troponin on its own.

Figure 1. Kaplan-Meier mortality curves

Conclusions

These multi-centre, real-world data from a large cohort of patients with suspected ACS identify hsCRP as a clinically meaningful prognostic marker in addition to troponin levels and point to its potential utility in selecting patients for novel treatments targeting inflammation.

Acknowledgement/Funding

Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs

Lean mass and lower limb muscle function in relation to hip strength, geometry and fracture risk indices in community-dwelling older women

In a population-based sample of British women aged over 70 years old, lean mass and peak lower limb muscle force were both independently associated with hip strength and fracture risk indices, thereby suggesting a potential benefit of promoting leg muscle strengthening exercise for the prevention of hip fractures in postmenopausal women.

INTRODUCTION

To investigate cross-sectional associations of lean mass and physical performance, including lower limb muscle function, with hip strength, geometry and fracture risk indices (FRIs) in postmenopausal women.

METHODS

Data were from the Cohort of Skeletal Health in Bristol and Avon. Total hip (TH) and femoral neck (FN) bone mineral density (BMD), hip geometry and total body lean mass (TBLM) were assessed by dual x-ray absorptiometry (DXA). Finite element analysis of hip DXA was used to derive FN, intertrochanteric and subtrochanteric FRIs. Grip strength, gait speed and chair rise time were measured objectively. Lower limb peak muscle force and muscle power were assessed by jumping mechanography.

RESULTS

In total, 241 women were included (age = 76.4; SD = 2.6 years). After adjustment for age, height, weight/fat mass and comorbidities, TBLM was positively associated with hip BMD (β_{TH BMD} = 0.36, P ≤ 0.001; β_{FN BMD} = 0.26, P = 0.01) and cross-section moment of inertia (0.24, P ≤ 0.001) and inversely associated with FN FRI (- 0.21, P = 0.03) and intertrochanteric FRI (- 0.11, P = 0.05) (estimates represent SD difference in bone measures per SD difference in TBLM). Lower limb peak muscle force was positively associated with hip BMD (β_{TH BMD} = 0.28, P ≤ 0.001; β_{FN BMD} = 0.23, P = 0.008) and inversely associated with FN FRI (- 0.17, P = 0.04) and subtrochanteric FRI (- 0.18, P = 0.04). Associations of grip strength, gait speed, chair rise time and peak muscle power with hip parameters were close to the null.

CONCLUSIONS

Lean mass and lower limb peak muscle force were associated with hip BMD and geometrical FRIs in postmenopausal women. Leg muscle strengthening exercises may therefore help prevent hip fractures in older women.

Evaluation of Response to Stereotactic Radiosurgery in Brain Metastases Using Multiparametric Magnetic Resonance Imaging and a Review of the Literature

AIMS

Following stereotactic radiosurgery (SRS), brain metastases initially increase in size in up to a third of cases, suggesting treatment failure. Current imaging using structural magnetic resonance imaging (MRI) cannot differentiate between tumour recurrence and SRS-induced changes, creating difficulties with patient management. Combining multiparametric MRI techniques, which assess tissue physiological and metabolic information, has shown promise in answering this clinical question.

MATERIALS AND METHODS

Multiparametric MRI techniques, including spectroscopy, diffusion and perfusion imaging, were used for the differentiation of radiation-related changes and tumour recurrence after SRS for intracranial metastases in six cases. All patients presented with enlargement of the treated lesion, an increase in perilesional brain oedema and aggravation or appearance of neurological signs and symptoms from 7 to 29 weeks after primary treatment.

RESULTS

Multiparametric imaging helped to differentiate features of tumour progression (n = 4) from radiation-related changes (n = 2). A low apparent diffusion coefficient (ADC) <1000 × 10^-6 mm²/s, high relative cerebral blood volume (rCBV) ratio > 2.1, high choline:creatine (Cho:Cr) ratio > 1.8 suggested tumour recurrence. A high ADC > 1000 × 10^-6 mm²/s, low rCBV ratio < 2.1, Cho:Cr ratio < 1.8 suggested SRS-induced radiation changes. Multiparametric MRI diagnosis was confirmed by histology or radiological and clinical follow-up.

CONCLUSION

Multiparametric MRI was helpful in the early identification of radiation-related changes and tumour recurrence and may be useful for monitoring treatment changes in intracranial neoplasms after SRS treatment.

Morality as a Basic Psychological Need

We investigate the long-standing yet understudied assumption that feeling moral is a basic psychological need, perhaps like the needs to feel autonomous, competent, and related (ACR). We report an empirical “entrance exam” on whether morality should be considered a need. Specifically, we applied to morality a pioneering method from which Sheldon and colleagues provided evidence that ACR are basic psychological needs. In two studies and four samples, participants recalled events in which they felt un/satisfied, meaningful, pleasurable, at their best, and at their worst. They rated how much candidate psychological needs were satisfied during them. Morality was frequently as or more satisfied than ACR during peak events. Further, it was positively related to indices of positive functioning. These findings suggest feelings of being moral may help people identify times when life is going well. Further, they suggest that morality may be a fundamental psychological need and warrants further investigation.

Dexamethasone-related adrenal insufficiency in patients with brain and skull base tumours

PURPOSE

This study aimed to evaluate the prevalence of glucocorticoid-induced adrenal insufficiency in a cohort of patients with brain and skull base tumours and to identify factors which may predict its occurrence.

METHODS

Patients with brain or skull base tumours attending for a short synacthen test (SST) (adrenocorticotropin hormone (ACTH) stimulation test) at a single institution over a 3-year period were retrospectively identified. Baseline demographics and dexamethasone exposure were examined. Only patients with dexamethasone exposure were included in the final analysis looking at the primary end point of SST failure. Fisher's exact test, Student's t test, Mann-Whitney test and the Kendall's tau-b test were used to evaluate the influence of age, gender, diagnosis and mean pituitary radiation dose on the primary endpoint. Receiver operating characteristic (ROC) curves were generated to explore the impact of duration and total exposure to dexamethasone on likelihood of SST failure.

RESULTS

Thirty-one of 51 patients with previous dexamethasone exposure failed their first SST (61%). No significant relationship was demonstrated between age, gender, diagnosis or mean pituitary radiation dose and SST failure. Duration of and total exposure to dexamethasone were significantly associated with SST failure (p = 0.001 and p = 0.007, respectively). ROC curves generated values of 78 days and 171 mg days to give a sensitivity of 94 and 97%, respectively, to detect SST failure.

CONCLUSIONS

Duration of dexamethasone use and total exposure predict for adrenal insufficiency in patients with brain and skull base tumours. Values derived from this study may be useful to identify patients at higher risk of adrenal suppression who require empirical hydrocortisone pending formal testing of the hypothalamic-pituitary-adrenal axis.

Feasibility of Dose-escalated Hypofractionated Chemoradiation in Human Papilloma Virus-negative or Smoking-associated Oropharyngeal Cancer

AIMS

Oropharyngeal squamous cell carcinoma (OPSCC) can be divided into favourable and poor prognostic groups by association with human papilloma virus (HPV) and smoking. This study prospectively investigated a dose-intensified schedule in poor/intermediate prognosis OPSCC.

MATERIALS AND METHODS

Patients with p16/HPV-negative or p16-positive N2b OPSCC with a greater than 10 pack-year smoking history were eligible. Patients were planned to receive 64 Gy in 25 fractions with cisplatin. The primary end point was absence of grade 3 mucositis at 3 months.

RESULTS

Fifteen patients were recruited over 14 months. All patients completed a minimum of 2 years of follow-up. All patients completed full-dose radiotherapy within a median treatment time of 32 days (31-35). Grade 3 mucositis was absent in all patients at 3 months. There was one grade 4 toxicity event due to cisplatin (hypokalaemia). Complete response rates at 3 months were 100% and 93% for local disease and lymph nodes, respectively. One patient developed metastatic disease and subsequently died. Overall survival at 2 years was 93% (95% confidence interval 61-99%).

CONCLUSIONS

The schedule of 64 Gy in 25 fractions with concomitant chemotherapy is tolerable in patients with poor and intermediate prognosis OPSCC.

Habitual levels of higher, but not medium or low, impact physical activity are positively related to lower limb bone strength in older women: findings from a population-based study using accelerometers to classify impact magnitude

This study assessed the effect of accelerometry-measured higher impacts resulting from habitual weight-bearing activity on lower limb bone strength in older women. Despite higher impacts being experienced rarely in this population-based cohort, positive associations were observed between higher vertical impacts and lower limb bone size and strength.

INTRODUCTION

We investigated whether the benefit of habitual weight-bearing physical activity (PA) for lower limb bone strength in older women is explained by exposure to higher impacts, as previously suggested by observations in younger individuals.

METHODS

Four hundred and eight women from the Cohort for Skeletal Health in Bristol and Avon (COSHIBA), mean 76.8 years, wore tri-axial accelerometers at the waist for a mean of 5.4 days. Y-axis peaks were categorised, using previously identified cutoffs, as low (0.5-1.0 g), medium (1.0-1.5 g), and higher (≥1.5 g) impacts. Mid and distal peripheral quantitative computed tomography scans of the tibia and radius were performed, as were hip and lumbar spine Dual X-ray Absorptiometry (DXA) scans. Regressions between (log transformed) number of low, medium and high impacts, and bone outcomes were adjusted for artefact error grade, age, height, fat and lean mass and impacts in other bands.

RESULTS

Eight thousand eight hundred and nine (4047, 16,882) low impacts were observed during the measurement week, 345 (99, 764) medium impacts and 42 (17, 106) higher impacts (median with 25th and 75th quartiles). Higher vertical impacts were positively associated with lower limb bone strength as reflected by cross-sectional moment of inertia (CSMI) of the tibia [0.042 (0.012, 0.072) p = 0.01] and hip [0.067 (0.001, 0.133) p = 0.045] (beta coefficients show standard deviations change per doubling in impacts, with 95 % confidence interval). Higher impacts were positively associated with tibial periosteal circumference (PC) [0.015 (0.003, 0.027) p = 0.02], but unrelated to hip BMD. Equivalent positive associations were not seen for low or medium impacts.

CONCLUSIONS

Despite their rarity, habitual levels of higher impacts were positively associated with lower limb bone size and strength, whereas equivalent relationships were not seen for low or medium impacts.

Feasibility and acceptability of using jumping mechanography to detect early components of sarcopenia in community-dwelling older women

OBJECTIVE

To determine the feasibility and acceptability of using peak power and force, measured by jumping mechanography (JM), to detect early age-related features of sarcopenia in older women.

METHODS

Community-dwelling women aged 71-87 years were recruited into this cross-sectional study. Physical function tests comprised the short physical performance battery (SPPB), grip strength and, if SPPB score≥6, JM. JM measured peak weight-adjusted power and force from two-footed jumps and one-legged hops respectively. Questionnaires assessed acceptability.

RESULTS

463 women were recruited; 37(8%) with SPPB⟨6 were ineligible for JM. Of 426 remaining, 359(84%) were able to perform ≥1 valid two-footed jump, 300(70%) completed ≥1 valid one-legged hop. No adverse events occurred. Only 14% reported discomfort. Discomfort related to JM performance, with inverse associations with both power and force (p⟨0.01). Peak power and force respectively explained 8% and 10% of variance in SPPB score (13% combined); only peak power explained additional variance in grip strength (17%).

CONCLUSIONS

Peak power and force explained a significant, but limited, proportion of variance in SPPB and grip strength. JM represents a safe and acceptable clinical tool for evaluating lower-limb muscle power and force in older women, detecting distinct components of muscle function, and possibly sarcopenia, compared to those evaluated by more established measures.

The Role of Positron Emission Tomography/Computed Tomography Imaging in Head and Neck Cancer after Radical Chemoradiotherapy: a Single Institution Experience

AIMS

Positron emission tomography/computed tomography (PET/CT) is used to restage head and neck cancer 3 months after chemoradiotherapy. The purpose of this study was to determine the negative predictive value (NPV) of a scan reported as having no abnormal uptake and the positive predictive values (PPV) for different maximum standardised uptake value (SUVmax) thresholds.

MATERIALS AND METHODS

Patients with squamous cell carcinoma of the oro-/hypopharynx/larynx (n = 206) were included. SUVmax and subsequent locoregional recurrence were documented.

RESULTS

The median SUVmax was 11.2 (range 4-33)/4.6 (range 2-30), respectively, in patients with/without definite primary site recurrence (P = 0.004). The median SUVmax was 4.4 (range 2.6-15.6)/3.1 (range 2.1-4.6), respectively, in patients with/without definite nodal recurrence (P = 0.003). The NPV for a scan reported as having no abnormal uptake was 92%. The PPV for the SUVmax thresholds 4, 6 and 8, respectively, were 53, 65 and 92% (primary site) and 93, 100 and 100% (nodes).

CONCLUSIONS

The NPV of PET/CT after chemoradiation is consistent with the literature and underlines the importance of PET/CT in restaging the primary site if salvage neck dissection is considered. The overall PPV of PET/CT remains low but is high for nodal SUVmax > 4. These data could be used to design risk-stratified follow-up schedules.

What impact has tendering had on trainees? Results of a national survey by British Association for Sexual Health and HIV Trainees' Collaborative for audit, research and quality improvement projects

In April 2013, local authorities gained responsibility for commissioning sexual health services in England. With many services going out to tender and resultant change in services or service provider, there is anecdotal evidence that this has impacted on the education, training and morale of genitourinary medicine (GUM) trainees. The aim of this study was to evaluate the impact of tendering on GUM trainees. An electronic survey designed by the British Association for Sexual Health and HIV Trainees' Collaborative for Audit, Research and Quality Improvement Projects (T-CARQ) was distributed to GUM trainees and newly appointed consultants. Eighty-two individuals responded (74% GUM trainees, 25% newly appointed consultants, 1% locum appointed for service). Sixty-three per cent (45/72) had experience of training within a service which was being tendered. Of these, 59% (24/41) felt their training was not considered during the tendering process and 20% (8/41) felt that it was. Forty-four per cent (18/41) felt adequately supported. Thirty per cent (12/40) reported active participation in the tendering process. On a scale of 0 (no impact) to 5 (major impact), the median score for impact of tendering on training was 2. The positive/negative impact of tendering on different training elements was rated: other than management experience the overall impact on all parameters was negative, namely morale, senior support and education. In conclusion, this survey describes the variable impact of service tendering on GUM training. Our recommendations for maintaining training standards despite tendering include actively involving trainees and education partners, inclusion of specialist GUM training in service specifications, development of guidance for commissioners and services for the management of GUM training within tendering.

Rechallenge of clozapine in a low secure setting following pericardial effusion

Introduction

Clozapine is licensed for treatment-resistant schizophrenia and when clozapine is not able to be used, less evidence based practices may be required. Full remission may require combinations or high doses of psychotropic medications having greater potential for interactions and side effects. If this is not successful, symptoms may persist and long-term disability may occur.

Aims

To explore safety and efficacy of a rechallenge of clozapine in a patient with treatment resistant schizoaffective disorder, who previously developed pericardial effusion. Collateral history reported best improvement with clozapine compared to other medications.

Objectives

To improve level of functioning and reduce need for less evidence based choices of medication.

Methods

Initial consultation with clozapine monitoring service over prospects of rechallenge. Full medication history and review. Consultation with a cardiologist regarding validity of local monitoring strategy. Obtain consent from the patient and his family. Titrate clozapine slowly. Once clozapine initiated, measure temperature, blood pressure, pulse rate and monitoring of symptoms of pericarditis including chest pain, cough and dyspnoea daily. ECG and echocardiography at baseline and 2 and 4 weeks after initiation of the rechallenge. ECGs monthly thereafter, with a further echocardiogram at 3 months. Weekly troponin and CRP for three months to monitor developing myocarditis and pericarditis.

Results

Successful rechallenge of clozapine with significant reduction in psychopathology, improvement in functioning and no adverse events reported. Reduction of risk enabled transfer to open ward conditions.

Conclusions

There is increasing evidence of successful rechallenges of clozapine however, further research is necessary to aid such clinical decisions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.